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Pulmonary Vascular Disease |

Arrested in the Act: Pulmonary Embolism With Right Atrial Thrombus-in-Transit Across a Patent Foramen Ovale

Alexander Mensah, MBChB; Gbolahan Ogunbayo, MD; mehul patel, MD
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Rochester General Hospital, Webster, NY


Chest. 2015;148(4_MeetingAbstracts):980A. doi:10.1378/chest.2281077
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Abstract

SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Paradoxical thromboembolism is an unusual but a well-recognized complication of venous thromboembolic disease. Mobile, right-sided cardiac thrombi are reported in up to 20% of patients with pulmonary embolism. The diagnosis is usually presumptive when a patent foramen ovale (PFO) is detected by echocardiography in a patient with deep vein thrombosis (DVT) or pulmonary embolism (PE) who develops ischemic stroke or other symptoms of systemic embolization. The real-time observation of a right atrial thrombus trapped in a PFO in a patient with pulmonary embolism is a rare event.

CASE PRESENTATION: An 80-year-old female presented with sudden onset dyspnea, chest discomfort and dizziness. She also had right leg pain and swelling for a week. On examination she was hypoxic with oxygen saturation of 88% in room air, tachycardic with heart rate of 125bpm and had a blood pressure of 112/82mmHg. Troponin and beta natriuretic peptide were slightly elevated. Chest x-ray was normal and elctrocardiogram showed sinus tachycardia with no acute ST changes. Computed tomography angiogram of the chest revealed a saddle pulmonary embolism in the main pulmonary arteries with extension into the segmental and sub-segmental branches. There was also flattening of the interventricular septum suggestive of right heart strain. Anticoagulation was started with unfractionated heparin and she also underwent ultrasound assisted catheter directed thrombolysis. Transthoracic echocardiogram revealed a moderate sized mobile thrombus across a patent foramen ovale traveling from the right to the left atrium. Emergent surgical embolectomy and closure of the PFO were successfully done.

DISCUSSION: Paradoxical embolism is an uncommon occurrence with a reported incidence of 4-20% in patients with DVT and PE. However, this may be an underestimation, as echocardiograms are not routinely done in all patients with DVT/PE. It is associated with increased morbidity and mortality and early detection with echocardiogram can lead to prompt treatment to avert systemic embolization. Treatment options for thrombus-in-transit include surgical embolectomy, thrombolysis, anticoagulation or a combination of the above.

CONCLUSIONS: This case illustrates a rare real-time echocardiographic finding of a clot in transit across a PFO in a patient with pulmonary embolism. It raises the question as to whether echocardiogram should be done in all patients with pulmonary embolism to avoid missing the diagnosis.

Reference #1: Casazza F, et al. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol, 1997;79: 1433-1435.

Reference #2: Myers PO, et al. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164-170

Reference #3: Fauveau E, et al. Surgical or medical treatment for thrombus straddling the patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008;101:637-644

DISCLOSURE: The following authors have nothing to disclose: Alexander Mensah, Gbolahan Ogunbayo, mehul patel

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