Correspondence

Medical Mystery — Paradoxical Embolism

N Engl J Med 2007; 356:1277March 22, 2007

Article

To the Editor:

With regard to Mathura and Jampol's answer to the Medical Mystery about the visual-field defect (Dec. 7 issue),1 we would like to raise a small point about the path taken by the paradoxical embolism to a left retinal artery branch in the patient with Eisenmenger's syndrome associated with ventriculoseptal defect and a patent ductus arteriosus. Although the embolism is attributed to the clot passing through the patent ductus arteriosus, it is more likely that it passed through the septal defect. The ductus enters the aorta distal to the left common carotid artery and subclavian artery. A clot passing through the ductus would be more likely to travel downstream to the thoracic and abdominal aortas than upstream to the left common carotid artery, whereas a clot passing from right to left across the septum would flow downstream through the ascending and transverse portions of the aorta into the left common carotid artery.

Fred Mishkin, M.D.
Harbor–UCLA Medical Center, Torrance, CA 90509-2910
mishkin@schlossbros.com

Marvin Mishkin, M.D.
209 S. Second St., Elkhart, IN 46516

1 References