European Journal of Echocardiography Advance Access originally published online on February 19, 2008
European Journal of Echocardiography 2008 9(5):692-693; doi:10.1093/ejechocard/jen013
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Caught in the act: entrapped embolus through a patent foramen ovale
Department of Cardiology and Angiology Kcinik Koesching, Krankenhausstr 19, 85092 Koesching
Received 4 October 2007; accepted after revision 18 November 2007; online publish-ahead-of-print 19 February 2008.
* Corresponding author. Tel: 00498456; fax: 00498456. E-mail address: alexander.hansen{at}klinik-koesching.de
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Abstract |
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A patent foramen ovale (PFO) is detected frequently by transesophageal echocardiography. The diagnosis of paradoxical embolism is usually presumptive when arterial emboli occur in the appropriate clinical setting. Presumably, paradoxical embolism of small thrombi arise in the venous system and pass through the PFO during a transient right-to-left shunt; however, cases demonstrating a thrombus traversing the PFO are relatively few.
Keywords: Thrombus; Foramen ovale
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Case report |
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A 46-year-old healthy woman was admitted with the first episode of transitoric ischemic attack. The first cranial computed tomography showed no abnormal finding. The patient had sinus rhythm and a normal tranthoracic echocardiogram. A thrombus wedged across a patent foramen ovale (PFO) was revealed by transesophageal echocardiography (TEE) (Figure 1). A peripheral venous source for the clot could not be detected by ultrasound, however, a phlebography was not performed.
After systemic anticoagulation with heparin for 5 days, repeat TEE revealed a PFO with septal aneurysm with no residual thrombus (Figure 2). Dissolution of the thrombus had no sign of recurrent embolism. The PFO was finally occluded by transcatheter placement of an intracardiac occlusive device.
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Discussion |
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With the use of contrast-enhanced TEE, a right-to-left intracardiac shunt via a PFO is detected frequently during evaluation of patients with an ischemic stroke. Paradoxical embolism occurs following the passage of embolic material from the venous to the arterial circulation through a right to left shunt—frequently a PFO. The diagnosis is usually presumptive when arterial emboli occur in the appropriate clinical setting. Presumably, most of the neurologic symptoms are secondary to paradoxical embolism of small thrombi that arise in the venous system and pass through the PFO during a transient right-to-left shunt; however, cases demonstrating a thrombus traversing the PFO are relatively few.1,2 In our patient, TEE showed criteria for the diagnosis of paradoxical embolism: first a large intracardiac thrombus was seen in both the right and left sides of the heart. Second, the potential communication, a PFO with septal aneurysm, was shown by the transit of contrast agent between the atria during valsalve manoeuvre.
This patient was unusual because of the marked size and extent of the thrombus seen by TEE in the atrium and because of the demonstration of the propagation of the thrombus across a PFO.
The diagnosis of impending paradoxical embolus by echocardiography is exceptional and its management remains unclear. Surgical removal of the thrombus and septal closure has been postulated as an option. However, in our case, systemic anticoagulation with heparin for 5 days was safe to dissolve the thrombus without evidence of further peripheral embolism.
Conflict of interest: none declared
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References |
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- De Castro S, Cartoni D, Conti G, Beni S. Continuous monitoring by biplane transesophageal echocardiography of pulmonary and paradoxical embolism. J Am Soc Echocardiogr. (1995) 8:217–20.[CrossRef][Medline]
- Mathew TC, Ramsaran EK, Aragam JR. Impending paradoxic embolism in acute pulmonary embolism: diagnosis by transesophageal echocardiography and treatment by emergent surgery. Am Heart J. (1995) 129:826–7.[CrossRef][Web of Science][Medline]
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