Thrombus in Transit through Patent Foramen Ovale

Abstract

A thrombus in transit through a patent foramen ovale (PFO) with impending paradoxical embolism is an extremely rare event. Due to its transient nature, it is unable to identify the thrombus, and most of the cases have been reported at autopsy. We are reporting a case of thrombus straddling the foramen ovale which was diagnosed by echocardiography and treated surgically. Through this personal case, an exhaustive review of the literature was performed. There were 88 cases reported. We concluded that there is no medical consensus about the best option for treatment. Nevertheless, surgery, which is associated with fewer complications of recurrent embolic events than those of thrombolysis and anticoagulation, appeared to be the best approach in patients who are not at a high surgical risk. Anticoagulant treatment appears to be an acceptable therapeutic alternative to surgery, particularly in patients with comorbidities who are at high surgical risk and for patients with small PFO. Thrombolysis is linked to the highest mortality, which could be explained by the severity of the patient's initial presentation. In conclusion, and after the cumulative effects of these case reports, we propose a diagram consisting of the use of the three therapeutic options in the different clinical scenarios.

A Woman in Her 80s With Anterior ST-Elevation Myocardial Infarction and Shock

“…Diagnosis of a myocardial infarction is based on history, physical examination, ECG, coronary angiography, and cardiac biomarkers. 2 The current patient's presentation of chest pain, ST-segment elevation, and new right bundle branch block is typical of both large anterior wall infarctions and can be mimicked by large PEs. Moreover, the coincidental appearance of a high-grade lesion in the correct anatomic distribution was consistent with coronary ischemia as a plausible etiology for the patient's presentation.…”

“…Moreover, the coincidental appearance of a high-grade lesion in the correct anatomic distribution was consistent with coronary ischemia as a plausible etiology for the patient's presentation. 2 PEs can present with dyspnea, chest pain, syncope, and hypotension. Diagnosis can be based on the probability of thromboembolism by using a probability model, such as the Wells score, in conjunction with diagnostic imaging.…”

video 4

“…Thrombus straddling the PFO rarely occurs as a consequence of thromboembolism, with the migration of thrombus to the left-sided chambers. Most reported cases have been treated with surgical embolectomy (1), yet there is no medical consensus about the best option for treatment with anticoagulant treatment remaining an acceptable alternative to surgery in patients at high risk for surgery (2).…”

Response to Letter Regarding Article “Fluttering Thrombus in Patent Foramen Ovale With Paradoxycal and Cerebral Embolism”

“…3 Because the "Images in Cardiovascular Medicine" Section is not intended as a primary vehicle for case reports, we didn't report anamnestic and clinical data of our patient. The medical history was positive for a cancer of the kidney previous treated with surgery and chemotherapy.…”