CASE PRESENTATION: A 67 year old male without significant medical history was admitted for a submassive acute pulmonary embolism (Figure 1) treated with intravenous systemic thrombolytics, but was complicated by an intracranial hematoma secondary to the anticoagulation. He was monitored for neurologic deficits while holding his anticoagulation. Considering his stability, he was readied for discharge without anticoagulation despite having a known left lower extremity deep vein thrombosis. An echocardiogram at the time showed resolution of right ventricular strain but was positive for a PFO. However, patient was transferred to the ICU for acute onset respiratory distress and hypoxia. His oxygen saturation was 93% on 100% non-rebreather mask and breathing at 20 b/ min. Lungs were clear on exam. There was no edema or JVD. A repeat transthoracic echocardiogram showed a severely dilated right atrium, right ventricular systolic pressure of 58 mm Hg, and a large thrombus extending from the right atrium into the right ventricle as well as through the PFO into the left ventricle (Fig 2). The patient was restarted on a continuous heparin infusion followed by emergentright bi-atrial thrombectomy and PFO closure. He had an uneventful postoperative course and was discharged in good condition.