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(Circulation. 2004;109:3056-3057.)
© 2004 American Heart Association, Inc.

Images in Cardiovascular Medicine

Massive Paradoxical Embolism

Caught in the Act

George J. Koullias, MD, PhD; John A. Elefteriades, MD; Ihui Wu, MD; Ion Jovin, MD; Farid Jadbabaie, MD; Robert McNamara, MD

From the Sections of Cardiothoracic Surgery (G.J.K., J.A.E., I.W.) and Cardiovascular Medicine (I.J., F.J., R.L.M.),Yale New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

Correspondence to George Koullias, MD, Department of Cardiothoracic Surgery, Yale New Haven Hospital-Yale University School of Medicine, 333 Cedar St, 121 FMB New Haven, CT 06520-8039. E-mail Koullias@hotmail.com

An extract of the first 250 words of the full text is provided, because this article has no abstract.

A 33-year-old scientist with recent exertional shortness-of-breath presented with new onset right flank and groin pain. For weeks, he had spent over 16 hours a day at his desk writing a grant. History and physical examination revealed resting tachypnea, sinus tachycardia, tender right flank with (+) Giordano sign, and resting oxygen saturation of 91% on room air. Computed tomography showed recent right renal infarct and ventilation/perfusion scan revealed multiple areas of mismatch. Transthoracic and transesophageal echocardiography revealed a large "snake-like" mass waving in the right atrium and a similar mobile mass in the left atrium (Figure 1), as well as thrombus in the inferior vena cava and a patent interatrial communication with positive bubble study.

View larger version (107K): [in this window] [in a new window]   Figure 1. Transthoracic echocardiographic imaging of a large waving tubular right atrial and left atrial thrombus through a patent foramen ovale (PFO).

The patient underwent emergency surgery. Right and left atriotomy revealed a large thrombus traversing a patent foramen ovale (Figure 2). An additional 13-cm recent thrombus was retrieved from a saddle position in the main and right pulmonary arteries (Figure 3).

View larger version (78K): [in this window] [in a new window]   Figure 2. Intraoperative demonstration of the large thrombus traversing the patent foramen ovale (arrows).

View larger version (127K): [in this window] [in a new window]   Figure 3. Intraoperative schematic reconstruction of the location of the thrombotic material through the patent foramen ovale (arrows) and the pulmonary artery in both right and left cardiac chambers.

Duplex examination of the lower extremities the next day revealed residual left distal popliteal vein thrombus. An inferior vena cava filter was placed and . . . [Full Text of this Article]

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