Copyright © 2005, The European Society of Cardiology
The Eustachian valve in pulmonary embolism: Rescue or perilous?
University Hospital Gasthuisberg, Cardiology Department, Herestraat 49, 3000 Leuven, Belgium
Received 8 March 2005; received in revised form 13 June 2005; accepted after revision 30 June 2005.
* Corresponding author. Tel.: +32 16 34 42 49. jan.dekeyser{at}uz.kuleuven.ac.be
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Abstract |
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This case illustrates the Eustachian valve as an ambiguous entity. By tethering a thrombus the valve prevented a major pulmonary embolism. However, in combination with a patent foramen ovale, it directs the thrombus into the left atrium, creating a threat for systemic embolisms.
Keywords: Eustachian valve; Patent foramen ovale; Floating right heart thrombus
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Case introduction |
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This is a case of a patient with an ovarian carcinoma who was transferred to our hospital with shortness of breath.
She had a blood pressure of 120/65mmHg, a pulse rate of 100bpm, a respiratory rate of 18 breaths per minute and a body temperature of 37°C. The clinical examination of the heart and lungs was normal but there was bilateral malleolar edema.
On suspicion of pulmonary embolisms a venous ultrasound of the lower extremities and a ventilation–perfusion lung scan were carried out on which a right-sided deep venous thrombosis and multiple small pulmonary embolisms were seen.
The transesophageal echocardiography showed a long floating serpiginous thrombus in the right atrium across the interatrial septum through a patent foramen ovale (Fig. 1). The thrombus was tethered to the Eustachian valve (Fig. 2).
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Fortunately, the patient has not suffered symptomatic systemic embolisms. Anticoagulation was started and she is doing well.
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Case discussion |
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The Eustachian valve and patent foramen ovale
The Eustachian valve (EV) is an endocardial fold extending from the anterior inferior margin of the inferior vena cava (IVC) to the anterior part of the limbus fossa ovalis.
During fetal life, the EV directs oxygen-rich blood from the IVC toward the foramen ovale and away from the tricuspid valve.
After birth the EV is ‘programmed’ to regress completely. In about 30% of the adult it persists in variable size and anatomy.1 This remnant is considered functionless and benign.
However, there are reports suggesting that the EV is not as innocent as we thought.2 The EV can be a site of infective vegetations3 or be mistaken for a thrombus, tumor4 or vegetations. The EV can also make interventional procedures (closure of ASD (atrial septal defect) or ablation for atrial flutter) more laborious.1 The presence of an EV together with a PFO may also cause cyanosis.5
Furthermore there is evidence that a persisting EV predisposes to patency of the foramen ovale.1
The presence of a PFO in patients with pulmonary embolism is associated with a 10-fold increase in death and a 5-fold increase in the risk of major adverse events during the hospital stay.6
In this case the EV appears as an ambiguous entity. By serving as a safety net it prevented a life-threatening pulmonary embolism but – in combination with a PFO – created a free floating right heart thrombus (FRHT) and floating left heart thrombus (FLHT).
Floating heart thrombi
Free floating right heart thrombi are a form of venous thrombo-embolic disease7 and occur in about 18% of patients with severe pulmonary embolism (PE).4 They can embolise at any moment and thus require emergency treatment, especially in view of their documented high mortality (>40%) rate.8 Once this risk of embolisation is overcome, the prognosis after discharge is similar to patients without FRHT.7
Therapeutic options are anticoagulation, fibrinolysis, surgery, catheter-tip embolectomy or catheter-tip fragmentation (depending on the experience of the physician and the availability of the procedure). Based on retrospective studies, none of these strategies has proven superiority but anticoagulation and fibrinolysis are considered as first-choice treatments.2,7,9
A study with serial echocardiographic examination throughout the infusion with a thrombolytic drug showed that the FRHT does not dissolve but rather migrates into the pulmonary vasculature without serious clinical deterioration or increase in risk of sudden death.2
Considering the fact that thrombolytic treatment may cause dislodgement of a fixed thrombus anticoagulation is first-choice treatment in case of a floating left heart thrombus (FLHT).
Our patient received low-weight heparin and is doing well. Although the thrombus has not disappeared completely (yet), there were no events of symptomatic embolisation.
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Conclusion |
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This case-report highlights the Eustachian valve as an ambiguous entity. In a patient with a thrombus-in-transit towards the pulmonary artery it served as a safety net and prevented a massive pulmonary embolism. On the other hand, the EV directed the thrombus through a patent foramen ovale into the left atrium and so created a threat of cerebral or other systemic embolisms.
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References |
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- Schuchlenz H.W., Saurer G., Weihs W., Rehak P. Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events. J Am Soc Echocardiogr (2004) 17:231–233.[CrossRef][Web of Science][Medline]
- Casazza F., Bongarzoni A., Centonze F., Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol (1997) 79:1433–1435.[CrossRef][Web of Science][Medline]
- Sawhney N., Palakodeti V., Raisinghani A., Rickman L., DeMaria A., Blanchard D. Eustachian valve endocarditis: a case series and analysis of the literature. J Am Soc Echocardiogr (2001) 14:1139–1142.[CrossRef][Web of Science][Medline]
- Carson W., Chiu S.S. Image in cardiovascular medicine: eustachian valve mimicking intracardiac mass. Circulation (1998) 97:2188.
[Free Full Text] - Yavuz T., Nazli C., Kinay O., Kutsal A. Giant eustachian valve with echocardiographic appearance of divided right atrium. Tex Heart Inst J (2002) 29:336–338.[Web of Science][Medline]
- Konstantinides S., Geibel A., Kasper W., Olschewiski M., Blümel L., Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation (1998) 97:1946–1951.
[Abstract/Free Full Text] - Chartier L., Béra J., Delomez M., Asseman P., Beregi J.P., Bauchart J.J., 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] - European Working Group on Echocardiography. The European cooperative study on the clinical significance of right heart thrombi. Eur Heart J (December 1989) 10:1046–1059.
[Abstract/Free Full Text] - Kinney E.L., Wright R.J. Efficacy of treatment with echocardiographically detected right-sided heart thrombi: a meta-analysis. Am Heart J (1989) 118(3):569–573.[CrossRef][Web of Science][Medline]
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