Impending Paradoxical Embolism

Meacham, Robert R.; Headley, A. Stacey; Bronze, Michael S.; Lewis, James B.; Rester, Michelle M.

doi:10.1001/archinte.158.5.438

Cited by 101 publications

(68 citation statements)

References 78 publications

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“…Paradoxical embolism can be considered proved only when the embolus is found located in the abnormal communication between venous and arterial circulation (the so-called impending paradoxical embolism). 16 Recent advances in the knowledge of prothrombotic disorders in children have demonstrated their relevant contribution in the pathogenesis of arterial ischemic events, venous thrombosis, and venous thrombo-embolism. [7][8][9] The prothrombin G20210A mutation has been shown to be associated with an increased risk of venous thrombosis.…”

Section: Discussionmentioning

confidence: 99%

Acute Myocardial Infarction in a Child: Possible Pathogenic Role of Patent Foramen Ovale Associated With Heritable Thrombophilia

Coppola

Agnetti²,

Hagler

et al. 2004

Pediatrics

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ABSTRACT. We report an 8-year-old girl who presented with clinical features of an acute myocardial infarction. The angiographic appearance of the coronary arteries was normal. A thrombophilic state caused by a homozygote genotype for the prothrombin G20210A mutation was detected, and a patent foramen ovale (PFO) with right-to-left shunting after Valsalva maneuver was demonstrated by transesophageal contrast echocardiography. No other embolic source was identified. We suggest that paradoxical embolization through a PFO resulted in a myocardial infarction in this young patient with hereditary thrombophilia. We closed the patient's PFO with a 25-mm PFO occluder. She was anticoagulated with warfarin for 6 months. S tudies of cryptogenic stroke in young patients have shown that the incidence of patent foramen ovale (PFO) is higher than in patients with established causes of stroke. [1][2][3][4][5] The suggested mechanism for a cerebrovascular event in patients with a PFO is based on a transient increase in right heart pressure, which would cause a transient right-to-left shunt through the PFO, with the possibility that a venous embolus could cross the PFO and embolize the cerebral circulation (paradoxical embolism). Paradoxical emboli could also reach other vascular beds, such as the coronary arteries, and cause acute myocardial infarction (MI). 6 Recent studies have shown that genetic or acquired prothrombotic disorders may represent risk factors for thromboembolic disease also in children. [7][8][9] We report a case of acute MI in an 8-year-old girl in whom, because of the presence of a PFO and inherited prothrombotic abnormality, after excluding all other possible causes, we presume that the MI had been caused by a paradoxical embolism. CASE REPORTSThis 8-year-old girl, who previously had been well except for asthma and allergic rhinitis and conjunctivitis caused by pollen allergy, experienced acute chest pain, localized at the sternal area, while she was playing basketball at school. She stopped playing and the pain disappeared within 20 minutes. Her mother arrived when the pain had already ceased and noted that she was pale. In the evening, she developed a mild fever. On the following day, she awoke early in the morning because of a severe precordial pain. She stated that the pain felt like a weight pushing on her chest. The girl appeared extremely ill, pale, and sweaty; therefore, she was taken to the local hospital. On admission, the pain had persisted for ϳ45 minutes, but the intensity had decreased. The pain disappeared completely in 1 hour. Physical examination did not reveal any abnormality, heart rate was 96 beats/min, blood pressure was 105/60 mm Hg, respiratory rate was 20 breaths/min, and transcutaneous oxygen saturation was 97%. The electrocardiogram (ECG) showed a sinus rhythm with 2.5-mm ST elevation in lead I, aVL, V 4 , V 5 , and V 6 and ST depression in V 1 , V 2 , and aVR (Fig 1). The markers of myocardial damage were significantly increased: myoglobin was 224 ng/mL (normal values: 0 -70 ng/mL),...

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Section: Discussionmentioning

confidence: 99%

Acute Myocardial Infarction in a Child: Possible Pathogenic Role of Patent Foramen Ovale Associated With Heritable Thrombophilia

Coppola

Agnetti²,

Hagler

et al. 2004

Pediatrics

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“…Thus a diagnosis of intracardiac shunting should be suspected in patients with pulmonary emboli with other systemic embolic manifestations. Paradoxical coronary embolism is a rare but recognized clinical entity [4][5][6]. Transoesophageal echocardiography is a Fig.…”

Section: Discussionmentioning

confidence: 99%

“…Fig. 2. sensitive investigation in the diagnosis of paradoxical embolism and intracardiac shunts [5]. Acute treatment options include anticoagulation, thrombolysis or surgical thrombectomy.…”

Section: Discussionmentioning

confidence: 99%

Acute ST-elevation myocardial infarction secondary to paradoxical embolism

Krishnamoorthy¹,

Osman²,

Nadir³

et al. 2008

International Journal of Cardiology

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“…3,7,9 However, in most patients with possible systemic embolic disease, it is rare that a transseptal thrombus is seen with cardiac imaging or that there is direct evidence for paradoxical embolism (ie, the embolic entry of a venous thrombus into the systemic circulation). 5,10,11 Therefore, the precise mechanism of stroke is still a matter of debate. Classically, a diagnosis of paradoxical embolism requires that the following 4 criteria be met: (1) presence of deep vein thrombosis or pulmonary embolism, (2) abnormal communication between the right to left circulation, (3) clinical, angiographic, or pathologic evidence for systemic embolism, and (4) presence of a favorable pressure gradient promoting R-L shunting.…”

Section: Discussionmentioning

confidence: 99%

Impending Paradoxical Cerebral Embolism in a Patient With Atrial Septal Aneurysm

Miyazaki

Hirai

Hosokawa

et al. 2005

Circ J

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atent foramen ovale (PFO) and atrial septal aneurysm (ASA) have been identified as potential risk factors for stroke; 1-5 when transesophageal echocardiography (TEE) is used, the prevalence of PFO in the normal population is as high as 22-38%. 6 However, it is often difficult to prove that the mechanism of systemic embolism was paradoxical embolism in stroke patients with PFO. 1 We present a case of impending paradoxical cerebral embolism diagnosed by TEE and contrast echocardiography. Case ReportAn 89-year-old man was admitted to the Hokushin General Hospital with hemiparesis of the left limbs and impaired consciousness. On physical examination, he had normal heart sounds, left hemiparesis, and no swelling of the lower limbs. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed cerebral infarction in the area of the right middle cerebral artery (Fig 1). Magnetic resonance angiography (MRA) showed no atherosclerotic changes in the large cerebro-vascular walls. Electrocardiogram showed sinus rhythm and he had an episode of chronic atrial fibrillation before admission. The chest X-ray and laboratory data presented no abnormalities.Because there was no definite evidence of artery to artery stroke, we performed transthoracic echocardiography (TTE) to rule out a cardiac source of the emboli. TTE showed a slightly enlarged right ventricle, mild tricuspid regurgitation (max pressure gradient =34 mmHg), atrial septal aneurysm, and a floating mass in the left atrium (Fig 2A). To further examine that mass, we performed TEE, which showed a large string-like mass transiting from the right atrium (RA) to the left atrium (LA) through the atrial septum (Fig 2B), and the absence of any thrombus on the left atrial appendage (Fig 2C).We diagnosed paradoxical cerebral embolism caused by intra-atrial thrombus. Peripheral Doppler echocardiography of the lower extremities revealed normal flow velocities and no existence of deep vein thrombosis. A hypercoagulability profile for intravascular blood stasis was also negative.We chose anticoagulation therapy rather than surgical embolectomy because of the patient's age and poor general condition. After 4 weeks of warfarin therapy, the atrial mass had completely disappeared from the TEE images. Right-to-left shunt flow was not identified with color flow Doppler, although it was proved with a contrast study under the provocative maneuver (Fig 3). We used a microbubble contrast agent (Levovist R , Shering Co Ltd) instead of hand-agitated saline to avoid possible systemic air Circ J 2005; 69: 246 -248 (Received September 10, 2003; revised manuscript received January 19, 2004; accepted February 18, 2004) Departments of Cardiology and *Neurology, Hokushin General Hospital, Nagano, Japan Mailing address: Toshihiko Takamoto, MD, FACC, Department of Cardiology, Hokushin General Hospital, 1-5-63 Nishi, Nakano, Nagano 383-8505, Japan. E-mail: ttakamoto-circ@umin.ac.jp Impending Paradoxical Cerebral Embolism in a PatientWith Atrial Septal Aneurysm

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Impending Paradoxical Embolism

Cited by 101 publications

References 78 publications

Acute Myocardial Infarction in a Child: Possible Pathogenic Role of Patent Foramen Ovale Associated With Heritable Thrombophilia

Acute Myocardial Infarction in a Child: Possible Pathogenic Role of Patent Foramen Ovale Associated With Heritable Thrombophilia

Acute ST-elevation myocardial infarction secondary to paradoxical embolism

Impending Paradoxical Cerebral Embolism in a Patient With Atrial Septal Aneurysm

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