An interesting case of entrapped thrombus in a patent with Foramen Ovale

Anna De Vita¹, Tiziana Ciarambino¹, Rossella Gottilla², Mauro Giordano³

1) Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, Italy
2) Department of Cardiology and Intensive Unit Coronary, A. O. Cardarelli, Naples, Italy
3) MD, PhD , Associate Professor of Internal Medicine  Chief of Postgraduate School of Emergency Medicine 
Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, Naples, Italy 

Background

The present case report shows a rare case of thrombus located through the patent foramen ovale (PFO), in a patent with pulmonary and paradoxical embolism. There is not consensus on an ideal treatment. Medical interventions or surgery can be applied for thrombi trapped through PFO. Thrombolysis is more frequently chosen in patients with severe pulmonary embolism and an unstable status, which cannot wait for surgery. In conclusion coexistence of pulmonary embolism and systemic arterial embolism suggests the diagnosis of paradoxical embolism which suggesting the presence of intracardiac defects such as PFO. In the reported case, the thrombus was migrated from right popliteal artery to the right atrium and then to the left atrium, through the patent foramen ovale.

Case Report

A 72 years old female patient was admitted to the Emergency Department of a different hospital for atypical chest pain and elevates blood arterial pressure. Electrocardiogram (EKG), echocardiogram, Computerized tomography (CT)-aortogram, routine laboratory exams and myocardial enzymes were performed. No sign of aortic dissection was observed after EKG, echocardiogram and CT aortogram. Chemistry showed a mild elevation of myocardial necrosis enzymes. For this reason, the patient underwent coronary angiography, which did not show any lesion involving the main epicardial coronary arteries. The procedure was performed via right radial artery, without complications.

The patient was discharged with a diagnosis of blood pressure elevation with mild elevation of myocardial enzymes. Therapy at discharge was: acetylsalicylic acid, clopidogrel, levotiroxin, atenolol, olmesartan, hydrochlorotiazide, calcium and calcitriol. After 5 days, the patient was hospitalized to Emergency Department of the same hospital for left arm acute pain associated with numbness and “tingling sensation”. Clinical examination found a pale and cold superior left limb and left-hand weakness. The patient decided to leave the hospital despite the diagnosis: left brachial artery obliteration. On the same day, the patient was admitted to our Emergency Department (A. Cardarelli Hospital, in Naples) for worsening of left limb pain and sudden-onset of dyspnea at rest. Clinical examination found normal arterial blood pressure and heart rate. Laboratory exams showed increased white blood cell numbers and plasma D-dimer levels (8850 µg), EKG showed right branch block (Figure 1).

Figure 1

Chest X-ray and abdominal CT scan showed no paradoxical embolism. Superior left limb arterial echo-Doppler showed brachial occlusion. Transthoracic echocardiography and transesophageal echocardiography (TEE) (Figure 2) revealed a mobile thrombus (cross-sectional area 0,94 x 4,5cm) extending from the right atrium to the left atrium through PFO, normal right cardiac cavities and arterial pulmonary hypertension.

Figure 2

The left atrial thrombus was mobile and, during diastole, protruded from the mitral valve in the left ventricle. Chest spiral computed tomography revealed bilateral pulmonary embolism. Doppler ultrasonography of the lower limbs revealed acute right popliteal deep-vein-thrombosis. Anticoagulant treatment was started and the patient reached respiratory and hemodynamic stability, cardiothoracic intervention was planned with the patient under cardiopulmonary bypass. The right atrium was incised and the thrombus in the right atrium was found entrapped within the PFO. The thrombus was removed from the right chambers, the PFO and the left atrium and PFO closed by direct patch.
The pulmonary arteries were incised and the pulmonary artery thrombi were removed via surgical embolectomy. The patient had an uncomplicated postoperative course and was admitted to the Internal Medicine Department, to perform post-surgical rehabilitation and to investigate the causes of thrombosis. Lab tests were performed and founding the presence of wild type FV Leiden G1691A, wild type FII G20210A and heterozygosis for methylenetetrahydrofolate reductase (MTHFR) A1298C. This coagulation pattern is not correlated with thrombophilia, but with an augmentation of fasting plasma homocysteine levels which can be related with an increased risk of thrombosis.

Discussion

The present case report shows a rare case of thrombus located through the PFO, in a patent with pulmonary and paradoxical embolism. There is not consensus on an ideal treatment¹. Medical interventions or surgery can be applied for thrombi trapped through PFO. Thrombolysis is more frequently chosen in patients with severe pulmonary embolism and an unstable status, which cannot wait for surgery. It was related with higher 60- day mortality as compared with surgery in patients who do not suffer from initial shock or cardiac arrest. Thrombectomy under extracorporeal circulation is the most frequently chosen treatment in the published literature and appears justified in the prevention of paradoxical embolism^2,3. Surgery is associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality^4,5.

Conclusions

In conclusion coexistence of pulmonary embolism and systemic arterial embolism suggests the diagnosis of paradoxical embolism which suggesting the presence of intracardiac defects such as PTO. In the reported case, the thrombus was migrated from right popliteal artery to the right atrium and then to the left atrium, through the patent foramen ovale. PDE (Paradoxycal embolism) can occur only when there is an abnormal vascular or intracardiac defect. The most common defect associated with PDE was PFO. This case report is crucial for the emergency doctor as cause of atypical chest pain.

References

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