Images in Clinical Medicine

Paradoxical Embolism — Thrombus in Transit through a Patent Foramen Ovale

T. Narain Srivastava, M.D., and Michael F. Payment, M.D.

N Engl J Med 1997; 337:681September 4, 1997

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Figure 1 An obese 46-year-old man came to the emergency room with the acute onset of numbness and a cold feeling in both hands; he had had shortness of breath and chest pain for the preceding 48 hours. Physical examination showed that he had no radial pulses. After arteriography that revealed emboli involving the right brachial and left axillary arteries, the patient underwent bilateral brachial embolectomy, and normal circulation was restored. Because paradoxical embolism was strongly suspected, two-dimensional transesophageal echocardiography was performed with an omniplane transducer. Panel A shows an image of the heart in the oblique plane (50 degrees), at the level of the aortic root. A large thrombus (T) is in transit from the right atrium (RA) to the left atrium (LA) through a patent foramen ovale. A transthoracic echocardiogram (not shown) was suggestive of an atrial septal aneurysm. The patient underwent emergency open-heart surgery: Panel B shows a large (13-cm-by-1.5-cm) thrombus with a band of constriction at the level where it traversed the defect — which was repaired, and the thrombus was extracted. Since his surgery, the patient has done well, with no recurrence of symptoms. IAS denotes interatrial septum, TV tricuspid valve, and AO aorta.

T. Narain Srivastava, M.D.
Michael F. Payment, M.D.
Veterans Affairs Medical Center, Jackson, MS 39216-5199

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   Basil (Vasilios) D. Thanopoulos, Petros D. Dardas, Evangelos Karanasios, Nicholaos Mezilis. (2006) Transcatheter closure versus medical therapy of patent foramen ovale and cryptogenic stroke. Catheterization and Cardiovascular Interventions 68:5, 741-746
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   Bernhard Meier. (2006) Patent Foramen Ovale, Guilty But Only as a Gang Member and for a Lesser Crime Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.. Journal of the American College of Cardiology 47:2, 446-448
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   Pieter A. Dijkmans, Cees A Visser, Otto Kamp. (2005) Paradoxical Embolism Due to Open Foramen Ovale with Atrial Septal Aneurysm as a Cause of Myocardial Infarction in a Young Male. The International Journal of Cardiovascular Imaging 21:6, 629-632
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   Yun-Ching Fu, Ziyad M Hijazi. (2005) Patent foramen ovale. Expert Review of Cardiovascular Therapy 3:5, 875-878
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   Shinsuke Miyazaki, Takashi Hirai, Noriyo Hosokawa, Eiichiro Hattori, Masatoshi Komura, Hideo Konagai, Hiroshi Sagai, Toshihiko Takamoto. (2005) Impending Paradoxical Cerebral Embolism in a Patient With Atrial Septal Aneurysm. Circulation Journal 69:2, 246-248
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    Stephan Windecker, Andreas Wahl, Krassen Nedeltchev, Marcel Arnold, Markus Schwerzmann, Christian Seiler, Heinrich P. Mattle, Bernhard Meier. (2004) Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. Journal of the American College of Cardiology 44:4, 750-758
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    Deborah R Gersony, Sang H Kim, Marco Di Tullio, Ali Fard, Leroy Rabbani, Shunichi Homma. (2001) Acute myocardial infarction caused by paradoxical coronary embolization in a patient with a patent foramen ovale. Journal of the American Society of Echocardiography 14:12, 1227-1229
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    Takuya Mitsui, Yoichi Aoki, Yuko Nagata, Yumi Kojima, Kenichi Tanaka. (2001) Patent Foramen Ovale Complicated by Paradoxical Embolism and Brain Infarct in a Patient with Advanced Ovarian Cancer. Gynecologic Oncology 83:3, 608-609
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    TUSHAR CHATTERJEE, BEAT C. AESCHBACHER, BERNHARD MEIER. (1999) Ischemic Attacks and Patent Foramen Ovale: Transcatheter Closure of Patent Foramen Ovale in Adults with Cryptogenic Systemic Embolism. Journal of Interventional Cardiology 12:1, 59-64
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    V Aboyans. (1998) Diagnosis and management of entrapped embolus through a patent foramen ovale. European Journal of Cardio-Thoracic Surgery 14:6, 624-628
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