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(Circulation. 1996;93:387-391.)
© 1996 American Heart Association, Inc.

Articles

Impending Paradoxical Embolus

Barry P. Rosenzweig, MD; Lawrence Glassman, MD; Itzhak Kronzon, MD

From the Departments of Medicine and Surgery (L.G.), New York University School of Medicine, NY.

Correspondence to Itzhak Kronzon, MD, 560 First Ave, HW 228, New York, NY 10016.

	Introduction

Top Introduction

 
The diagnosis of paradoxical embolization typically requires evidence of acute systemic arterial occlusion, systemic venous thrombosis, and a pathway for the thromboembolus to bypass the pulmonary vasculature. However, even when all of these findings are present, they cumulatively represent only a "smoking gun" from which a diagnosis is inferred. It is rare that one captures the actual process of paradoxical embolization "red-handed."

These transthoracic and transesophageal echocardiographic images demonstrate a thrombus traversing the patent foramen ovale of a 76-year-old woman (Fig 1). She had presented with syncope, and a ventilation-perfusion lung scan revealed a segmental abnormality strongly suggestive of pulmonary embolus. Emergency surgery confirmed the echocardiographic diagnosis and may have saved her the devastation of systemic arterial occlusion. The thrombus that was extricated from the atria and the patent foramen ovale is shown in Fig 2.

View larger version (183K): [in this window] [in a new window]   Figure 1. Top left, Transthoracic echocardiographic image obtained from the apical view. A long thrombus (arrows) is seen within both atria apparently traversing the interatrial septum in its midportion. In real time, its ends were wildly mobile and even entered the atrioventricular valve orifices during diastole. LA indicates left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle. Bottom left, Transesophageal echocardiographic image in the longitudinal plane. A thrombus (C) extends from the right atrium (RA) across the interatrial septum via a patent foramen ovale (arrow) into the left atrium (LA). The full length of the thrombus and its extent into the left atrium as well as its wild motion are lost in this still frame image. Ao indicates aorta.

View larger version (0K): [in this window] [in a new window]   Figure 2. Top right, Gross pathological specimen removed from the heart via a right atriotomy. This elongated thrombus traversed a patent foramen ovale and was freely mobile in both atria.

	Footnotes

 
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Lukes Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Heart Institute, 6720 Bertner, MC 4-265, Houston, TX 77030.

This article has been cited by other articles:

				V. Aboyans, P. Lacroix, E. Ostyn, E. Cornu, and M. Laskar Diagnosis and management of entrapped embolus through a patent foramen ovale Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 624 - 628. [Abstract] [Full Text] [PDF]

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