Asian Cardiovasc Thorac Ann 2006;14:170-171
© 2006 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Impending Paradoxical Thromboembolism Associated with Acute Pulmonary Embolism
Yoshiyuki Takami, MD,
Akihiro Terasawa, MD1
Division of Cardiovascular Surgery
1 Division of Cardiology, Kasugai Municipal Hospital, Kasugai, Japan
For reprint information contact: Yoshiyuki Takami, MD Tel: 81 568 570 057 Fax: 81 568 570 067 Email: cvs{at}hospital.kasugai.aichi.jp, Division of Cardiovascular Surgery, Kasugai Municipal Hospital, 1-1-1 Takagi-cho, Kasugai City 486-8510, Japan.
A 58-year-old woman presented with palpitation and dyspnea over 4 days. An enhanced CT showed massive obstruction in the right pulmonary artery and partial embolization of the right kidney (Figure 1
).
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Figure 1. Enhanced CT scans demonstrating (A) occlusion of the right pulmonary artery and (B) partial embolization of the right kidney.
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Perfusion lung scans using technesium 99m-labeled particles revealed multiple segmental defects. Transesophageal echocardiography showed mobile mass, probably thrombi, attached to the atrial septum in both right and left atria (Figure 2A and 2B). The patient underwent urgent surgery under cardiopulmonary bypass to remove the abnormal mass, which would cause further embolization, in the atria and pulmonary artery. Although we could not remove the mass in the right pulmonary artery, the intra-atrial mass was extracted, which proved to be thrombus penetrating the atrial septum through the patent foramen ovale (Figure 3). The postoperative recovery was uneventful and she is now out of hospital with anticoagulation therapy using warfarin. We should know that, in acute pulmonary embolism, increased pressure in the right-side heart is likely to cause impending paradoxical systemic embolization1 of the thrombus in the right atrium through the patent foramen ovale.
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Figure 2. Transesophageal echocardiograms showing mobile mass, probably thrombi, attached to the atrial septum in both (A) right atrium (RA) and (B) left atrium (LA). There is marked dilatation of the RA and right ventricle (RV), suggesting pulmonary hypertension. LV=left ventricle.
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Figure 3. The intraoperative photograph showing the bi-atrial thrombus removed in surgery under cardiopulmonary bypass, arrows indicate the penetrating point of the atrial septum.
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REFERENCES
- Meacham III RR, Headley S, Bronze MS, Lewis JB, Rester MM. Impending paradoxical embolism. Arch Intern Med 1998; 158(5): 438–48.[Abstract/Free Full Text]
