Management strategies for right-to-left intraatrial shunt with thrombus in transit: a systematic review of 297 patients and associated mortality outcomes
Mustafa Alkhawam, Jack Simmons, Trent Ray, Ryan W. Wong, Brett J. Cooke, Moses Sghayyer, Yaser Ahmad, Scott Nguyen, Aubrey Pridemore, Ali J. Ebrahimi, Ekaterina Bakradze, Mustafa I. AhmedBackground:
Thrombus in transit (TIT) through a patent foramen ovale (PFO) or atrial septal defect (ASD) is a rare but potentially life-threatening condition associated with paradoxical embolism. Despite advances in imaging and interventional techniques, optimal management strategies remain poorly defined.
Objectives:
To systematically characterize the clinical presentation, diagnostic approaches, management strategies, and outcomes of adult patients with TIT across right-to-left intra-atrial shunts.
Design:
Systematic review of published cases.
Data sources and methods:
Following PRISMA guidelines, PubMed, Embase, and Scopus were searched from inception through March 2025 for case reports, case series, and letters describing adult patients with TIT visualized by transthoracic or transesophageal echocardiography. After screening 1736 records, 278 studies reporting 297 patients were included. Two independent reviewers extracted demographic, clinical, imaging, treatment, and outcome data. Descriptive statistics were summarized, and treatment groups were compared using chi-square and Mann–Whitney
Results:
A total of 297 patients from 278 studies were included. The mean age was 58.5 ± 15.8 years, and 50.2% were male. Respiratory symptoms predominated (77.7%), followed by cardiac (29.7%) and neurological (23.0%) manifestations. Provoked events accounted for 70.3% of cases, most commonly in the postoperative setting. Thrombi were detected by transthoracic echocardiography in 92.1% of cases and by transesophageal echocardiography in 100%. Management strategies included surgical embolectomy (57.8%), anticoagulation (36.5%), thrombolysis (13.5%), and percutaneous aspiration (2.7%); 61.1% underwent PFO/ASD closure. Overall mortality was 8.3%. Surgical management was associated with the lowest mortality (3.0%) and the highest short-term clinical improvement (90.5%;
Conclusion:
In this largest synthesis of TIT cases to date, surgical management and PFO/ASD closure were associated with favorable short-term outcomes. Surgical intervention demonstrated the lowest observed mortality, while anticoagulation provided acceptable outcomes in selected patients. Thrombolysis and percutaneous aspiration were associated with higher mortality. These findings support the role of definitive management and shunt closure in selected patients, although prospective studies are needed to establish standardized treatment strategies.
Trial registration:
This study was registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) (Registration number: INPLASY202630021).