Accepted Manuscript Neither here nor there: impending paradoxical embolism Ryan Yuan, MD, PhD, FACC Ruiwu Yuan, MD PII:
S0002-9343(14)00673-1
DOI:
10.1016/j.amjmed.2014.08.001
Reference:
AJM 12636
To appear in:
The American Journal of Medicine
Received Date: 7 February 2014 Revised Date:
7 August 2014
Accepted Date: 7 August 2014
Please cite this article as: Yuan R, Yuan R, Neither here nor there: impending paradoxical embolism, The American Journal of Medicine (2014), doi: 10.1016/j.amjmed.2014.08.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neither here nor there: impending paradoxical embolism Ryan Yuan, MD, PhD, FACC,a Ruiwu Yuan, MDb a
Section of Cardiology
RI PT
Group Health Bellevue Medical Center 11511 NE 10th Street, Bellevue, WA 98004 Tel: 425-761-7471
SC
Fax: 425-502-3161 Email: [email protected] b
M AN U
Department of Surgery
Affiliated Hospital, Lintong Sanatorium of Lanzhou Military Area Command Xi'An, China 710600 a
Corresponding author.
Type of manuscript: Images in Radiology.
Word Count: 1495. Funding: None. Conflict of Interest: None.
TE D
Key Words: impending paradoxical embolism.
AC C
EP
Authorship: All authors have access to the data and a role in writing the manuscript.
ACCEPTED MANUSCRIPT
Images in Radiology
Neither here nor there: impending paradoxical embolism
RI PT
Robert G. Stern, MD, Images in Radiology Editor Ryan Yuan, MD, PhD,a Ruiwu Yuan, MDb
Section of Cardiology, Department of Internal Medicine, Group Health Bellevue
SC
a
Medical Center, Bellevue, WA and bDepartment of Surgery, Affiliated Hospital, Lintong
M AN U
Sanatorium of Lanzhou Military Area Command, Xi’An, China.
Requests for reprints should be addressed to Ryan Yuan, MD, PhD, Section of Cardiology, Group Health Bellevue Medical Center, 11511 NE 10th St, Bellevue, WA, 98004.
PRESENTATION
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Email address: [email protected]
EP
The challenges inherent in the diagnosis and management of a rare condition were clearly illustrated after a 35-year-old man was admitted to the hospital with ominous symptoms.
AC C
He first detected a problem when he got up to use the bathroom during the previous night and had trouble balancing. This difficulty persisted when he woke up in the morning, and it was now compounded by double vision, left-sided weakness, and left facial droop. When questioned, he also reported new-onset dyspnea on exertion of 3-4 weeks’ duration. The patient was morbidly obese and had a history of gout. His current drug therapy consisted of prednisone, allopurinol, and colchicine. He had quit smoking 1 month earlier.
ASSESSMENT
ACCEPTED MANUSCRIPT
On examination, the patient was in moderate distress. His weight was 368 pounds (167 kg), and his vital signs at presentation were as follows: temperature, 99.7° F (37.6° C); blood pressure, 104/49 mmHg; pulse rate, 107 beats per minute; respiration rate, 15 breathes per minute; and oxygen saturation, 94% on 2 liters of oxygen. The
RI PT
cardiopulmonary examination was otherwise unremarkable. A neurological examination revealed that he had 4 out of 5 left-side weakness, unequal pupil size, and abnormal
extraocular motion. He had no signs of deep vein thrombosis. An electrocardiogram
showed sinus tachycardia with no ST- or T-wave changes. Results of a complete blood
cardiopulmonary process was seen on a chest x-ray.
SC
cell count and chemistry panel were all within normal limits. No evidence of an acute
M AN U
Similarly, computed tomography (CT) of the head without contrast disclosed no abnormalities. However, magnetic resonance imaging of the brain demonstrated acute ischemia in the anterior right thalamus (Figure 1). Based on the patient’s young age and lack of risk factors for stroke, such as diabetes, hyperlipidemia, and hypertension, suspicion was raised for paradoxical embolus. Transthoracic and transesophageal echocardiography were performed to investigate this concern. In fact, transesophageal
TE D
echocardiography did show an impending paradoxical embolus: a large mobile thrombus in the right atrium traversed a patent foramen ovale and extended into the left atrium where during diastole, it prolapsed into the left ventricle (Figures 2A and 2B). Right ventricular dilatation and dysfunction, moderate tricuspid regurgitation, and pulmonary
EP
hypertension with an estimated pulmonary artery systolic pressure of 60 mmHg were also evident. Transthoracic echocardiography, limited by the patient’s morbidly obese body
AC C
habitus, did not uncover the intracardiac thrombus. Because the patient had new-onset dyspnea on exertion, pulmonary CT
angiography was ordered as well. Extensive diffuse bilateral pulmonary emboli of the left and right pulmonary arteries and a saddle embolus involving the main pulmonary artery bifurcation (Figure 3) were apparent. Ultrasound examination revealed a nonocclusive deep vein thrombosis in the left popliteal vein. Serological screening was negative for thrombophilia, primary hypercoagulable state, autoimmune disease, and vasculitis.
DIAGNOSIS
ACCEPTED MANUSCRIPT
Usually, pulmonary embolism occurs when a clot in the deep veins of the lower extremities moves into the inferior vena cava, progresses through the right side of the heart, and lands in one of the pulmonary arteries, where it causes obstruction. In paradoxical embolism, a clot moves from the right side of the heart to the left through a
RI PT
patent foramen ovale, an atrial septal defect, or a ventricular septal defect, thus gaining access to the arterial circulation—and possibly, the brain. Under certain circumstances, passage of a thrombus through a patent foramen ovale can be unknowingly facilitated during a Valsalva maneuver or when a patient has massive pulmonary embolism in
SC
conjunction with acutely elevated pulmonary arterial pressure.1 A clot that becomes
wedged within the opening between the atria or between the ventricles is referred to as an
M AN U
impending paradoxical embolism.
While an estimated 15-35% of people have a patent foramen ovale, few will ever develop a paradoxical embolism.2 Several factors are necessary for its diagnosis. The patient must have a deep vein thrombosis or pulmonary embolism; a patent foramen ovale or other aberrant communication between the right and left circulation; signs of systemic embolism that are clinically evident or documented by angiography or
TE D
pathology; and a favorable pressure gradient fostering right-to-left shunting.1 Impending paradoxical embolism, first reported in 1985, is especially unusual with fewer than 200 events documented in the medical literature.2,3 Spurred by the rarity of this entity, Myers et al conducted a systematic review of observational studies.1 Of 174
EP
patients, 91% presented with pulmonary embolism. Systemic embolism— cerebrovascular accident or peripheral vascular ischemia, for example—was documented
AC C
in 55%. Clinically evident deep vein thrombosis was noted in 22%. The 30-day mortality rate was 18.4%, a percentage representing 32 patients; however, 20 died within 24 hours of diagnosis. Shock and hemodynamic collapse, coma, and systemic embolization at presentation were significantly more common among nonsurvivors than survivors. Another report stressed that the clinical presentation of patients with impending
paradoxical embolism was nonspecific, but rather reflected the signs and symptoms of more evident thromboembolic disease or systemic embolism.4 Of 88 patients, 30 or 34%, presented with severe pulmonary embolism; 41% had pulmonary and systemic embolism. Systemic embolism was most frequently traced to the cerebrum, with patients presenting
ACCEPTED MANUSCRIPT
with transient ischemic attacks or ischemic strokes. Yet, numerous other sites were cataloged as well. Our patient presented with several manifestations of thromboembolic disease: deep vein thrombosis, pulmonary embolism, impending paradoxical embolism, and systemic embolism with stroke.
RI PT
Transesophageal echocardiography is usually essential for the diagnosis of
impending paradoxical embolism, and it should be the test of choice. While transthoracic echocardiography is often performed initially when intracardiac thrombus is suspected, impending paradoxical embolism may not be visualized well—or at all. This was true in
SC
our patient. Transesophageal echocardiography was necessary to make the final
diagnosis. Right ventricular size and function should be evaluated at the same time.
M AN U
Dilation and reduced function indicate a worse prognosis and a need for more aggressive treatment.
MANAGEMENT
Impending paradoxical embolism, with its high risk for morbidity and mortality, is an emergency demanding prompt diagnosis and treatment. The best treatment has yet to be
TE D
identified, as data are limited. Further, it is likely that no specific management scheme will work for all patients, since presentation varies greatly between cases. Surgery, thrombolysis, anticoagulation, or a combination of these is an option, and successful treatment with each has been reported.4-8 Important considerations when formulating a
EP
therapeutic plan are the patient’s clinical presentation, comorbidities, hemodynamic stability, clot size, risk for bleeding, and risk for systemic embolism.5 At present,
AC C
surgery—thromboembolectomy and closure of a patent foramen ovale or atrial septal defect—generally seems to be favored over thrombolysis or anticoagulation, which can trigger fragmentation of the thrombus and ensuing massive pulmonary or paradoxical systemic embolism.
In their evaluation of patients described in the literature, Myers et al found that
compared with anticoagulation alone, surgical thromboembolectomy significantly reduced the odds of a composite of 30-day mortality and systemic embolism (odds ratio, 0.26; p = 0.001).1 They also noted a significant reduction in the odds of systemic embolism among patients who underwent surgery versus those treated with
ACCEPTED MANUSCRIPT
anticoagulation. Systemic embolism occurred in 23.5% of patients after thrombolysis was administered; the association was nonsignificant. An earlier review indicated that surgery was the most common approach; heparin was used in patients who were older, were more vulnerable to stroke, or had
RI PT
comorbidities.4 Thrombolysis was administered to patients with severe pulmonary
embolism and hemodynamic instability. The group treated with thrombolysis had the highest percentage of deaths, but these patients also tended to be in the most critical condition on presentation.
SC
Upon diagnosis of impending paradoxical embolism, our patient was immediately given intravenous heparin. Due to the high risk for recurrence of systemic and pulmonary
M AN U
embolism and the potential for life-threatening consequences, he was transferred to a regional surgical center. There, he underwent removal of a friable thrombus measuring 4.5 inches (11.5 cm). The clot extended from the right atrium across the patent foramen ovale into the left atrium. In addition, the interatrial septum was oversewn to close the patent foramen ovale, and thrombi were removed from the left and right pulmonary arteries via thromboendarterectomy. Because the patient presented with stroke,
TE D
thrombolysis was not administered, as it posed a risk for hemorrhagic transformation and fragmentation of the thrombus with recurrent embolism. To prevent future coronary or pulmonary embolism, an inferior vena cava filter device was inserted 4 days after the initial surgery. Life-long anticoagulation was
EP
recommended during a hematology consultation. At the 1-year follow-up visit, the patient was doing well with long-term anticoagulation treatment, and he had remained free of
AC C
thromboembolic events.
References
1. Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164-170. 2. Ghent F, Bassin L, Keller M, Cranney G, McKenzie D, Grant P. Impending paradoxical embolism: Have we lost the clot? Clin Respir J. 2013. doi: 10.1111/crj.12093.
ACCEPTED MANUSCRIPT
3. Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol. 1985;5:1002-1004. Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical
RI PT
4.
treatment for thrombus straddling the patent foramen ovale: impending
paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008;101:637–644.
SC
5. Dietz DM, Cleveland JD, Chewning KG, Dent JM, Kern JA, Keeley EC.
Impending paradoxical embolism presenting as myocardial infarction. J Cardiol
M AN U
Cases. 2013;7: e145-e148.
6. Turfan M, Vatankulu MA, Murat SN, Oksuz F, Duran M, Ornek E. Thrombolytic treatment of simultaneous pulmonary embolism and impending paradoxical embolism through a patent foramen ovale: a different thrombolytic regimen. Heart, Lung Circ. 2012;21:225-228.
7. Citro R, Panza A, Bottiglieri G, et al. Surgical treatment of impending paradoxical
TE D
embolization associated with pulmonary embolism in a patient with heterozygosis of factor V Leiden. J Cardiovasc Med (Hagerstown). 2013;14:745-747. 8. Faustino A, Costa G, Providência R, Paiva L. Impending paradoxical embolism with a thrombus crossing a patent foramen ovale. BMJ Case Rep. 2012.
EP
doi:10.1136/bcr-2012-006662.
AC C
FIGURE LEGENDS
Figure 1. Brain magnetic resonance imaging (MRI) demonstrated acute ischemia in the patient’s anterior right thalamus (arrow). This axial diffusion weighted image, which had a repetition time of 6,500 and an echo time of 100, showed a 1.5-cm increased signal indicating a focal area of early changes after an acute stroke.
Figure 2. Transesophageal echocardiography demonstrated a large mobile thrombus trapped in a patent foramen ovale (arrow). A, The clot was lodged in both atria. B, It extended to the left ventricle. LA: left atrium; RA: right atrium; IAS: interatrial septum;
ACCEPTED MANUSCRIPT
Tm: thrombus; AV: aortic valve; MV: mitral valve; Ao: aorta; RVOT: right ventricular outflow tract.
Figure. 3. Pulmonary computed tomography angiography demonstrated a saddle embolus
AC C
EP
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M AN U
SC
RI PT
(arrow) involving the main pulmonary artery bifurcation.
AC C
EP
TE D
M AN U
SC
RI PT
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EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
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M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
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M AN U
SC
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ACCEPTED MANUSCRIPT
S0002-9343(14)00673-1
DOI:
10.1016/j.amjmed.2014.08.001
Reference:
AJM 12636
To appear in:
The American Journal of Medicine
Received Date: 7 February 2014 Revised Date:
7 August 2014
Accepted Date: 7 August 2014
Please cite this article as: Yuan R, Yuan R, Neither here nor there: impending paradoxical embolism, The American Journal of Medicine (2014), doi: 10.1016/j.amjmed.2014.08.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neither here nor there: impending paradoxical embolism Ryan Yuan, MD, PhD, FACC,a Ruiwu Yuan, MDb a
Section of Cardiology
RI PT
Group Health Bellevue Medical Center 11511 NE 10th Street, Bellevue, WA 98004 Tel: 425-761-7471
SC
Fax: 425-502-3161 Email: [email protected] b
M AN U
Department of Surgery
Affiliated Hospital, Lintong Sanatorium of Lanzhou Military Area Command Xi'An, China 710600 a
Corresponding author.
Type of manuscript: Images in Radiology.
Word Count: 1495. Funding: None. Conflict of Interest: None.
TE D
Key Words: impending paradoxical embolism.
AC C
EP
Authorship: All authors have access to the data and a role in writing the manuscript.
ACCEPTED MANUSCRIPT
Images in Radiology
Neither here nor there: impending paradoxical embolism
RI PT
Robert G. Stern, MD, Images in Radiology Editor Ryan Yuan, MD, PhD,a Ruiwu Yuan, MDb
Section of Cardiology, Department of Internal Medicine, Group Health Bellevue
SC
a
Medical Center, Bellevue, WA and bDepartment of Surgery, Affiliated Hospital, Lintong
M AN U
Sanatorium of Lanzhou Military Area Command, Xi’An, China.
Requests for reprints should be addressed to Ryan Yuan, MD, PhD, Section of Cardiology, Group Health Bellevue Medical Center, 11511 NE 10th St, Bellevue, WA, 98004.
PRESENTATION
TE D
Email address: [email protected]
EP
The challenges inherent in the diagnosis and management of a rare condition were clearly illustrated after a 35-year-old man was admitted to the hospital with ominous symptoms.
AC C
He first detected a problem when he got up to use the bathroom during the previous night and had trouble balancing. This difficulty persisted when he woke up in the morning, and it was now compounded by double vision, left-sided weakness, and left facial droop. When questioned, he also reported new-onset dyspnea on exertion of 3-4 weeks’ duration. The patient was morbidly obese and had a history of gout. His current drug therapy consisted of prednisone, allopurinol, and colchicine. He had quit smoking 1 month earlier.
ASSESSMENT
ACCEPTED MANUSCRIPT
On examination, the patient was in moderate distress. His weight was 368 pounds (167 kg), and his vital signs at presentation were as follows: temperature, 99.7° F (37.6° C); blood pressure, 104/49 mmHg; pulse rate, 107 beats per minute; respiration rate, 15 breathes per minute; and oxygen saturation, 94% on 2 liters of oxygen. The
RI PT
cardiopulmonary examination was otherwise unremarkable. A neurological examination revealed that he had 4 out of 5 left-side weakness, unequal pupil size, and abnormal
extraocular motion. He had no signs of deep vein thrombosis. An electrocardiogram
showed sinus tachycardia with no ST- or T-wave changes. Results of a complete blood
cardiopulmonary process was seen on a chest x-ray.
SC
cell count and chemistry panel were all within normal limits. No evidence of an acute
M AN U
Similarly, computed tomography (CT) of the head without contrast disclosed no abnormalities. However, magnetic resonance imaging of the brain demonstrated acute ischemia in the anterior right thalamus (Figure 1). Based on the patient’s young age and lack of risk factors for stroke, such as diabetes, hyperlipidemia, and hypertension, suspicion was raised for paradoxical embolus. Transthoracic and transesophageal echocardiography were performed to investigate this concern. In fact, transesophageal
TE D
echocardiography did show an impending paradoxical embolus: a large mobile thrombus in the right atrium traversed a patent foramen ovale and extended into the left atrium where during diastole, it prolapsed into the left ventricle (Figures 2A and 2B). Right ventricular dilatation and dysfunction, moderate tricuspid regurgitation, and pulmonary
EP
hypertension with an estimated pulmonary artery systolic pressure of 60 mmHg were also evident. Transthoracic echocardiography, limited by the patient’s morbidly obese body
AC C
habitus, did not uncover the intracardiac thrombus. Because the patient had new-onset dyspnea on exertion, pulmonary CT
angiography was ordered as well. Extensive diffuse bilateral pulmonary emboli of the left and right pulmonary arteries and a saddle embolus involving the main pulmonary artery bifurcation (Figure 3) were apparent. Ultrasound examination revealed a nonocclusive deep vein thrombosis in the left popliteal vein. Serological screening was negative for thrombophilia, primary hypercoagulable state, autoimmune disease, and vasculitis.
DIAGNOSIS
ACCEPTED MANUSCRIPT
Usually, pulmonary embolism occurs when a clot in the deep veins of the lower extremities moves into the inferior vena cava, progresses through the right side of the heart, and lands in one of the pulmonary arteries, where it causes obstruction. In paradoxical embolism, a clot moves from the right side of the heart to the left through a
RI PT
patent foramen ovale, an atrial septal defect, or a ventricular septal defect, thus gaining access to the arterial circulation—and possibly, the brain. Under certain circumstances, passage of a thrombus through a patent foramen ovale can be unknowingly facilitated during a Valsalva maneuver or when a patient has massive pulmonary embolism in
SC
conjunction with acutely elevated pulmonary arterial pressure.1 A clot that becomes
wedged within the opening between the atria or between the ventricles is referred to as an
M AN U
impending paradoxical embolism.
While an estimated 15-35% of people have a patent foramen ovale, few will ever develop a paradoxical embolism.2 Several factors are necessary for its diagnosis. The patient must have a deep vein thrombosis or pulmonary embolism; a patent foramen ovale or other aberrant communication between the right and left circulation; signs of systemic embolism that are clinically evident or documented by angiography or
TE D
pathology; and a favorable pressure gradient fostering right-to-left shunting.1 Impending paradoxical embolism, first reported in 1985, is especially unusual with fewer than 200 events documented in the medical literature.2,3 Spurred by the rarity of this entity, Myers et al conducted a systematic review of observational studies.1 Of 174
EP
patients, 91% presented with pulmonary embolism. Systemic embolism— cerebrovascular accident or peripheral vascular ischemia, for example—was documented
AC C
in 55%. Clinically evident deep vein thrombosis was noted in 22%. The 30-day mortality rate was 18.4%, a percentage representing 32 patients; however, 20 died within 24 hours of diagnosis. Shock and hemodynamic collapse, coma, and systemic embolization at presentation were significantly more common among nonsurvivors than survivors. Another report stressed that the clinical presentation of patients with impending
paradoxical embolism was nonspecific, but rather reflected the signs and symptoms of more evident thromboembolic disease or systemic embolism.4 Of 88 patients, 30 or 34%, presented with severe pulmonary embolism; 41% had pulmonary and systemic embolism. Systemic embolism was most frequently traced to the cerebrum, with patients presenting
ACCEPTED MANUSCRIPT
with transient ischemic attacks or ischemic strokes. Yet, numerous other sites were cataloged as well. Our patient presented with several manifestations of thromboembolic disease: deep vein thrombosis, pulmonary embolism, impending paradoxical embolism, and systemic embolism with stroke.
RI PT
Transesophageal echocardiography is usually essential for the diagnosis of
impending paradoxical embolism, and it should be the test of choice. While transthoracic echocardiography is often performed initially when intracardiac thrombus is suspected, impending paradoxical embolism may not be visualized well—or at all. This was true in
SC
our patient. Transesophageal echocardiography was necessary to make the final
diagnosis. Right ventricular size and function should be evaluated at the same time.
M AN U
Dilation and reduced function indicate a worse prognosis and a need for more aggressive treatment.
MANAGEMENT
Impending paradoxical embolism, with its high risk for morbidity and mortality, is an emergency demanding prompt diagnosis and treatment. The best treatment has yet to be
TE D
identified, as data are limited. Further, it is likely that no specific management scheme will work for all patients, since presentation varies greatly between cases. Surgery, thrombolysis, anticoagulation, or a combination of these is an option, and successful treatment with each has been reported.4-8 Important considerations when formulating a
EP
therapeutic plan are the patient’s clinical presentation, comorbidities, hemodynamic stability, clot size, risk for bleeding, and risk for systemic embolism.5 At present,
AC C
surgery—thromboembolectomy and closure of a patent foramen ovale or atrial septal defect—generally seems to be favored over thrombolysis or anticoagulation, which can trigger fragmentation of the thrombus and ensuing massive pulmonary or paradoxical systemic embolism.
In their evaluation of patients described in the literature, Myers et al found that
compared with anticoagulation alone, surgical thromboembolectomy significantly reduced the odds of a composite of 30-day mortality and systemic embolism (odds ratio, 0.26; p = 0.001).1 They also noted a significant reduction in the odds of systemic embolism among patients who underwent surgery versus those treated with
ACCEPTED MANUSCRIPT
anticoagulation. Systemic embolism occurred in 23.5% of patients after thrombolysis was administered; the association was nonsignificant. An earlier review indicated that surgery was the most common approach; heparin was used in patients who were older, were more vulnerable to stroke, or had
RI PT
comorbidities.4 Thrombolysis was administered to patients with severe pulmonary
embolism and hemodynamic instability. The group treated with thrombolysis had the highest percentage of deaths, but these patients also tended to be in the most critical condition on presentation.
SC
Upon diagnosis of impending paradoxical embolism, our patient was immediately given intravenous heparin. Due to the high risk for recurrence of systemic and pulmonary
M AN U
embolism and the potential for life-threatening consequences, he was transferred to a regional surgical center. There, he underwent removal of a friable thrombus measuring 4.5 inches (11.5 cm). The clot extended from the right atrium across the patent foramen ovale into the left atrium. In addition, the interatrial septum was oversewn to close the patent foramen ovale, and thrombi were removed from the left and right pulmonary arteries via thromboendarterectomy. Because the patient presented with stroke,
TE D
thrombolysis was not administered, as it posed a risk for hemorrhagic transformation and fragmentation of the thrombus with recurrent embolism. To prevent future coronary or pulmonary embolism, an inferior vena cava filter device was inserted 4 days after the initial surgery. Life-long anticoagulation was
EP
recommended during a hematology consultation. At the 1-year follow-up visit, the patient was doing well with long-term anticoagulation treatment, and he had remained free of
AC C
thromboembolic events.
References
1. Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164-170. 2. Ghent F, Bassin L, Keller M, Cranney G, McKenzie D, Grant P. Impending paradoxical embolism: Have we lost the clot? Clin Respir J. 2013. doi: 10.1111/crj.12093.
ACCEPTED MANUSCRIPT
3. Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol. 1985;5:1002-1004. Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical
RI PT
4.
treatment for thrombus straddling the patent foramen ovale: impending
paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008;101:637–644.
SC
5. Dietz DM, Cleveland JD, Chewning KG, Dent JM, Kern JA, Keeley EC.
Impending paradoxical embolism presenting as myocardial infarction. J Cardiol
M AN U
Cases. 2013;7: e145-e148.
6. Turfan M, Vatankulu MA, Murat SN, Oksuz F, Duran M, Ornek E. Thrombolytic treatment of simultaneous pulmonary embolism and impending paradoxical embolism through a patent foramen ovale: a different thrombolytic regimen. Heart, Lung Circ. 2012;21:225-228.
7. Citro R, Panza A, Bottiglieri G, et al. Surgical treatment of impending paradoxical
TE D
embolization associated with pulmonary embolism in a patient with heterozygosis of factor V Leiden. J Cardiovasc Med (Hagerstown). 2013;14:745-747. 8. Faustino A, Costa G, Providência R, Paiva L. Impending paradoxical embolism with a thrombus crossing a patent foramen ovale. BMJ Case Rep. 2012.
EP
doi:10.1136/bcr-2012-006662.
AC C
FIGURE LEGENDS
Figure 1. Brain magnetic resonance imaging (MRI) demonstrated acute ischemia in the patient’s anterior right thalamus (arrow). This axial diffusion weighted image, which had a repetition time of 6,500 and an echo time of 100, showed a 1.5-cm increased signal indicating a focal area of early changes after an acute stroke.
Figure 2. Transesophageal echocardiography demonstrated a large mobile thrombus trapped in a patent foramen ovale (arrow). A, The clot was lodged in both atria. B, It extended to the left ventricle. LA: left atrium; RA: right atrium; IAS: interatrial septum;
ACCEPTED MANUSCRIPT
Tm: thrombus; AV: aortic valve; MV: mitral valve; Ao: aorta; RVOT: right ventricular outflow tract.
Figure. 3. Pulmonary computed tomography angiography demonstrated a saddle embolus
AC C
EP
TE D
M AN U
SC
RI PT
(arrow) involving the main pulmonary artery bifurcation.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
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SC
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ACCEPTED MANUSCRIPT
