3. Thrombus in-transit and pulmonary emboli

Multiple thrombi can be seen in transit through the right atrium. A second thrombus is seen near the subvalvular apparatus. Multiple other small thrombi are also visualized. Aside from obvious clot caught in transit, the ultrasound displays other classical signs that can be associated with pulmonary embolism. When compared to the TEE performed 2 days prior (video 1), the right ventricle was now noted to be moderately to severely dilated with an RV/LV ratio of approximately 1.2/1 (1). The right ventricular function was also now moderately reduced with hypokinesis of the base and relative sparing of the apex (McConnell’s sign) (2). This sign is associated with acute pulmonary embolism and also acute right ventricular infarction. The image below shows video 2, with an “M” placed just below the point where the sparing of the apical motion meets the hypokinesis of the free wall (hinge point) (video 3). Also noted is a bowing intra-atrial septum (right to left) indicated elevated right atrial pressures.

Video 3. Mid-esophageal four chamber view of the right and left ventricle AFTER deterioration, with letter “M” placed just below the “hinge point” associated with McConnell’s sign.

The source of the emboli was determined to be thrombus adherent other patient’s intravascular cooling catheter, used to normalize temperature in this patient with traumatic brain injury. Vena caval thrombus is a described complication of these types of catheters.


  1. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35:3033–69. [CrossRef] [PubMed]
  2. Lodato JA, Ward RP, Lang RM. Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardiography. 2008;25:584–90. [CrossRef] [PubMed]

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