European Journal of Echocardiography 2007 8(3):223-226; doi:10.1016/j.euje.2006.01.004
Copyright © 2006, The European Society of Cardiology
Momentarily stuck in the foramen ovale
Maxime Roussellea,
Pierre-Vladimir Ennezata,*,
Jean-Marc Auberta,
Julie Darchisa,
Xavier Gonina,
Daniel Lenicaa,
Jean-Jacques Baucharta,
Jean-Luc Auffraya,
Virginia Gaxottea,
Thierry H. LeJemtelc,
Patrick Goldsteinb and
Philippe Assemana
aCardiology Hospital, Lille, France
bEmergency Department, University Hospital, Lille, France
cTulane Medical School of Medicine, New Orleans, LA, USA
Received 25 October 2005; received in revised form 20 January 2006; accepted after revision 29 January 2006.
* Corresponding author. Cardiology Hospital, Bd Pr J. Leclercq, 59000 Lille, France. Tel.: +33 03 20 44 53 30; fax: +33 03 20 44 65 04. ennezat{at}yahoo.com
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Abstract
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An 80-year-old woman was admitted for a diagnosis of severe
pulmonary embolism. A large serpentine thrombus stuck in a patent
foramen ovale (PFO) completely resolved without the patient
experiencing any manifestation. The right renal artery was the
final destination. Thromboaspiration was unsuccessful. Three
months later, the patient was diagnosed with a malignant melanoma
and metastatic dissemination.
Keywords: Patent foramen ovale; Pulmonary embolism; Paradoxical renal embolism; Vascular ultrasound imaging
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Introduction
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The thrombus is rarely caught passing through the patent foramen
ovale (PFO) in the event of a paradoxical embolism: nearly 40
cases have been described in the literature and only one case
documenting the serial passage of a thrombus across a PFO in
real time.
1 We report the hospital course of a patient who,
hospitalized for massive pulmonary embolism, was found to have
a large thrombus stuck in the patent foramen ovale. The thrombus
was resolved without surgical intervention. A complete vascular
work up revealed a right renal artery occlusion that was clinically
silent.
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Case report
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An 80-year-old woman was hospitalized for increasing shortness
of breath of 48h duration. She had no past medical history and
risk factors for thrombosis. At admission, blood pressure was
110/60mmHg. Heart and respiration rate were 105 and 32 per minute,
respectively. Oxygen saturation was 90%. Physical examination
revealed clear lungs, spontaneous jugular venous distension
and a loud P
2 at cardiac auscultation. Anticoagulation with
heparin was started. Lung spiral CT scan confirmed a massive
bilateral pulmonary embolism (
Fig. 1). Lower limbs Doppler ultrasound
revealed left femoral vein thrombosis. The presence of a large
thrombus stuck in the patent foramen ovale suspected by transthoracic
echocardiography was confirmed by transesophageal echocardiography
(
Fig. 2). Right ventricular systolic pressure was estimated
at 62mmHg and the right ventricle was dilated and hypokinetic.
A repeat transthoracic echocardiogram performed one hour later
while the patient was awaiting surgical removal of the patent
foramen ovale thrombus, revealed that it had completely resolved
without the patient experiencing any manifestation suggesting
a peripheral embolism. A thorough vascular arterial ultrasound
examination disclosed complete occlusion of the right renal
artery that was confirmed by abdominal CT scan and renal angiography
(
Fig. 3). Thromboaspiration of the renal thrombus was unsuccessful.
The patient recovered with unfractionated heparin treatment.
A transient mild renal failure was managed with hydration. The
patient declined percutaneous closure of the patent foramen
ovale. Three months later, she was diagnosed with a malignant
melanoma and metastatic dissemination.
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Discussion
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Paradoxical embolism is a rare etiology of acute renal arterial
occlusion. Most frequent causes of occlusion of renal artery
are complications of atherosclerosis, atrial fibrillation and
aortic dissection. Venous thrombi from the limbs passing across
a patent foramen ovale cause arterial events, mainly strokes.
The diagnosis of paradoxical embolism is usually presumed on the following triad: (1) presence of a thrombus in the venous system, (2) clinical, angiographic or pathologic evidence of systemic embolization in the absence of other sources of emboli, (3) demonstration of an abnormal communication between the right and the left circulations (atrial septal defect, patent foramen ovale and persistent eustachian valve).2 Transthoracic or transesophageal echocardiography, and transcranial Doppler using peripheral injection of agitated saline or galactose contrast agent and Valsalva maneuver have emerged as the main tools for diagnosis and assessment of patent foramen ovale.3–4 In our case, the documentation of the transit of the thrombus across the patent foramen ovale directly made the diagnosis of paradoxical embolism. Patent foramen ovale is just an innocent passive conduit in absence of the coexistence of a venous thrombus. However, it exposes to a risk of paradoxical embolism during the whole life.5
The overall early mortality of the reported cases is high. However, therapeutic implications of such entrapped embolus through a patent foramen ovale remain controversial. Thrombolysis has already been attempted with variable results as well as cardiac surgery.6 Nevertheless, when surgical removal seems too hazardous, as in elderly patients, heparin treatment with echocardiographic monitoring has been suggested.7
The symptoms of peripheral embolism are often so minor and non specific (transient abdominal discomfort, leg cramp) that the diagnosis is often missed. Only about 2% of the patients with cardiogenic brain embolism have clinically recognized peripheral emboli.8 A thorough vascular examination is needed before stating that the thrombus resolved without sequellae.
In conclusion, the present case shows that paradoxical embolism may be underestimated, and illustrates that it may be the first presenting sign of malignancy. The presence of a hypercoagulable disorder associated or not with malignancy should be searched in every case of paradoxical embolism.9
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References
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- Thanigaraj S., Zajarias A., Valika A., Lasala J., Perez J.E. Caught in the act: serial, real time images of a thrombus traversing from the right to left atrium across a patent foramen ovale. Eur J Echocardiogr (2005 Jun 28) [Epub ahead of print].
- 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 March) 17:231–233.[CrossRef][ISI][Medline]
- Uzuner N., Horner S., Pichler G., Svetina D., Niederkom K. Right-to-left shunt assessed by contrast transcranial Doppler sonography: new insights. J Ultrasound Med (2004 Nov) 23:1475–1482.[Abstract/Free Full Text]
- Clarke N.R., Timperley J., Kelion A.D., Banning A.P. Transthoracic echocardiography using second harmonic imaging with Valsalva manoeuvre for the detection of right to left shunts. Eur J Echocardiogr (2004 Jun) 5:176–181.[Abstract/Free Full Text]
- Bogousslavsky J., Garazi S., Jeanrenaud X., Aebischer N., Van Melle G. Stroke recurrence in patients with patent foramen ovale: The Lausanne Study. Neurology (1996) 46:1301–1305. for the Lausanne Stroke with Paradoxal Embolism Study Group.[Abstract/Free Full Text]
- Maroto L.C., Molina L., Carrascal Y., Rufilanchas J.J. Intracardiac thrombus trapped in a patent foramen ovale. Eur J Cardiothorac Surg (1997) 12:807–810.[Abstract]
- Aboyans V., Lacroix P., Ostyn E., Cornu E., Laskar M. Diagnosis and management of entrapped embolus through a patent foramen ovale. Eur J Cardiothorac Surg (1998) 14:624–628.[Abstract/Free Full Text]
- Mohr J.P., Caplan L.R., Melski J.W., Goldstein R.J., Duncan G.W., Kistler J.P., et al. The Harvard Cooperative Stroke registry: a prospective study. Neurology (1978) 28:754–762.[Abstract/Free Full Text]
- Monreal M., Casals A., Boix J., Olazabal A., Moutserrat E., Mundo M.R. Occult cancer in patients with acute pulmonary embolism. A prospective study. Chest (1993) 103:816.[CrossRef][ISI][Medline]
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Abstract
Introduction
