European Journal of Echocardiography 2007 8(2):158-160; doi:10.1016/j.euje.2006.01.001
Copyright © 2006, The European Society of Cardiology
Large emboli on their way through the heart – First live demonstration of large paradoxical embolisms through a patent foramen ovale
Lars S. Maiera,*,
Nils Teucherb,
Hilmar Dörgeb and
Stavros Konstantinidesa
aAbt. Kardiologie & Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
bAbt. Thorax-, Herz,- Gefäßchirurgie/Herzzentrum, Georg-August-Universität Göttingen, Germany
Received 25 October 2005; received in revised form 2 January 2006; accepted after revision 11 January 2006.
* Corresponding author. Tel.: +49 551 39 9481; fax: +49 551 39 8941. lmaier{at}med.uni-goettingen.de
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Abstract
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We report a case of large paradoxical embolisms through a patent
foramen ovale in a patient with acquired heparin-induced thrombocytopenia
type II (HIT). One large ventricular thrombus embolizing through
the aortic valve was documented on videotape for the first time
while performing transesophageal echocardiography.
A 56-year-old man was admitted with acute respiratory failure initially believed to have an exacerbated chronic obstructive pulmonary disease. Arterial oxygen saturation was only 33%. He received antibiotic and anti-obstructive treatments and was mechanically ventilated for 7 days. Few hours after extubation, he developed recurrent severe dyspnea accompanied by acute pain and pulselessness in his left leg. Transthoracic echocardiography revealed an enlarged right ventricle and suggested the presence of free-floating thrombi both in the right and in the left-heart cavities. During transesophageal echocardiography, a large serpentine left-heart thrombus embolized through the aortic valve and disappeared. The patient developed ventricular fibrillation and underwent successful cardiopulmonary resuscitation including emergency thrombolysis with alteplase. Four hours later, the surgeon retrieved a 20-cm long thrombus from the left femoral artery.
Keywords: Patent foramen ovale; Paradoxical embolism; Heparin-induced thrombocytopenia type II; Thrombus
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Introduction
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Patients with a patent foramen ovale (PFO) have a high incidence
of cerebral and peripheral ischemic events due to paradoxical
embolism.
1 During acute major pulmonary embolism
2 increased
pressure in the pulmonary circulation leads to a right-to-left
shunt through a PFO which was found to be associated with high
risk of death.
1 In 1877 Cohnheim
3 first described the entity
of paradoxical embolism through a PFO. Paradoxical embolism
or thrombosis in patients treated with heparin was first described
by Weismann and Tobin.
4 Heparin-induced thrombocytopenia type
II (HIT) is defined as a decrease of 50% or more from baseline
platelet numbers, the absence of other causes of thrombocytopenia,
confirmation by heparin-associated antibodies, and a decrease
to normal platelet numbers when heparin application is stopped.
HIT occurs in 2–4% of the patients receiving heparin for
at least 5 days independent of dosage. In addition, in HIT patients
additional thrombosis (HITT) occurs in about 25% of the patients
resulting in severe venous and arterial thrombosis.
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Case report
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A 56-year-old man was admitted to a hospital with acute respiratory
insufficiency on the basis of infect-exacerbated chronic obstructive
pulmonary disease. The patient presented with severe dyspnea,
tachypnea, and tachycardia (130beats/min). His capillary arterial
blood gas analysis revealed a pCO
2 of 73mmHg, a pO
2 of 23mmHg,
and an O
2 saturation of only 33%. Lab results showed increased
white blood cell count of 13,100/µl and a C-reactive protein
of 118mg/l with normal platelet count of 307,000/µl. Subsequently,
he had to be intubated and oxygenated. He was treated with anti-obstructive
and antibiotic medication and was given liquemin i.v. After
1 week his respiratory situation had improved and he could be
extubated. Liquemin therapy was continued with 15,000IU/day
s.c. Another week later, the patient complained about a sudden
pain in his right foot accompanied by paleness and pulselessness.
The right foot was also significantly colder compared to the
left one and arterial Doppler revealed no blood flow in the
posterior tibial artery or in the arteria dorsalis pedis.
Suspecting an acute arterial embolism the patient was immediately admitted to the surgery department of our university hospital. Here the patient presented with additional tachycardia (110beats/min) and an S1Q3-type in the ECG. Initial lab values included high D-dimers of >27mg/l, thrombocytopenia of 58,000/µl, and a C-reactive protein of >24mg/l. Again, he was treated with 1000IU/h liquemin i.v. Magnetic resonance angiogram (MRA) showed multiple embolic closures of the great iliac and femoral arteries on both sides. Popliteal arteries were free of thrombi. He immediately underwent surgical embolectomy of the right leg. Control MRA showed free right external iliac and femoral arteries. However, there were new closures of popliteal arteries on the right and also on the left leg.
At this time a transthoracic echocardiogram was performed showing two huge thrombi: one in the right heart reaching from the liver veins through the inferior caval vein and further into the right atrium and the ventricle. The other thrombus reached from the left atrium to the left ventricle (Fig. 1a, Video 1). Immediately, he was admitted to our intensive care unit. Fifteen minutes later, a transesophageal echocardiogram was performed and now no right-heart thrombus was seen, only a slow flow phenomenon in the right atrium. However, the huge thrombus in the left ventricle was documented on videotape and suddenly the thrombus appeared between the aortic valves (Fig. 1b Video 2) and finally embolized into the periphery (Fig. 1c). The left arm and leg presented with paleness and a sudden temperature difference compared to the right side. About 10min after this documented arterial embolism the patient had ventricular fibrillation and had to be defibrillated. At this moment we decided to treat the patient with alteplase (5mg/kgbodyweight) to recanalize the blocked arteries in the left arm and leg. Transthoracic control echocardiogram showed no residual thrombi in the heart but acute right heart failure with dilation of the right heart and paradoxical septum movements as a marker of acute major pulmonary embolism. The left arm warmed up again while the leg became increasingly colder. Together with the cardiac surgeon we decided to perform a second embolectomy. At this time the surgeon informed us that just today antibodies against heparin–platelet-factor-4-complex were found and an HIT II was diagnosed. Anticoagulation immediately was changed to hirudin. The patient was admitted to the operation room where the surgeon found a 20-cm long thrombus reaching from the left internal iliac artery to the superficial femoral artery (Fig. 2). Back on intensive care unit the patient was quickly extubated. When the patient recovered quickly, lab parameters such as thrombocytes normalized to >300,000/µl. Control transthoracal echocardiogram showed good LV function. Transesophageal echocardiogram revealed a patent foramen ovale (Fig. 3). The patient was released shortly later to a rehabilitation center in good health.
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Figure 1 (a) Transthoracal echocardiogram with two large thrombi in the right and left atrium and ventricle (arrows). Apical 4 chamber view. (b) Transesophageal echocardiogram with the thrombus (arrows) in the left ventricle embolizing through the aortic valve. (c) Transesophageal echocardiogram of the left ventricle after embolization through the aortic valve.
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Acknowledgements
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Dr. Maier is funded by the German Research Foundation (Deutsche
Forschungsgemeinschaft; DFG) through an Emmy Noether-grant (MA
1982/4-1).
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References
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- Konstantinides S., Geibel A., Kasper W., Olschewski M., Blumel 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]
- Maier L.S., Hermann H.P., Scholz K.H. Massive pulmonary embolism with large floating thrombus in the truncus of the pulmonary artery. Intensive Care Med (2001) 27:1674–1676.[CrossRef][Web of Science][Medline]
- Cohnheim J. Thrombose und Embolie: Vorlesung über allgemeine Pathologie (1877) vol. 1. Berlin, Germany: Hirschwald. p. 134.
- Weismann R.E., Tobin R.W. Arterial embolism occurring during systemic heparin therapy. Arch Surg (1958) 76:219–227.[Abstract/Free Full Text]
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Abstract
Introduction
