BACKGROUND AND AIM: A biatrial thrombus straddling a patent foramen ovale (PFO) is rare. The optimal management is controversial. This report offers an additional report and brief review of the literature. CASE REPORT: A 72-year-old female presented with paroxysmal dyspnea. Transthoracic echocardiography showed distended right heart cavities, pulmonary artery hypertension, and a thrombus in the right atrium passing through the PFO into the left atrium. Urgent surgical embolectomy confirmed an 11.5 cm serpentine biatrial thrombus and allowed PFO closure and bilateral pulmonary embolectomy. Postoperative recovery was uneventful. CONCLUSIONS: The risk of systemic embolization during thrombolytic or heparin treatment for biatrial thrombus makes most authors recommend surgical or interventional thrombectomy and PFO closure. Given the limited number of cases, there is no evidence that any of the treatment strategies provide a better survival.