Impending Paradoxical Embolism Traversing Three Cardiac Chambers Presenting With Stroke and Pulmonary Embolism

Abstract

A straddling thrombus within a patent foramen ovale (PFO), also known as an impending paradoxical embolism, is an infrequent event that is rarely encountered in clinical practice. This should be considered whenever there is an arterial embolism in the presence of right-sided thromboembolic disease. Symptoms are widely variable depending on the severity of thrombus and obstructive embolic events. We present a patient who arrived at the hospital with signs and symptoms consistent with a cerebrovascular disease that was ultimately diagnosed with small foci of acute ischemic cerebral infarcts, bilateral pulmonary emboli, and a straddling thrombus traversing three cardiac chambers. Treatment included PFO closure, inferior vena cava filter placement, and surgical thrombectomy with a successful outcome. Consensus for treatment of an impending paradoxical embolism in the medical literature is a subject of controversy and is our reason behind contributing this case presentation with our treatment strategy.

Anesthetic management and the role of TEE in the entrapment of a paradoxical embolus by a patent foramen ovale

“…3 Photo illustrating the thrombus in the RA and passing through the PFO between 0° and 90°. Thrombus in the right ventricle RV may best be seen in a midesophageal four-chamber view or in a transgastric view between 80° and 110° [4]. The LA and LA appendage (LAA) can be assessed for thrombi in a midesophageal view between 0° and 150°.…”

“…This leads to a one-way communication passage between atria wherein a right to left shunt can occur. The incidence of PFOs in adults range from 27 to 30%, but less than 6% are found to be greater than a width of 5 mm [4].…”

“…This is increased when a right heart clot is in transit. In acute PE, a clot in transit is rarely seen, but if seen, the estimated mortality is 21-28% in treated populations and 80-100% in untreated populations [1][2][3][4]. Paradoxical emboli occur when a clot passes through an intracardiac shunt, to the left side of the heart and into the systemic circulation.…”

“…Paradoxical emboli occur when a clot passes through an intracardiac shunt, to the left side of the heart and into the systemic circulation. A PFO is the most common adult intracardiac shunt [4]. A PFO is an interatrial fetal circulation remnant that occurs when the septum primum and septum secundum fail to fuse.…”

“…Signs and symptoms of PDE can be nonspecific including dyspnea, chest pain, tachycardia, hypoxia, hypotension, electrocardiographic changes, neurological changes, and hemoptysis [2][3][4][5][6][7]. Diagnostic workup for PDE includes but is not limited to d-dimer levels, duplex ultrasound of the lower extremities, and imaging modalities such as computed tomography scans.…”