(Circulation. 2001;103:e113.)
© 2001 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Impending Paradoxical Embolism
From the Cardiac Department, University of Aberdeen, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
Correspondence to Dr M. Egred, Cardiac Research Department, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland UK. E-mail M.Egred{at}arh.grampian.scot.nhs.uk
A56-year-old man was admitted with shortness of breath and a painful and pulseless cold left leg. A successful surgical embolectomy from the left femoral artery was performed. A ventilation-perfusion lung scan was consistent with multiple pulmonary emboli. Two months previously, the patient had an anterolateral non–Q-wave myocardial infarction. At coronary arteriography, the coronaries were normal apart from mild (40%) plaque disease in the proximal left anterior descending artery. He had deep venous thrombosis of the left leg at the age of 54. He also had had a cerebrovascular accident with residual right-sided weakness at the age of 41.
The patient was referred for cardiac evaluation. A
subsequent transesophageal echocardiogram revealed a
large thrombus straddling a patent foramen ovale (PFO) and crossing
from the right to the left atrium, together with an interatrial septal
aneurysm
(Figure 1
). The thrombus pro-lapsed into the left and
right ventricles through the tricuspid and mitral valves
(Figure 2).
|
|
At emergency thromboembolectomy under
cardiopulmonary bypass, a 19-cm-long thrombus, which crossed
the interatrial septum, was removed, and the PFO was closed by direct
suture. A left internal mammary artery graft was inserted into the left
anterior descending coronary artery. A repeat echocardiogram
was normal
(Figure 3).
|
PFO is present in 17% to 35% of persons at autopsy in all age groups, and it is associated with potential paradoxical embolism in 16% of cases. Imaging of thrombi crossing a PFO and reports on paradoxical embolism causing a myocardial infarction in people with normal coronary arteries are rare. Echocardiography plays an important role in recognizing this potentially life-threatening but treatable condition.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||