Tromboembolismo pulmonar y embolia paradójica concomitante. A propósito de un caso

Although patent foramen ovale is a relatively common disease, the presence of paradoxical embolism is a rare clinical condition, representing less than 2% of arterial ischemias. We report the case of a 55-year-old male diagnosed with massive pulmonary embolism and paradoxical embolism in the right arm, secondary to patent foramen ovale. We also highlight some uncertainties in the diagnosis and treatment of patients with paradoxical embolism.     

Paradoxical embolism: a case]

We report a case of pulmonary embolism complicated by paradoxical embolism (which is rarely diagnosed in life). Foramen ovale patency is a relatively common condition and this, together with the presence of pulmonary embolism, increases the probability of paradoxical embolism.     

Paradoxical embolization of brachiocephalic and pulmonary arteries in a case of persistent foramen ovale: a case report

Paradoxical embolism is the result of systemic arterial embolism and pulmonary embolism. It indicates the presence of an intracardial defect in the area of the atrial or ventricular septum. The most frequent cause of an intracardiac defect associated with paradoxical embolism is a patent foramen ovale (PFO). In the case presented here, the symptoms, diagnostics and surgical therapy are discussed.     

Embolies coronaires secondaires à un thrombus adhérent de l’oreillette droite par un foramen ovale perméable

This observation relates to the discovery of native coronary paradoxical embolism secondary to thrombus adherent to the right atrium through a patent foramen ovale (PFO). A patient of 64 years, with a history of mitral regurgitation not followed, was hospitalized for acute respiratory distress due to a mitral insufficiency (MI) with a ruptured chordae and pulmonary embolism. Coronary angiography was performed and revealed two typical images of coronary embolism associated to a non-atheromatous coronary tree. The patient underwent a mitral valve replacement. After the establishment of cardiopulmonary bypass, adherent fibrin and cruoric thrombus of the right atrium and a PFO were found. The analysis of the valves did not reveal any arguments for infective endocarditis. A CT scan, performed as the patient remained unconscious after surgery, showed several cerebral infarcts. Paradoxical embolism coronary was diagnosed in front of the combination of adherent thrombus in the right atrium, pulmonary embolism and systemic coronary and cerebral embolism with a PFO. Coronary embolism rarely happens. It is mainly due to three causes: iatrogenic origin in most cases, direct causes due to micro emboli, particularly from infectious endocarditis and paradoxical embolic origin. There are two types of right atrial thrombus; the most common is the mobile thrombus from the peripheral venous system. The other one, which is more rare, is the adherent thrombus, which occurs in situ. Coronary embolism of paradoxical origin represents a small proportion of the causes of coronary embolism. However, this diagnosis must be considered.     

Pulmonary embolism and paradoxical embolism in a patient with chronic respiratory insufficiency treated with mechanical ventilation

The authors report a case of paradoxical embolism associated with pulmonary embolism in a male patient under mechanical ventilation for chronic respiratory failure. They review the present diagnostic criteria of paradoxical embolism and insist on the determinant contribution of contrast echocardiography to the diagnosis. They also discuss the factors which make this type of patient liable to reopening of the foramen ovale and to paradoxical embolism. The clinical and gasometric characteristics of pulmonary embolism occurring in patients under mechanical ventilation are detailed.     

Patent foramen ovale in cryptogenic stroke: current understanding and management options

There is increasing interest in the association between patent foramen ovale (PFO) and documented stroke of unknown cause, commonly referred to as cryptogenic stroke. We reviewed the literature and, on the basis of the available data, designed a diagnostic and treatment algorithm for patients with PFO and cryptogenic stroke. Patent foramen ovale is relatively common in the general population, but its prevalence is higher in patients with cryptogenic stroke. Importantly, paradoxical embolism through a PFO should be strongly considered in young patients with cryptogenic stroke. There is no consensus on the optimal management strategy, but treatment options include antiplatelet agents, warfarin sodium, percutaneous device closure, and surgical closure. High-risk features in the patient's history (ie, temporal association between Valsalva-inducing maneuvers and stroke, coexisting hypercoagulable state, recurrent strokes, and PFO with large opening, large right-to-left shunt, or right-to-left shunting at rest, and a coexisting atrial septal aneurysm) should prompt PFO closure.     

矛盾性栓塞八例临床分析

目的提高对矛盾性栓塞的认识，减少误诊和漏诊。方法采用病例分析和文献复习的方法。结果本组8例肺栓塞合并矛盾性栓塞患者，男性6例、女性2例；平均年龄为47．6岁。3例发生脑血管栓塞，2例为肾动脉栓塞，左心房血栓、下肢动脉和主动脉栓塞各1例；3例发现卵圆孔开放合并右向左分流。确诊矛盾性栓塞是发现嵌顿于动静脉交通处的栓子，其余皆为临床诊断。本组矛盾性栓塞诊断，7例为临床诊断，1例为确诊。结论矛盾性栓塞并非少见，应加强诊断意识。对于静脉血栓栓塞症合并体循环动脉栓塞或不明原因的体循环动脉栓塞应考虑到矛盾性栓塞可能。     

Paradoxical Embolism

Paradoxical embolism is an important clinical entity among patients with venous thromboembolism in the presence of intracardiac or pulmonary shunts. The clinical presentation is diverse and potentially life-threatening. Although the serious nature and complications of paradoxical embolism are recognized, the disease entity is still rarely considered and remains under-reported. This paper provides an overview on the different clinical manifestations of paradoxical embolism, describes the diagnostic tools for the detection of intracardiac and pulmonary shunts, reviews therapeutic options, and summarizes guideline recommendations for the secondary prevention of paradoxical embolism.     

Eustachian valve,interatrial shunt,and paradoxical embolism

Randomized clinical trials demonstrate that percutaneous closure of the patent oval foramen is a safe and effective treatment for secondary prevention of cryptogenic stroke in selected patients. The Eustachian valve is generally considered an incidental finding without any significant pathophysiological consequences in adults. However, a persistent Eustachian valve, particularly a prominent one, is significantly more prevalent in patients with patent oval foramen and cryptogenic stroke, and is associated with adverse outcomes following percutaneous closure. Therefore, the Eustachian valve may not be an incidental finding or an innocent bystander. By directing the blood flow from the inferior caval vein to the interatrial septum, the persistence of a Eustachian valve may prevent spontaneous closure of the oval foramen, and predispose to paradoxical embolism during adulthood. The Eustachian valve should be considered an adjunctive risk factor for paradoxical embolism in patients with patent oval foramen. Furthermore, the Eustachian valve has been included in several risk prediction models to identify patients at the highest risk of paradoxical embolism and such patients may benefit the most from an intervention.     

Cine angiographic diagnosis of patent foramen ovale in paradoxical embolism

A case of paradoxical embolism is presented in which the antemortem diagnosis was facilitated by a new simple angiographic technique that demonstrated a patent foramen ovale. An additional 14 patients were studied by this technique, and one had a patent foramen ovale. The mechanism of reversal of the normal intraatrial pressure gradient and subsequent right to left shunt through a patent foramen ovale is discussed. This angiographic technique may be readily applied in any diagnostic catheterization laboratory and complements existing methods for detecting patency of the foramen ovale in patients with suspected paradoxical embolism.     

Kussmaul's paradoxical pulse. Etiopathogenic aspects

Paradoxical pulse (reduction in systolic blood pressure during inspiration) is a sign common to many pathological conditions affecting the heart and lungs. The aim of this paper was to determine its mechanism on the basis of recent publications in the literature, supported by personal clinical cases. Three cases of pulmonary embolism with paradoxical pulses of over 30 mm Hg are reported. In all three cases, cardiac and pulmonary function were normal before the embolism. The significant findings were a marked elevation in inspiratory transmural RA pressure (average 10 mm Hg), contrasting in one case with normal LV inspiratory transmural pressures. Two factors seem to play a role in the genesis of a paradoxical pulse: firstly, increased left ventricular afterload due to negative intrathoracic pressure during inspiration, and, secondly, a reduction of left ventricular compliance during inspiration related to mechanical interference between the two ventricles. In the absence of increased central venous pressure, increased left ventricular afterload probably plays the major role in the inspiratory reduction of peak systolic pressure (e.g. "physiological" paradoxical pulse, hypovolaemia, asthma). On the other hand, when central venous pressure is increased, the phenomenon of mechanical interference related to improved right ventricular filling during inspiration, added to increased left ventricular afterload, may result in very considerable paradoxical pulses (e.g. pulmonary embolism, cf. the cases reported: paradoxical pulses of over 30 mm Hg). Finally, certain pathological entities are associated with the greater role of mechanical interference (e.g. tamponade, constrictive pericarditis) for the principal causes, especially pulmonary embolism and pericardial effusion.     

Characteristics of adult patients with atrial septal defects presenting with paradoxical embolism

Background : The association between patent foramen ovale (PFO), atrial septal aneurysm, and cryptogenic stroke due to paradoxical embolism has been established. The correlation between atrial septal defect (ASD) in adults and paradoxical embolism is less well defined. Methods : We examined our single center experience with 329 adult patients undergoing percutaneous device closure of interatrial communication defects to identify clinical and morphologic differences among adult patients with ASDs who presented with or without paradoxical embolism. Comparison was made with patients with PFO. Results : Although a significant left‐to‐right shunt was the predominant indication for ASD closure, 20 patients (14%) presented with a paradoxical embolism. These patients tended to be younger and had smaller defects (both by size and shunt ratio) than ASD patients without paradoxical embolism, and were more likely to be female than PFO patients. Conclusions : The incidence of adult patients with ASD who presented with paradoxical embolism is higher than expected and suggests that this diagnosis should be considered in patients with cryptogenic stroke. © 2009 Wiley‐Liss, Inc.     

Paradoxical Peripheral Embolism – a Rare and Underestimated Event

We present a case of paradoxical peripheral embolism related to a patent foramen ovale (PFO) in a young female with clinical signs of pulmonary embolism and simultaneous left hand acute ischaemia. A PFO associated with a right-to-left pressure gradient was revealed by trans-oesophageal echocardiography. She underwent a successful bilateral brachial thrombo-embolectomy with cerebral protection by clamping of the right common carotid and simultaneous proximal right common carotid thrombo-embolectomy, according to prior angiographic study. Paradoxical embolism is still rarely considered as a possible cause of acute limb ischaemia and may be underestimated.     

Paradoxical embolism. Diagnosis during life

Of 128 reported cases of paradoxical embolism, only twelve have been diagnosed during life. However, five cases of paradoxical embolism have been detected during life at this hospital in two years. These five cases are presented to illustrate the pathophysiologic features that allow detection of paradoxical embolism during life.     

Exclusion of patients with arteriosclerosis reduces long-term recurrence rate of presumed arterial embolism after PFO closure

BACKGROUND: Percutaneous transcatheter closure of patent interatrial communications after presumed paradoxical embolism is used as an alternative to surgery or long-term anticoagulation for the treatment of patients who are at risk for recurrent thromboembolism. To avoid atherosclerotic events to be judged as recurrent paradoxical embolism, we prospectively excluded all patients with detectable arteriosclerosis from our series and investigated long-term results. METHODS AND RESULTS: We report the outcome of 180 patients who underwent percutaneous transcatheter closure of patent foramen ovale (PFO), PFO like atrial septal defect (ASD), or an ASD because of paradoxical embolism. One hundred four patients had cerebral embolism, 57 had transient ischemic attacks, 16 coronary embolism, and 3 had peripheral embolism. Twenty-three patients experienced multilocal arterial embolism. One hundred twenty-five patients had a PFO, 63 of them with an atrial septal aneurysm (ASA), 24 a PFO-like ASD (7 of them with an ASA), and 31 had an ASD. After 18 months, only 5 patients (2.8%) showed a trivial residual shunt. At a mean follow-up of 40 months (range 4 to 88), resulting in 602 observed patient-years, only 1 patient experienced a presumed paradoxical (coronary) embolism (calculated annual risk to suffer a recurrent thromboembolic event: 0.16%). CONCLUSIONS: Percutaneous transcatheter closure of PFO/ASD is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. It is associated with a high success rate, low incidence of hospital complications, and very low frequency of recurrent systemic embolic events.     

Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature

Patent foramen ovale (PFO) is the most common type of inter‐atrial shunt, with prevalence as high as 30%. Detection of PFO has implications in patients with stroke, peripheral embolism, decompression illness, and other conditions. Transesophageal echo (TEE) with saline contrast injection is the current standard for PFO detection, but even with TEE, PFOs are sometimes missed. With advances in percutaneous PFO closure therapies and proven long‐term benefit of closure, accurate PFO detection takes on cardinal importance. Various provocative maneuvers to enhance PFO detection are in clinical use and have been studied. The Valsalva maneuver has long‐held position as the ideal provocation to unmask PFO, but other maneuvers such as cough, sniff, Müller's, and more have gained relevance. In this article, we will examine various maneuvers and discuss their utility in PFO detection.     

Paradoxical embolism to the superior mesenteric artery

Paradoxical embolism occurs when venous thrombi embolize into the systemic arterial circulation by passage of clots through an intracardiac septal defect. This paper describes a case of paradoxical embolism to the superior mesenteric artery in a patient with recent myocardial infarction and pulmonary embolism. This phenomenon was first described in 1877 (Cohnheim, 1877) and many case reports have followed but most of these have been autopsy findings. We emphasize that this diagnosis should be suspected in all patients who suffer systemic arterial emboli without any evidence of left heart origin and/or in association with pulmonary emboli. One author has reviewed 19 cases since 1930, most of which were reported in the past 15 years (Johnson, 1951). This probably reflects an increased awareness of the diagnosis and more sophisticated diagnostic modalities. It also raises the possibility that paradoxical embolism may be more common than originally believed.     

Patent foramen ovale closure in non-lacunar cryptogenic ischemic stroke:where are we now?

Patent foram ovale(PFO)is the most common anatomical cause of an interarterial shunt.It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults.Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment,six subsequent randomized clinical trials(CLOSURE I,PC Trial,RESPECT,CLOSE,REDUCE,and DEFENSE-PFO)performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure.However,the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO,but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt,an atrial septal aneurysm and no evidence of atrial fibrillation,as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.     

Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience

BACKGROUND: Patients with a patent foramen ovale (PFO) after cerebral, coronary, or systemic embolic events of presumed paradoxical origin are at risk for recurrent thromboembolism. We report our single-center experience of interventional closure of interatrial communications for secondary prevention of presumed paradoxical embolism. Methods and Results- Since 1997, percutaneous closure of interatrial communications was performed at our institution in 66 patients (mean age 47.8+/-12.7 years; 31 males) with a PFO or an atrial septal defect and at least 1 documented presumed paradoxical thromboembolic event. Fifty-eight patients had cerebral embolism, 10 had coronary embolism, and 3 had peripheral embolism. Several patients experienced multilocal arterial embolism. Fifty-four patients had a PFO, 33 of them with an atrial septal aneurysm, and 12 had an atrial septal defect. The implantation procedure was successful and without complication in all patients. After 3 months, only 2 patients showed a residual shunt, which disappeared in both cases after 12 months. In 112.2 patient-years of follow-up (range, 5 weeks to 3.5 years), we have not seen any recurrent thromboembolic event. CONCLUSIONS: Interventional closure of interatrial communications is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. To further evaluate this strategy, randomized trials comparing interventional closure with anticoagulation have been initiated by us and others.     

肺动静脉瘘致反常脑栓塞一例

肺动静脉瘘(PAVF)是一种绕过肺毛细血管直接将肺循环与体循环连接起来的血管畸形,可单发或多发,下叶较上、中叶多见,其主要临床症状包括劳累后呼吸困难、发绀、咯血、栓塞等,可通过胸部X线、胸部CT、胸部CT血管成像(CTA)诊断。PAVF导致的反常性栓塞卒中通常伴有遗传性出血性毛细血管扩张症(HHT),引起反常脑栓塞的不伴有遗传性出血性毛细血管扩张症的单纯性肺动静脉瘘较少见。作者报道1例不伴HHT的单纯PAVF导致的反常性脑栓塞患者,该患者因突发右上肢无力且病情逐渐进展入院,MRI提示脑梗死,为查明栓子来源及确定治疗方案,对患者完善发泡实验及肺动脉CTA,结果显示为少见的单纯PAVF,治疗上行肺动脉封堵术并抗凝治疗后好转出院,提示当临床医师未明确栓子来源时,应将PAVF考虑在内。