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European Journal of Echocardiography Advance Access originally published online on July 7, 2008
European Journal of Echocardiography 2008 9(6):824; doi:10.1093/ejechocard/jen186
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

Spontaneous left atrial thrombus during patent foramen ovale closure

Lucy Hudsmith*, Sara Thorne and Paul Clift

The Queen Elizabeth Hospital, Birmingham, UK

Received 16 March 2008; accepted after revision 25 May 2008; online publish-ahead-of-print 7 July 2008.

* Corresponding author: Tel: +44 121 627 2959. E-mail address: lucyhudsmith{at}hotmail.com


   Abstract
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A 52-year-old male smoker suffered a left-sided stroke. Bubble contrast echocardiography demonstrated an aneurysmal atrial septum and patent foramen ovale (PFO). The patient was referred for percutaneous closure of his PFO to reduce his risk of further stroke. Despite dual antiplatelet therapy and pre-procedural heparin, he developed a spontaneous thrombus during balloon sizing of the defect identified by transoesophageal echocardiography. The balloon was immediately withdrawn to the right side and removed. Periprocedural echocardiography using either transoesophageal or intracardiac echo is essential to monitor for this potential procedural complication of percutaneous PFO closure.

Keywords: Patent foramen ovale; Transoesphageal echocardiography; Stroke; Atrial septal aneurysm; Thrombus

A 52-year-old male smoker suffered a left-sided stroke. Bubble contrast echocardiography demonstrated an aneurysmal atrial septum and patent foramen ovale (PFO). The patient was referred for percutaneous closure of his PFO to reduce his risk of further stroke.

The patient received pre-procedural dual antiplatelet therapy.

Transoesphageal echocardiography showed an aneursymal atrial septum and flap-like PFO, good left ventricular function with no intracardiac thrombus, and no significant valvular lesion. After access and immediate heparinization (5000 units), the PFO was balloon-sized with a 24 mm AGA sizing balloon. Immediately after inflation, a strand-like thrombus was seen attached to the balloon on the left atrial side (Figure 1, see Supplementary data online, movie). The balloon was withdrawn across the interatrial septum to the venous side and removed (see Supplementary data online, Figure). The procedure was abandoned and the patient was fully anticoagulated with warfarin and aspirin. There were no new neurological findings. The patient is well to follow up, but has declined further intervention.


Figure 1
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  		Figure 1 Transoesphageal echocardiography

 
The association between PFO and stroke and the benefits of closure in patients with no other cardiovascular risk factors is known.1

This case illustrates the importance of the use of imaging techniques such as TOE during PFO closure and the potential serious risk of thrombus formation during the procedure.


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Supplementary data are available at European Journal of Echocardiography online.


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  1. Meier B. Closure of patent foramen ovale: technique, pitfalls, complications, and follow up. Heart (2005) 91:444–448.[Free Full Text]

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This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Supplementary Data
Right arrow All Versions of this Article:
9/6/824    most recent
jen186v1
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Right arrow Alert me if a correction is posted
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Right arrow Articles by Hudsmith, L.
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