Successful surgical treatment for a thrombus straddling a patent foramen ovale: a case report
© Nemoto et al.; licensee BioMed Central Ltd. 2013
Received: 5 November 2012
Accepted: 27 May 2013
Published: 30 May 2013
Paradoxical embolism (PDE) occurs after embolic material passes from the venous to the arterial circulation through a right-to-left shunt, which is frequently a patent foramen ovale (PFO). We describe the case of a patient with deep venous thrombosis and an intracardiac thrombus straddling a PFO and who was successfully treated with an emergency surgery.
KeywordsParadoxical embolism Patent foramen ovale Economy class syndrome Pulmonary embolism
“Economy class syndrome” is a well-known condition characterized by a venous thromboembolism associated with long periods of travel . The association between long-distance travel and stroke has been reported as “economy class stroke syndrome,” which typically results from PDE through a PFO and is often accompanied by deep venous thrombosis (DVT) and pulmonary embolism (PE).
We report a case of a patient with an intracardiac thrombus straddling a PFO, which was revealed by echocardiography and was treated successfully with an emergency surgery.
An obese 55-year-old man (body mass index, 29.4 kg/m2) presented at the emergency room of our hospital with dyspnea and cough. He was returning home from a business trip to Kuwait on a 34-h long flight. His symptoms began just after the aircraft landed.
We started heparin infusion immediately after achieving hemostasis. And we converted it to Coumadin. The postoperative course was uncomplicated; the patient was discharged and was asymptomatic at the 1-year follow-up.
He underwent bone marrow transplantation for chronic myelogenous leukemia 13 years ago and was under imatinib (Glivec®) therapy for 9 years. His CML status was CR and his platelet count was 24000 /μl at that time. No other remarkable medical history was reported.
PDE occurs after embolic material passes from the venous to the arterial circulation through a right-to-left shunt, frequently a PFO. In The prevalence of a PFO in the normal population is approximately 27% , it rarely causes any adverse medical condition. However, during the Valsalva maneuver or after acute elevation in pulmonary arterial pressure due to massive acute PE, a foramen ovale may become patent and result in a catastrophic arterial embolization . A thrombus straddling a PFO in PE is extremely rare and has a high risk of impending PDE (IPDE). The mortality rate with IPDE has been reported to be 16%–21% [3–6]; therefore, IPDE should be promptly diagnosed and treated.
Echocardiography is essential for making a diagnosis [3–8]. The intracardiac thrombus was suspected on TTE; however, TEE was required to confirm the diagnosis. Although TTE is mandatory to detect intracardiac thrombi in patients with DVT or PE, TEE should also be performed, if possible, for detailed observation of the nature of the thrombi and to determine the treatment strategy. A review of previous reports revealed that some patients presented with atypical symptoms; therefore, patients should be carefully evaluated.
Although treatment options include surgery, thrombolysis, and anticoagulation, it is not clear which option is superior and surgery was preferred in several cases.
In the present case, an emergency surgery was performed. Absence of a major cerebrovascular event or systemic emboli before surgery justified the use of cardiopulmonary bypass with systemic heparinization. We decided that pulmonary embolectomy was not necessary because the emboli did not cause hemodynamic instability. No neurological complication was observed after the surgery.
In patients having comorbidities, including advanced age, progressive cancer, stroke, previous cardiac surgery, and hemodynamic instability, thrombolysis and/or anticoagulation therapy are other options [4, 7, 9]. In our case, the patient walked to the emergency department and presented with dyspnea and cough. He was desaturated but was relatively hemodynamically stable. After oxygen was administered, his symptoms improved and he did not require a ventilator. Therefore, we had ample time to evaluate the patient, and we performed only emergency thrombectomy, which provided good results.
We should aggressively consider surgical treatment to prevent systemic embolism in this situation.
The patient has provided permission to publish these features of his case, and the identity of the patient has been protected.
The authors wish to acknowledge Hiroyuki Kawajiri and Sohsyu Kotani. They were members of our Cardiovascular surgery team.
- O’Keeffe DJ, Baglin TP: Travellers’ thrombosis and economy class syndrome: incidence, aetiology and prevention. Clin Lab Haematol. 2003, 25: 277-281. 10.1046/j.1365-2257.2003.00533.x.View ArticlePubMedGoogle Scholar
- Hagen PT, Scholz DG, Edwarda WD: Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984, 59: 17-20. 10.1016/S0025-6196(12)60336-X.View ArticlePubMedGoogle Scholar
- Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A: Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010, 137: 164-170. 10.1378/chest.09-0961.View ArticlePubMedGoogle Scholar
- Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H: Surgical or medical treatment for thrombus straddling the patent foramen ovale: Impending paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008, 101: 637-644. 10.1016/j.acvd.2008.08.011.View ArticlePubMedGoogle Scholar
- Aboyans V, Lacroix P, Ostyn E, Cornu E, Laskar M: Diagnosis and management of entrapped embolus through a patent foramen ovale. Eur J Cardiothorac Surg. 1998, 14: 624-628. 10.1016/S1010-7940(98)00251-6.View ArticlePubMedGoogle Scholar
- Ekut B, Kocak H, Becit N, Senocak H: Massive pulmonary embolism complicated by a patent foramen ovale with straddling thrombus: report of a case. Surg Today. 2006, 36: 528-533. 10.1007/s00595-006-3195-8.View ArticleGoogle Scholar
- Fontanella B, Vizzardi E, Bordonali T, D’Aloia A, Chiari E, Dei Cas L: Pulmonary embolism comlicated by impending paradoxical embolism-a case report and review of literature. Kardiol Pol. 2010, 68: 314-316.PubMedGoogle Scholar
- Shah DK, Ritter MJ, Sinak LJ, Miller JA, Sundt TM: Paradoxical embolus caught in transit through a patent foramen ovale. J Card Surg. 2011, 26: 151-153. 10.1111/j.1540-8191.2010.01168.x.View ArticlePubMedGoogle Scholar
- Hansen A, Kuecherer H: Caught in the act: entrapped embolus through a patent foramen ovale. Eur J Echocardiogr. 2008, 9: 692-693. 10.1093/ejechocard/jen013.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.