Copyright © 2005, The European Society of Cardiology
Caught in the act: Serial, real time images of a thrombus traversing from the right to left atrium across a patent foramen ovale
Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Avenue, Box 8086, Saint Louis, MO 63110, USA
Received 20 December 2004; received in revised form 8 May 2005; accepted after revision 12 May 2005.
* Corresponding author. Tel.: +1 314 362 5363; fax: +1 314 747 4758. harit{at}im.wustl.edu
 |
Abstract |
|---|
 Top Abstract Case reportDiscussionReferences |
|---|
Aims To illustrate the association between a patent foramen ovale (PFO) and paradoxical embolization.
Methods and results We report a unique case of a paradoxical embolization across a PFO noted during a transesophageal echocardiographic study. Serial images demonstrate the thrombus migrating from the superior vena cava to the left atrium across the PFO.
Conclusions This case establishes the association between the PFO and paradoxical embolism unequivocally.
Keywords: Paradoxical embolism; Transesophageal echocardiography; Patent foramen ovale; Right to left shunt
Paradoxical embolization across a patent foramen ovale (PFO) is a rare but clinically well recognized entity. The transit of a thrombus across a PFO has been serendipitously documented on imaging studies on extremely rare instances. We present a unique case of paradoxical embolism, wherein we were able to document a thrombus traversing in "real time" from the superior vena cava to the left atrium across a PFO during the course of a transesophageal echocardiographic study. This case distinctly illustrates the potential risk of paradoxical embolization associated with a PFO.
|
Case report |
|---|
|
TopAbstractCase reportDiscussionReferences |
|---|
A 74-year-old woman underwent elective coronary artery bypass grafting surgery for management of her recently diagnosed coronary artery disease. On the fourth post-operative day the patient suffered a new cerebral embolic event that prompted a transesophageal echocardiogram (TEE) to evaluate for cardiac source of emboli.
Initial TEE images demonstrated a lobulated, highly mobile echogenic mass in the superior vena cava (SVC), consistent with a thrombus (Fig. 1a). Another echogenic mass, suggestive of a thrombus, was also seen attached to the free wall of the right atrium (Fig. 1a). Also noted were an atrial septal aneurysm and a PFO. Over the course of the following ten minutes the thrombus from the SVC was seen migrating into the right atrium adjacent to the limbus fossa ovalis (Fig. 1b), and traversing across the PFO (Fig. 1c). Within minutes it freely embolized into the left atrium (Fig. 1d). A repeat bicaval view obtained shortly thereafter showed that the thrombus in the SVC was no longer present (Fig. 1e) confirming that it had embolized systemically.
|
|
Discussion |
|---|
|
TopAbstractCase reportDiscussionReferences |
|---|
The diagnosis of paradoxical embolization is often presumed when there is: 1) evidence of systemic embolization in the absence of an embolic source from the left heart, and great vessels; and 2) demonstration of a PFO, atrial septal defect, or other abnormal communication between the venous and arterial circulations. Few cases of thrombus traversing through or lodged in a PFO have been identified at autopsy, and on rare occasions on imaging studies.
Nearly 40 cases of thrombus in transit diagnosed antemortem using various imaging studies have been described in the literature.1,2 In all these cases the thrombus was found adjacent to or lodged in the PFO, and their traversed path was often extrapolated based on the clinical circumstances. The case presented herein is the first to document the serial passage of a thrombus originating from the superior vena cava, as it traversed from the right to left side of the heart across a PFO in real time.
Management of paradoxic embolus in transit is usually challenging, as the mortality rate may be as high as 30–40%.3 Guidelines for managing paradoxical embolus suggest initial treatment with systemic anticoagulation, with subsequent thrombectomy, and surgical or percutaneous closure of the PFO. Treatment with thrombolytics may also be an alternative. The case described herein establishes the association between PFO and paradoxical embolization conclusively and supports the rationale for percutaneous closure of PFO in selected patients.
|
References |
|---|
|
TopAbstractCase reportDiscussionReferences |
|---|
- Nellessen U., Daniel W.G., Matheis G., Oelert H., Depping K., Lichtlen P.R. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol (1985) 5:1002–1004.[Abstract]
- Meacham R.R. III, Headley A.S., Bronze M.S., et al. Impending paradoxical embolism. Arch Intern Med (1998) 158:438–448.
[Abstract/Free Full Text] - Chartier L., Bera J., Delomez M., et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation (1999) 99:2779–2783.
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  R. A. Krasuski, S. A. Hart, D. Allen, A. Qureshi, G. Pettersson, P. L. Houghtaling, L. H. Batizy, and E. Blackstone Prevalence and Repair of Intraoperatively Diagnosed Patent Foramen Ovale and Association With Perioperative Outcomes and Long-term Survival JAMA, July 15, 2009; 302(3): 290 - 297. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||