Asian Cardiovasc Thorac Ann 2002;10:342-343
© 2002 Asia Publishing EXchange Pte Ltd
Caught in the Act: Impending Paradoxical Embolism
Alex M Fabricius, MD,
Martin Krüger, MD,
Michaela Hanke, MD,
Friedrich W Mohr, MD
|
Division of Cardiovascular Surgery University of Leipzig Leipzig, Germany
|
|
|
For reprint information contact: Alex M Fabricius, MD Tel: 49 341 865 1421 Fax: 49 341 865 1452 email: faba{at}medizin.uni-leipzig.de Division of Cardiovascular Surgery, University of Leipzig, Strümpelstr 39, Leipzig D-04289, Germany.
|
 |
ABSTRACT
|
|---|
In a 73-year-old woman admitted with pulmonary embolism, a thrombus wedged across a patent foramen ovale was revealed by transesophageal echocardiography. After systemic anticoagulation, cardiac embolectomy and closure of the atrial septal defect were considered. Before surgery, repeat transesophageal echocardiography revealed only a small patent foramen ovale with no residual thrombus. We assumed dissolution of the thrombus as the patient had no sign of systemic or recurrent pulmonary embolism.
|
INTRODUCTION
|
|---|
The advent of echocardiography has led to more frequent detection of impending paradoxical embolism, but it is rare to see a thrombus wedged through a patent foramen ovale (PFO). Management of this potentially lifethreatening condition is controversial. We report a case of a thrombus lodged in a PFO.
|
CASE REPORT
|
|---|
A 73-year-old woman was admitted to a local hospital with unilateral leg pain and swelling besides acute dyspnea. She had hip surgery 3 months earlier. At admission, arterial oxygen tension was 87 mm Hg and carbon dioxide tension 43 mm Hg with a base excess of –1.2 mmol.L–1. Serum glutamic-oxaloacetic transaminase was mildly increased. The electrocardiogram showed sinus tachycardia, a right axis deviation, and an incomplete right bundle branch block. The chest radiograph revealed right heart enlargement. Doppler ultrasound studies of the right leg revealed unilateral deep vein thrombosis. Transesophageal echocardiography (TEE) showed a large thrombus (Figure 1
) wedged across a PFO, dilated right atrium and right ventricle, and severe tricuspid valve regurgitation; while transesophageal and transthoracic echocardiography revealed a thrombus in the pulmonary artery. Right heart catheterization showed severely elevated pulmonary pressure of 50 mm Hg. Heparin therapy was initiated to achieve an activated partial thromboplastin time at 1.5 to 2 times the control value; in addition, 1,000 IU antithrombin III was administered twice. The patient was referred to our clinic for cardiac embolectomy and closure of the PFO to preempt systemic embolization. Upon admission, preoperative TEE revealed only a small PFO, visualized using echo contrast and provoked Valsalva maneuver. We assume dissolution of the thrombus since no clinical signs of systemic embolism were seen. Consequently, a noninterventional course was decided on.
View larger version (104K):
[in this window]
[in a new window]
|
Figure 1. Transesophageal echocardiogram showing the thrombus (arrows). LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
|
|
|
DISCUSSION
|
|---|
A PFO has been reported in up to 35% of the general population with a 16% incidence of paradoxical embolism.1,2 Transient events such as coughing or acute pulmonary embolism, or chronic hemodynamic changes such as chronic pulmonary hypertension, may result in a right-to-left shunt through a PFO, allowing a venous thromboembolus access to the arterial circulation. Patients with acute pulmonary embolism and a sudden rise of right atrial pressure are especially prone to paradoxical embolism.
Heparin therapy resulting in complete dissolution of the thrombus has been reported, as well as systemic and pulmonary embolization after anticoagulation therapy in patients with an impending thrombus.3,4 The latter should be anticipated when administering anticoagulation therapy, which leaves cardiac embolectomy as the only reasonable therapeutic approach.5,6 In the case of chronic thromboembolic pulmonary hypertension, pulmonary thromboendarterectomy should be performed since a significant reduction of pulmonary artery pressure and vascular resistance can be achieved.7
Transthoracic followed by transesophageal echocardiography remains the quick, inexpensive, and simple standard tools for screening the heart for a thrombus.8 To ascertain the operative indication, TEE should always be repeated just before surgery.
|
REFERENCES
|
|---|
- Konstadt SN, Louie EK, Black S, Rao TL, Scanlon P. Intraoperative detection of patent foramen ovale by transesophageal echocardiography. Anesthesiology
1991;74:212–6.[Medline]
- Chaikof EL, Campbell BE, Smith RB III. Paradoxical embolism and acute arterial occlusion: rare or unsuspected? J Vasc Surg
1994;20:377–84.[Medline]
- Schreiter SW, Phillips JH. Thromboembolus traversing a patent foramen ovale: resolution with anticoagulation. J Am Soc Echocardiogr
1994;7:659–62.[Medline]
- Cazzani E, Benvenuto M, Muzio L. Pulmonary and systemic embolism in a case of biatrial thrombosis. Role of two-dimensional echocardiography [Italian]. G Ital Cardiol
1987;17:1169–72.[Medline]
- Caes FL, van Belleghem YV, Missault LH, Coenye KE, van Nooten GJ. Surgical treatment of impending paradoxical embolism through patent foramen ovale. Ann Thorac Surg
1995;59:1559–61.[Abstract/Free Full Text]
- Falk V, Walther T, Krankenberg H, Mohr FW. Trapped thrombus in a patent foramen ovale. Thorac Cardiovasc Surg
1997;45:90–2.[Medline]
- Mayer E, Dahm M, Hake U, Schmid FX, Pitton M, Kupferwasser I, et al. Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Ann Thorac Surg
1996;61:1788–92.[Abstract/Free Full Text]
- Tanus-Santos JE, Moreno Junior H. Pulmonary embolism and impending paradoxical embolism: a role for transesophageal echocardiography? Clin Cardiol
1999;22:158–9.
This article has been cited by other articles:
|
|
|
|
 
M. A. Ford, G. S. Reeder, R. J. Lennon, R. D. Brown, G. W. Petty, A. K. Cabalka, F. Cetta, and D. J. Hagler
Percutaneous Device Closure of Patent Foramen Ovale in Patients With Presumed Cryptogenic Stroke or Transient Ischemic Attack: The Mayo Clinic Experience
J. Am. Coll. Cardiol. Intv.,
May 1, 2009;
2(5):
404 - 411.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. P. Adams Jr
Patent Foramen Ovale: Paradoxical Embolism and Paradoxical Data
Mayo Clin. Proc.,
January 1, 2004;
79(1):
15 - 20.
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
