Traversing boundaries: thrombus in transit with paradoxical embolism

Abstract

A 72-year-old male is diagnosed with paradoxical embolus after he presented with concurrent deep vein thrombosis, stroke, and multiple arterial emboli in the presence of a patent foramen ovale (PFO). Paradoxical embolus requires the passage of a thrombus from the venous into the arterial circulation through a right-to-left shunt leading to systemic embolism. But, despite the high incidence of PFO (27.3% across all age groups by autopsy), paradoxical embolism (PDE) is uncommon, representing <2% of all arterial emboli. We present a case report where a thrombus has been directly observed passing through the PFO during an echocardiogram study; thus, clearly delineating the true cause of multiple thromboemboli and stoke in our patient. Subsequent Transesophageal Echocardiography (TEE) also interestingly showed the thrombus in transit in the aorta and pulmonary artery.

Emergent pulmonary thromboembolectomy and atrial septal aneurysmectomy for intracardiac impending paradoxical embolism: An en bloc approach to prevent clot embolism and facilitate repair

“…Although the presence of a PFO is common in the general population (about 20%),[ 1 ] confirmed reports of thrombus entrapped within a PFO are uncommon in the literature. [ 1 2 3 4 5 6 7 ] The first reported IPE, occurred in 1985 using transthoracic echocardiography. [ 4 ] Reports have increased with widespread use of both transthoracic and transesophageal echocardiography in the intervening years; however, the condition likely remains underdiagnosed overall.…”

Multiorgan paradoxical embolism in an elderly female with a patent foramen ovale: a case report

“…PDE was first described by Julius Friedrich Cohnhein (1839–1884) in 1877 [5,6]. He introduced the term PDE when during autopsy in a 35 years old female observed the concurrent occurrence of venous thrombosis in the lower extremity, a clot in the middle meningeal artery, and a patent foramen ovale (PFO) [5,6].…”

Atypical manifestations of pulmonary embolism

“…An analysis of 12 anecdotal reports of PE-related PDE [92][93][94][95][96][97][98][99][100][101][102][103][104][105] reveals three patterns of clinical presentation (Table 4), namely, simultaneous occurrence of typical PE symptoms(or hypoxaemia) and symptoms of PDE, occurrence of PE symptoms followed by occurrence of stroke a day or so later, and occurrence of stroke without any documentation of breathlessness. In the latter category were four patients [102][103][104][105] in whom PDE-related stroke occurred in a PE patient who had reported neither breathlessness, chest pain or cough. Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE.…”

“…In the latter category were four patients [102][103][104][105] in whom PDE-related stroke occurred in a PE patient who had reported neither breathlessness, chest pain or cough. Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE. The utility of TTE in identifying PE in patients with PDE [102][103][104][105] has its counterpart in the utility of TTE for differentiating PE from suspected AMI [106].…”

“…Nevertheless, subsequent transthoracic echocardiography(TTE) revealed either right heart dilatation and elevation in pulmonary artery systolic pressure [103], or intracardiac thrombus [102,104,105], thereby raising the index of suspicion for PE. The utility of TTE in identifying PE in patients with PDE [102][103][104][105] has its counterpart in the utility of TTE for differentiating PE from suspected AMI [106]. In the latter case report a 32 year old man presented with anterior chest pain and dyspnoea, and he had ST segment elevation in V3-V6.…”