Pulmonary Vascular Disease: Student/Resident Case Report Poster - Pulmonary Vascular Disease I |

A Hole Through the Heart: A Case of Paradoxical Embolism Through a Patent Foramen Ovale FREE TO VIEW

Omar Ahmed, MD; Andrew McCue, MD
Author and Funding Information

Emory University, Decatur, GA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1214A. doi:10.1016/j.chest.2016.08.1323
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Patent foramen ovale (PFO) have an incidence of roughly 25% based on autopsy reports. They are increasingly seen as culprits in cryptogenic strokes in that they act as a route for venous thromboembolic events to the arterial circulations. An impending paradoxical embolism (IPDE) is where a clot is caught in transit through a PFO with the potential to embolize into systemic circulation. This is a case of an IPDE treated successfuly through surgical intervention.

CASE PRESENTATION: A 67 year old male without significant medical history was admitted for a submassive acute pulmonary embolism (Figure 1) treated with intravenous systemic thrombolytics, but was complicated by an intracranial hematoma secondary to the anticoagulation. He was monitored for neurologic deficits while holding his anticoagulation. Considering his stability, he was readied for discharge without anticoagulation despite having a known left lower extremity deep vein thrombosis. An echocardiogram at the time showed resolution of right ventricular strain but was positive for a PFO. However, patient was transferred to the ICU for acute onset respiratory distress and hypoxia. His oxygen saturation was 93% on 100% non-rebreather mask and breathing at 20 b/ min. Lungs were clear on exam. There was no edema or JVD. A repeat transthoracic echocardiogram showed a severely dilated right atrium, right ventricular systolic pressure of 58 mm Hg, and a large thrombus extending from the right atrium into the right ventricle as well as through the PFO into the left ventricle (Fig 2). The patient was restarted on a continuous heparin infusion followed by emergentright bi-atrial thrombectomy and PFO closure. He had an uneventful postoperative course and was discharged in good condition.

DISCUSSION: IPDEs are rare and are associated with high mortality (18%). They are caused by elevated right heart pressures that open the foramen ovale in the the presence of a right-to-left shunt. There is little data on proper management. Thrombectomy has not been shown to improve survival when compared to anticoagulation alone, however, it may decrease the rate of embolization. However, it appears that anticoagulation alone is not adequate for treatment. This case is further complicated by the patient’s recent hemorrhagic stroke in that adding anticoagulation alone was deemed too risky except as adjunct to surgery.

CONCLUSIONS: This is a case of an impending paradoxical embolism that underwent successful thrombectomy with good outcomes. The decision to treat initally with anticoagulation was controversial given the risk for hemorrhagic stroke, however, it was deemed necessary due to the extent of the thrombus.

Reference #1: O'Meyers, P, Bounameaux, H, et al “Impending Paradoxical Embolism: Systemic Review of Literature of Prognostic Factors and Treatment” Chest 2010; 137(1):164-170

Reference #2: Kutty, S, Sengupta, P, et al “Patent Foramen Ovale: The Known and the To Be Known” Journal of American College of Cardiology. 2012;59(19):1665-1671

DISCLOSURE: The following authors have nothing to disclose: Omar Ahmed, Andrew McCue

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543