Correspondence

Embolism Interruptus

N Engl J Med 1994; 330:1761-1762June 16, 1994

Article

To the Editor:

The detection of a patent foramen ovale by transesophageal echocardiography in patients with arterial ischemic events is increasingly thought to be associated with a paradoxical embolism1. Except for one report of an impending paradoxical embolism detected by transthoracic echocardiography,2 all diagnoses of paradoxical embolism through a patent foramen ovale have been either presumptive3 or, as in the image by Silverman (Sept. 23 issue),4 postmortem. We report a diagnosis of paradoxical embolism made by means of transesophageal echocardiography.

A 51-year-old obese woman was admitted to the hospital with dyspnea, migrating abdominal pain, and bloody diarrhea of five days' duration. A ventilation-perfusion lung scan revealed bilateral perfusion defects, and an abdominal computed tomographic scan revealed areas of attenuation in the spleen that were suggestive of infarcts. Intravenous heparin was started, but on the third hospital day the patient's left arm suddenly became painful, cold, and pulseless. Extensive amounts of thrombus were removed from the left subclavian and axillary arteries by means of an open arteriotomy. Transthoracic echocardiography showed an ill-defined mobile mass in the left ventricle and another possible mass in the right atrium.

Transesophageal echocardiography showed a large, lobulated mass in both atria crossing the inferior interatrial septum (Figure 1Figure 1Transesophageal Echocardiogram Showing Thrombus Lodged in the Foramen Ovale.). The left atrial portion prolapsed through the mitral valve into the apex of the left ventricle (Figure 2Figure 2Long-Axis View of the Left Ventricle Showing the Left-Sided Portion of the Thrombus Extending to the Apex of the Left Ventricle.). The left-sided mass was 1 cm wide at the septum and 9.5 cm long. The right atrial portion was 1 cm by 4.5 cm.

At surgery, a 15-cm thrombus was removed from a small foramen ovale where it had lodged. The foramen was sutured closed. The patient received anticoagulation therapy with warfarin and recovered, with no further symptoms. A Doppler study of the legs suggested the presence of deep venous thrombosis of the right thigh.

The studies in this patient provided a rare opportunity to observe an embolus originating in the venous circulation in the process of crossing a patent foramen ovale to enter the arterial circulation. Presumably, multiple pulmonary emboli and the accompanying pulmonary hypertension initially caused right-to-left interatrial shunting, forcing a large venous embolus across the patent foramen ovale, where it lodged. The thrombus then gave rise to multiple emboli in the subclavian, mesenteric, and splenic arteries. These findings confirm the hypothesis that large paradoxical emboli can cross a patent foramen ovale.

David Brogno, M.D.
Good Samaritan Hospital, Suffern, NY 10901

Gilead Lancaster, M.D.
Danbury Hospital, Danbury, CT 06810

Marlon Rosenbaum, M.D.
Columbia-Presbyterian Medical Center, New York, NY 10032

4 References

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   Movsowitz C, Podolsky LA, Meyerowitz CB, Jacobs LE, Kotler MN. Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology? J Am Soc Echocardiogr 1992;5:259-270
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   Nelson CW, Snow FR, Barnett M, McRoy L, Wechsler AS, Nixon JV. Impending paradoxical embolism: echocardiographic diagnosis of an intracardiac thrombus crossing a patent foramen ovale. Am Heart J 1991;122:859-862
   CrossRef | Web of Science | Medline

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   Cheng TO. Echocardiography and paradoxical embolism. Ann Intern Med 1981;95:515-515
   Web of Science | Medline

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   Silverman ME. Paradoxical embolus. N Engl J Med 1993;329:930-930
   Full Text | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Bilgehan Erkut, Hikmet Kocak, Necip Becit, Huseyin Senocak. (2006) Massive Pulmonary Embolism Complicated by a Patent Foramen Ovale with Straddling Thrombus: Report of a Case. Surgery Today 36:6, 528-533
   CrossRef

2. 2

   V Aboyans. (1998) Diagnosis and management of entrapped embolus through a patent foramen ovale. European Journal of Cardio-Thoracic Surgery 14:6, 624-628
   CrossRef

3. 3

   Cyril S. Ofori, LeRoy C. Moore, George Hepler. (1995) Massive cerebral infarction caused by paradoxical embolism: Detection by transesophageal echocardiography. Journal of the American Society of Echocardiography 8:4, 563-566
   CrossRef