Impending Paradoxical Embolism
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.
- Copyright © 2001 by American Heart Association