European Journal of Echocardiography 2008 9(1):155; doi:10.1016/j.euje.2007.05.003
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
A dumbbell thrombus entrapped in patent foramen ovale
Kamran Aghasadeghi and
Reza Mollazadeh*
Cardiology Department, Nemazee Hospital, University of Medical Science, Zand Avenue, Shiraz, P.O. Box 71435-1414, Islamic Republic of Iran
Received 10 April 2007; accepted after revision 4 May 2007; online publish-ahead-of-print 9 July 2007.
* Corresponding author. Tel: +98 (0)917 313 3749; fax: +98 (0)711 6261089. E-mail address: mollazar{at}yahoo.com
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Abstract
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A 75-year-old lady came to emergency room due to dizziness and
presyncopal attacks during exertion since two days prior to
admission. Transesophageal echocardiography revealed a thrombus
like mass in right atrium traversing patent foramen ovale and
extending to left atrium. Spiral chest CT scan showed bilateral
pulmonary thromboemboli. Operative and pathological findings
confirmed the diagnosis.
Keywords: Pulmonary; Emboli; Paradoxical; Foramen ovale
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Case Presentation
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A 75-year-old lady came to emergency room due to dizziness and
presyncopal attacks during exertion since two days prior to
admission. Her past medical history was insignificant except
for 40 packs/year cigarette smoking and decrease in her physical
activity due to knee pain recently. Her physical examination
was unremarkable. Electrocardiographic findings were sinus tachycardia,
T wave inversion in V1–V3, ST segment elevation in aVR
and S1Q3T3 pattern. Transthoracic echocardiography showed a
mass in right atrium with right atrial and ventricular dilatation.
For better delineation, transesophageal echocardiography was
performed which showed thrombus like mass in right atrium traversing
patent foramen ovale and extending to left atrium (Video clip 1,
Figure 1) with both right and left atrial extensions completely
mobile. Spiral chest CT scan showed bilateral pulmonary thromboemboli.
Immediately she was taken to operating room and a 20 cm thrombus
was found and was excised. Pulmonary embolectomy was performed
thereafter. Her postoperative course was uneventful and she
was discharged one week later.
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Figure 1 Transesophageal echocardiography in high esophageal position in horizontal plane shows a large thrombus (arrow) entrapped in patent foramen ovale (arrow head) with its extensions in right and left atrium. LA, left atrium; Ao, aorta; RA, right atrium.
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Thrombus entrapped in patent foramen ovale is a rare form of
right heart and paradoxical thromboembolism, and our knowledge
is derived from reported cases.
1 This is unique in which an
embolic substrate originating from the venous system is entrapped
in an intracardiac shunt; patent foramen ovale is the most common
such conduit. Pulmonary embolism accompanies most cases of impending
paradoxical embolism. Transesophageal echocardiography is an
available, safe and informative tool for delineation of thrombus
extension. Without treatment this condition has a high mortality
rate. A review recommended initial systemic heparinization,
followed by emergent surgical embolectomy when the surgical
risk is acceptable.
2
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Supplementary material
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Supplementary data associated with this article can be found in the online version.
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References
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- Aggarwal K, Jayam VK, Meyer MA, Nayak AK, Nathan S. Thrombus-in-transit and paradoxical embolism. J Am Soc Echocardiogr (2002) 15:1021–2.[CrossRef][Web of Science][Medline]
- Chow BJ, Johnson CB, Turek M, Burwash IG. Impending paradoxical embolus: a case report and review of the literature. Can J Cardiol (2003) 19:1426–32.[Web of Science][Medline]
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Abstract
Case Presentation