Images in Clinical Medicine

Paradoxical Embolism — Thrombus in a Patent Foramen Ovale

Marcus Dörr, M.D., and Astrid Hummel, M.D.

N Engl J Med 2007; 357:2285November 29, 2007

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Thrombus in a Patent Foramen Ovale

An 85-year-old woman was admitted with progressive dyspnea and chest pain that had started suddenly 2 days earlier. Physical examination revealed formerly undiagnosed atrial fibrillation with a normal heart rate and normal blood pressure. Examination of the lungs did not show any pathological findings. Pulmonary embolism was diagnosed on spiral computed tomography (Panel A, sagittal reconstruction), which showed intraluminal filling defects (arrows) and total occlusions of the upper and lower segmental arteries by clots (arrowheads). Duplex ultrasonography revealed an underlying deep-vein thrombosis of the right superficial femoral vein. Transthoracic echocardiography showed typical signs of moderate right heart strain. Anticoagulation therapy with low-molecular-weight heparin was started. One week later, repeated transthoracic echocardiography showed a fluttering thrombus within the right atrium (Panel B, arrow). Two-dimensional transesophageal echocardiography revealed a vermicular thrombus trapped in the patent foramen ovale with floating parts in the right and left atrium (Panel C, arrow, and video clip, available with the full text of this article at www.nejm.org). Emergency cardiac surgery was performed in which a thrombus of approximately 8 cm in length was extracted and the foramen ovale was closed. Surprisingly, the left atrial fraction of the thrombus had already disappeared without clinical signs of arterial embolism. The patient was discharged in good clinical condition 2 weeks later while receiving anticoagulant therapy for persistent atrial fibrillation. Ten months later, she was still doing well without relapse.

Marcus Dörr, M.D.
Astrid Hummel, M.D.
Ernst Moritz Arndt University, D-17487 Greifswald, Germany
mdoerr@uni-greifswald.de

Citing Articles (4)

Citing Articles

1. 1

   G. P. ANZOLA, L. GIUSTI DEL GIARDINO, M.P. PIRAS. (2010) Patent foramen ovale (PFO) and cryptogenic stroke. Journal of Thrombosis and Haemostasis 8:8, 1675-1677
   CrossRef

2. 2

   Yoko Horibata, Kazuhiro Nishigami, Ayako Tomita, Hideyuki Uesugi, Koichi Nakao. (2009) Serial images of thrombi traversing the interaterial septum through a patent foramen ovale. Journal of Echocardiography 7:3, 61-62
   CrossRef

3. 3

   Jeff A. McKenzie, William D. Edwards, Donald J. Hagler. (2009) Anatomy of the patent foramen ovale for the interventionalist. Catheterization and Cardiovascular Interventions 73:6, 821-826
   CrossRef

4. 4

   S. Reverté Villarroya. (2008) Detección shunt derecha-izquierda en pacientes con ictus isquémico: Colaboración de enfermería en la técnica de detección. Revista Científica de la Sociedad Española de Enfermería Neurológica 2008:27, 27-30
   CrossRef