Thrombus Trapped in Patent Foramen Ovale and Bilateral Pulmonary Embolism
A One-Stop Shop Ultrasound Diagnosis
Case report: An 88 year-old woman was admitted with a 2-week history of generalized weakness, anorexia, and repeated falls. Clinical examination revealed atactic gait. Her blood pressure was 150/70 mm Hg. Cerebral computed tomography revealed nonspecific vascular leukoencephalopathy. Transthoracic echocardiography showed a large mass across the atrial septum, floating in both atria. The right ventricle was dilated and its systolic function appeared moderately depressed. Peak velocity of the regurgitant tricuspid flow was 3.5 m/s, consistent with pulmonary hypertension. Transesophageal echocardiography showed a large thrombus (5.1 cm in length) in the foramen ovale (Figure 1). In addition, there were large masses in the right (2.5×2.5 cm, Figure 2) and left (2.7×1.5 cm, Figure 3) main pulmonary arteries, consistent with massive bilateral pulmonary embolism (PE). Thromboses in the right superficial femoral vein and left external iliac vein were seen on venous Doppler ultrasound examination. Because of the age of the patient, intravenous unfractionated heparin was deemed the only therapeutic option. Despite optimal anticoagulation level, however, the patient developed a large retroperitoneal hematoma, and hemorrhagic shock ensued. The patient died 2 days later.
This is the first report of concomitant echocardiographic diagnosis of PE associated with thrombus trapped in the foramen ovale. Identification of a straddling thrombus is a very rare occurrence. An associated PE causes a poor prognosis, and the diagnosis is usually made by angiographic pulmonary computed tomography. Transesophageal echocardiography may be used to assess the extent and surgical accessibility of the thrombus; however, its role in the diagnostic algorithm of PE is limited to patients with unexplained cardiac arrest and pulseless electrical activity. The left pulmonary artery is difficult to image because of left main bronchus interposition in its middle portion, but the sensitivity of transesophageal echocardiography may be improved if appropriate rotation of the transducer is performed. In the present case, thrombi were clearly documented by transesophageal echocardiography in the right and left pulmonary arteries.
The present report illustrates that the presentation of venous thromboembolic disease may be subtle and atypical in the elderly and emphasizes the importance of imaging both pulmonary arteries when a thrombus crossing the foramen ovale or a right atrial thrombus is visualized, even in patients without hemodynamic instability.
Sources of Funding
Dr Unger has received a grant from the Fonds pour la Chirurgie Cardiaque, Brussels, Belgium.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/11/e154/DC1.