Abstract 15578: The Combination of an Ostium Secundlum Type Atrial Septal Defect with a Pulmonary Arterial Thromboembolism Caused an Enlarged Pulmonary Artery, Pulmonary Hypertension and Recurrent Paradoxical Cerebral Embolism due to Deep Vein Thrombosis
A 65 year old female was referred to our hospital with dyspnea on effort. When she was 42 years old, she was diagnosed by transthoracic echocardiology (TTE) with an ostium secundlum type atrial septal defect (ASD) with a pre-existing right to left shunt through the ASD. When she was 60 years old, she was diagnosed with a brain abscess due to a paradoxical cerebral embolism and admitted to our brain surgery ward a total of three times. The diagnosis was confirmed and treatment with Clopidogrel sulfate was started. Six months ago, she felt dyspnea on effort and gradually worsened. She was referred to our department for further examination. Chest X ray revealed cardiac enlargement with a cardiothoracic ratio of 61%. Serum d dimer and brain natriuretic peptide were elevated to 3.3μg/ml and 492pg/mL, respectively. TTE showed an enlarged PA, right atria (RA) and right ventricle (RV) with a thickened RV wall. A bidirectional shunt through a large ASD could also be observed. PA systolic pressure was estimated, by the pressure gradient from tricuspid valve regurgitation, at 94mmHg. CT revealed an enlarged, calcified PA with a mural thrombus, enlarged and thickened RV wall and a right to left shunt through the ASD. The LV was compressed by the RV, suggesting RV pressure load. Because a mural thrombus was observed in the PA, CT acquisitions of the lower extremities were added 3 minutes after contrast injection. An enlarged popliteal vein with a deep venous thrombus (DVT) was observed. Tadalafil was prescribed for pulmonary hypertension to improve oxygen concentration. Heparin followed by warfarin was administered for the DVT and mural thrombus in the PA.
At follow up, CT showed no change to the mural thrombus in the PA, therefore home oxygen therapy was started.
From experience of this case, and in subjects with Eisenmenger ASD, if severe PA dilation and PA hypertension and paradoxical cerebral embolism are detected, one should also suspect PA thromboembolism due to DVT.
Author Disclosures: N. Funabashi: None. H. Takaoka: None. K. Ozawa: None. N. Tanabe: None. K. Tatsumi: None. Y. Kobayashi: None.
- © 2014 by American Heart Association, Inc.