Paradoxical embolism.

Case presentation: A 69-year-old woman presented to the hospital with sudden-onset shortness of breath that occurred while standing from a sitting position. The patient was in moderate respiratory distress with a blood pressure of 109/78 mm Hg, heart rate of 109 bpm, and peripheral blood oxygen saturation level of 95% on 3 L of oxygen per nasal cannula. She had an accentuated pulmonary component of the second heart sound, sinus tachycardia on ECG, and an elevated troponin-I level. A large proximal pulmonary embolism was diagnosed by computed tomography. Transthoracic echocardiography demonstrated a right atrial (RA) mass. Transesophageal echocardiography revealed a 3.2-cm thrombus extending from the RA to the left atrium (LA) through a patent foramen ovale (PFO), consistent with impending paradoxical embolism (Figure and Figure I in the online-only Data Supplement).

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