SESSION TITLE: Pulmonary Vascular Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Paradoxical embolism as a source of arterial thrombosis has been recognized for some time, and investigations into percutaneous patent foramen ovale closure in the prevention of recurrent ischemic stroke are currently underway. Less commonly seen or perhaps recognized is the potential for paradoxical emboli to cause myocardial infarction. The following case describes a patient with a thrombus straddling a patent foramen ovale who manifested emboli in the pulmonary, cerebral, and coronary arteries.
CASE PRESENTATION: A 76 year old man with a history of type 2 diabetes mellitus was brought for evaluation after being found by his family to have left sided weakness and facial droop. He was additionally found to be in respiratory distress and was endotracheally intubated and placed on mechanical ventilation. Computerized tomography of the head without contrast was consistent with a complete right MCA infarction with intraarterial thrombus. A CT angiogram of the chest to investigate hypoxemia revealed bilateral segmental pulmonary emboli. Electrocardiogram revealed Q waves in the inferior leads. Transthoracic echocardiogram was significant for biventricular failure and a thrombus in both the right and left atria, traversing a patent foramen ovale. Because of the biventricular failure and ECG abnormalities, coronary artery angiography was performed revealing thrombi in the left main, left circumflex, and left anterior descending arteries for which thrombectomy was performed. Right heart catheterization and pulmonary arteriogram showed diffuse bilateral distal thrombi which were not amenable to thrombectomy. Doppler ultrasound of the lower extremity deep veins revealed occlusive deep venous thormbosis involving the entire left superficial femoral and bilateral popliteal veins. The patient was started on continuous intravenous unfractionated heparin and an inferior vena cava filter was placed. He was not judged to be a good candidate for surgical thrombectomy due to his poor neurologic status. Despite aggressive support, his neurologic function did not improve, and ventilatory support was discontinued after discussion with family.
DISCUSSION: Patent foramen ovale with paradoxical embolism is widely accepted as a potential mechanism for ischemic stroke, and less commonly associated with myocardial infarction, renal infarcts, and limb ischemia. Thrombus straddling a patent foramen ovale is rare, and case descriptions in the literature even more rarely describe myocardial infarction in this context. The options for management of entrapped thrombus include anticoagulation, thrombolysis both systemic and catheter directed, and surgical thrombectomy. In a review of the literature, the patients most likely to receive surgical intervention were younger in age and had fewer preoperative incidence of stroke. Thrombolysis was used most often in patients with hemodynamic compromise as a result of pulmonary emboli for whom surgery was not available in a timely fashion. In a comparison of mortality rates, surgical thrombectomy and systemic anticoagulation appeared similar while thrombolysis was associated with an elevated risk of death.
CONCLUSIONS: Thrombus straddling a patent foramen ovale is a rare cause of systemic emboli, and thus data is limited. Management typically varies based on the patient's age, comorbidities, and the presence of stroke. Anticoagulation and surgical thrombectomy seem equivalent in mortality risk; thrombolytic therapy appears to be associated with increased mortality,
Reference #1: Fauveau, Elodie, et al. "Surgical or medical treatment for thrombus straddling the patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature review." Archives of cardiovascular diseases 101.10 (2008): 637-644.
Reference #2: Homma, Shunichi, and Ralph L. Sacco. "Patent foramen ovale and stroke."Circulation 112.7 (2005): 1063-1072.
Reference #3: Dao, Catherine N., and Jonathan M. Tobis. "PFO and paradoxical embolism producing events other than stroke." Catheterization and Cardiovascular Interventions 77.6 (2011): 903-909.
DISCLOSURE: The following authors have nothing to disclose: Charles Hebenstreit, Francisco Fuentes
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