Two cases of complications of the thrombolysis of right heart free-floating thrombi with pulmonary embolism: important role of echocardiographically based management

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely.     

Paradoxical embolism to the left main coronary artery: visualization by transesophageal echocardiography.

A case of myocardial infarction is described with transesophageal echocardiography visualization of left main coronary artery thrombus arising from paradoxical embolism of mobile venous thrombus by patent foramen ovale.     

The role of echocardiography and venous ultrasonography in the diagnosis of acute pulmonary thromboembolism

Patients with pulmonary embolism (PE) are undergoing echocardiography and venous ultrasonography with increasing frequency. Echocardiography is ideal because it is readily available and is useful for the differential diagnosis in hemodynamically unstable patients. Although predominantly employed to characterize RV pressure overload, echocardiography may detect right heart thrombus or may provide alternative diagnosis. Echocardiography also is useful in assessing the prognosis of patients as well as their response to therapy. Right ventricular hypokinesis, a patent foramen ovale, and right heart thrombus are markers identifying patients at risk for death. PE and deep vein thrombosis are different clinical manifestations of a common disease entity. Venous ultrasonography may reduce pulmonary angiography in patients with non-diagnostic lung scan.     

Impending paradoxical embolus: Clinical imaging and successful surgical treatment

In a patient with pulmonary emboli, transesophageal echocardiography showed a thrombus straddling the foramen ovale (impending paradoxical embolism). Proximal pulmonary emboli were visualized by spiral computed tomography and subsequent surgical treatment, consisting of removal of intracardiac clot, closure of the open foramen ovale and pulmonary embolectomy, was successful.     

End-inspiratory occlusion maneuver during transesophageal echocardiography for patent foramen ovale detection in intensive care unit patients

Objective Mechanically ventilated patients in the intensive care unit cannot cooperate to perform the Valsalva maneuver during echocardiography for detection of patent foramen ovale. We evaluated the effectiveness of the end-inspiratory occlusion maneuver to enhance detection of patent foramen ovale in this patient population. Design Prospective interventional study. Setting The 40-bed intensive care unit of a university hospital. Patients and participants Twenty five sedated and mechanically ventilated intensive care unit patients referred by their attending physician for bedside transesophageal echocardiography and agitated saline contrast study for detection of patent foramen ovale. Intervention Agitated saline contrast study with end-inspiratory occlusion maneuver. Measurements and results All patients underwent a complete transesophageal echocardiographic study without any complications. Reduction in right atrial cross-sectional area (from 15.80 ± 6.08 cm² to 12.40 ± 4.63 cm²; p < 0.001) and interatrial septum deviation during the maneuver were recorded in all patients. Microbubbles imaged in the left atrium within three cardiac cycles after injection of agitated saline diagnosed patent foramen ovale in three patients. When end-inspiratory occlusion maneuver was added, patent foramen ovale was diagnosed in seven patients (McNemar χ² = 9.33, p = 0.0023). Conclusions The end-inspiratory occlusion maneuver enhances the sensitivity of transesophageal echocardiography with agitated saline contrast study for diagnosing intermittent patent foramen ovale in critically ill mechanically ventilated patients. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Patent foramen ovale as lifesaving purging valve.

Patent foramen ovale is considered as a potential risk factor for stroke owing to paradoxic embolism, leading to the question "to close or not to close the patent foramen ovale". We report a 26-year-old woman with chest pain, dyspnoea, sudden severe pain in both legs and paraplegia. Thoracic and abdominal computed tomography revealed massive pulmonary embolism and complete obstruction of the abdominal aorta. Interventional removal of the aortic thrombus was undertaken using the Fogarty catheter technique via the femoral arterial approach. As a result of worsening of cardiopulmonary function during the procedure, additional local thrombolysis, with a total of 50 mg recombinant tissue plasminogen activator, and fragmentation of the thrombus in the right pulmonary artery were performed via a femoral vein approach. Ultrasound studies revealed a patent foramen ovale of about 12 mm diameter with a significant right to left shunt. Under favourable conditions, a patent foramen ovale may allow the escape of a thrombus, sufficient to cause a potentially fatal pulmonary embolism, into the arterial system, where it can be removed by interventional manoeuvres.     

Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiography

We describe a patient with a paradoxical coronary embolism diagnosed by transesophageal echocardiography. The patient developed a stroke followed by a myocardial infarction. Coronary angiography showed an obstruction of the left main coronary artery. Transesophageal echocardiography showed the mechanism of the neurologic and cardiac events to be a paradoxical embolism. Emergency surgical retrieval of the thrombus lodged in the left main coronary ostium and of a separate thrombus traversing a patent foramen ovale was performed. To our knowledge, direct visualization of the paradoxical coronary embolism by echocardiography has not been reported previously. We discuss mechanisms responsible for paradoxical coronary embolism and review the literature pertaining to this condition.     

Thrombus-in-transit and paradoxical embolism.

Paradoxical embolism is an uncommon but clinically important phenomenon. Elements of diagnosis include the presence of: (1) a venous thrombus, (2) an arterial embolus, (3) a communication between the right and left heart, and (4) a thrombus traversing such a communication. Unfortunately, all of these elements can be rarely demonstrated in each case but the probability should be considered in any patient with 2 or more present. It should be suspected in patients who have evidence of systemic arterial emboli without apparent cause. A transesophageal echocardiogram with contrast should be considered in cases where paradoxical embolism is a possibility. We present a case in which a "thrombus-in-transit" was imaged across the interatrial septum in a patient with a patent foramen ovale, deep venous thrombosis, and an embolic cerebrovascular stroke.     

Recurrent transient ischemic attacks in a patient with intrapulmonary arteriovenous shunting detected after closure of a patent foramen ovale.

Paradoxical embolism through right-to-left shunts is widely accepted as a potential cause of cerebral ischemia. Contrast echocardiography is an excellent tool for detection of these shunts. The timing of the appearance of bubbles in the left atrium (ie, early vs late) allows differentiation of foramen ovale patency from intrapulmonary shunting as a result of arteriovenous malformations. We report a patient with recurrent neurologic deficit after surgical closure of a patent foramen ovale. Transesophageal echocardiography demonstrated residual right-to-left shunting from previously unrecognized pulmonary arteriovenous malformations associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu). This case illustrates the fact that contrast echocardiography may fail to identify intrapulmonary shunts when a resting patent foramen ovale coexists.     

Paradoxical embolism-report of a case involving four organ systems

Paradoxical embolism through a patent foramen ovale (PFO) can involve multiple organs simultaneously. The most commonly involved sites are the cerebrum and the extremities. Paradoxical embolism to coronary arteries or upper extremities is relatively uncommon. We report a case of acute pulmonary embolism and paradoxical embolism through a patent foramen ovale involving the left upper extremity, brain, and coronary artery. Early diagnosis in the emergency department was made by a trans-esophageal echocardiogram, and the patient was successfully treated with intravenous t-PA and heparin. Patients with acute pulmonary embolism or deep venous thrombosis who also develop signs of systemic embolism should be evaluated for a patent foramen ovale.     

Embolic occlusion of a patent foramen ovale: a cause of false negative contrast echocardiogram.

A 74-year-old man who had dyspnea and cyanosis demonstrated venous thrombosis and multiple lung ventilation-perfusion mismatches suggesting pulmonary emboli. Transthoracic echocardiography demonstrated a right atrial mass and a microbubble contrast study did not reveal right-to-left shunt. Transesophageal echocardiography revealed an embolus entrapped in the foramen ovale projecting into the left atrium that was subsequently removed. Embolic occlusion of patent foramen ovale is an important cause of false negative microbubble contrast study.     

Intra-atrial thrombus after surgical closure of patent foramen ovale.

Patent foramen ovale (PFO) represents a potential path for paradoxical embolism and is associated with cryptogenic stroke. It has been suggested that because a PFO represents a repairable lesion (by surgical or transcatheter methods), repair may be the optimal treatment to prevent recurrent stroke. This report describes a patient with recurrent neurologic and peripheral embolic events, which occurred approximately 6 months after the surgical closure of a PFO. The diagnosis of an intra-atrial thrombus with a small residual PFO was made by subsequent transesophageal echocardiography. Thrombus formation at the closure site needs to be considered in a patient with recurrent embolic events after closure of a PFO.     

Differential diagnosis between patent foramen ovale and pulmonary arteriovenous fistula in two patients with previous cryptogenic stroke caused by presumed paradoxical embolism.

Development of improved devices for interventional closure of atrial septal defect and patent foramen ovale increased the number of adult patients who are being referred for transcatheter closure. We report two cases that were scheduled for patent foramen ovale closure because of a right-to-left atrial shunt detected at contrast transesophageal echocardiography in another institution and that were found to have pulmonary arteriovenous fistulas. Embolization of pulmonary arteriovenous fistulas was carried out successfully by transcatheter technique.     

Detection of right atrial mass by echocardiography in pulmonary thromboembolism

An echodense mass in the right atrium was detected incidentally by two-dimensional echocardiography (ECHO) in a patient with clinical suggestions of cardiogenic shock. Autopsy revealed a cylindrical thrombus extending from the right atrium through a patent foramen ovale, and bilateral massive pulmonary thromboembolism (PTE). Pulmonary thromboembolism should be one of the differential diagnoses in patients with an echodense mass in the right heart.     

Major pulmonary embolism and hemodynamic stability from shunting through a patent foramen ovale

While the combination of a patent foramen ovale (PFO) and thromboembolic disease is thought to portend increased morbidity and mortality, PFO presence in the setting of major pulmonary embolism (PE) may serve as a means to rescue patients from immediate hemodynamic collapse and death. We present two patients with major pulmonary embolism and right-to-left shunting consistent with PFO as seen on transthoracic echocardiography. In the setting of major PE, PFO may prevent acute right ventricular failure by acting as a 'pop-off' valve, alleviating increased ventricular pressures; but concomitantly portend deleterious effects in the form of paradoxical embolism and intractable hypoxemia.     

Acute myocardial infarction caused by paradoxical coronary embolization in a patient with a patent foramen ovale

We describe the case of a young woman without cardiac risk factors who had an acute inferoapical myocardial infarction. Coronary angiographic appearance was consistent with thrombus in the distal left anterior descending coronary artery. A patent foramen ovale with moderate right-to-left shunting after the Valsalva maneuver was detected by contrast transesophageal echocardiography. No other cardioembolic source was identified. Paradoxical embolization through a patent foramen ovale is a rare phenomenon, which appeared to have resulted in myocardial infarction in this patient.     

Impending Paradoxical Embolism: A Case Report

Background

A thrombus straddling a patent foramen ovale (i.e., impending paradoxical embolism) is a very rare event. Most cases have been reported at autopsy only after finding a patent foramen ovale and arterial emboli. Patent foramen ovale in the population is common.

Objectives

The objective of this case report is to remind physicians that common presentations can have uncommon causes. Some of these uncommon causes are easy to find and may significantly change outcomes if treated early.

Case Report

We present the case of a dyspneic patient with concomitant pulmonary embolism, deep vein thrombosis, and impending paradoxical embolism. Emergency Physicians should be aware that dyspnea may be the only initial symptom. Although dyspnea may be linked to a pulmonary embolus, it may not represent the entire clinical picture. A thrombus formed within a patent foramen ovale portends the possibility of a larger pulmonary embolus and an arterial embolus.

Conclusion

Early detection of an impending paradoxical embolism may result in an improved outcome. Treatment choices consist of anticoagulation, thrombectomy, or thrombolysis. Choice of treatment is difficult but should be made quickly to reduce the possibility of adverse patient outcomes.     

Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology?

A patent foramen ovale (PFO) is an embryological remnant found in 27% of adults. It is a potential right-to-left intracardiac shunt. Shunting may be the result of reversal in the interatrial pressure gradient or abnormal streaming of blood in the right atrium. The pathologic consequences of right-to-left shunting include hypoxemia and paradoxical embolism. PFO may exacerbate preexisting hypoxemia or be its primary cause. Paradoxical embolism through a PFO is well documented. Its role in cryptogenic stroke remains controversial. A PFO may be detected by both invasive and noninvasive techniques. Contrast transesophageal echocardiography with provocative maneuvers is the diagnostic method of choice allowing visualization of the shunt. Patients with cryptogenic stroke should be screened for a PFO. If detected, noninvasive studies for deep vein thrombosis are recommended. Treatment must be tailored to the presentation. Surgical or transcatheter closure is recommended for hypoxemia. Prevention of venous embolism (air or thrombus) with or without closure of the PFO is recommended for paradoxical embolism.     

Patent foramen ovale presenting as platypnea-orthodeoxia: diagnosis by transesophageal echocardiography.

Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale or atrial septal defect. We describe the case of a 65-year-old woman with progressive dyspnea and hypoxia when standing and walking, which was relieved by assuming the recumbent position. The diagnosis was confirmed by tilt-table transesophageal echocardiography demonstrating a large right-to-left shunt through a patent foramen ovale while the patient was in a semiupright position and no significant shunt while in a recumbent position. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be clearly demonstrated by the technique of contrast transesophageal echocardiography performed on a tilt table.     

Paradoxical brain embolism shadowing massive pulmonary embolism

Patent foramen ovale is frequently observed in the general population. In case of massive pulmonary embolism, the sudden increase in the right heart cavity's pressure may cause a right-to-left shunting across this foramen, which could be associated with conflicting outcomes. Herein, we report a case of reversible cardiac arrest preceded by seizures, and followed by hemodynamic stability without any vasopressor. A brain CT-scan showed a limited ischemic stroke. Initial echocardiographic assessment revealed an acute cor pulmonale and a right-to-left intracardiac shunt across a large patent foramen ovale, suggesting the diagnosis of massive pulmonary embolism that was lately confirmed by a multidetector CT-angiography. Anticoagulation therapy was rapidly complicated by a hemorrhagic transformation of the ischemic stroke leading to a fatal outcome. This case illustrates the double-edged circulatory effect of shunting across a patent foramen ovale in case of massive pulmonary embolism: it may have limited circulatory failure but caused in the meanwhile a fatal paradoxical brain embolism.