scholarly journals Thrombus in Transit Through a Patent Foramen Ovale: catch it if you can—a case report

2021 ◽  
Author(s):  
Inês Pires ◽  
Inês Almeida ◽  
João Miguel Santos ◽  
Miguel Correia
Keyword(s):  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Heart Defects ◽  
Interatrial Septum ◽  
Hemodynamic Instability ◽  
Paradoxical Embolism ◽  
Right Atrial ◽  
Safe Procedure ◽  
Foramen Ovale ◽  
In Transit

Abstract Background Patent foramen ovale (PFO) is one of the most common congenital heart defects, but the finding of a thrombus in transit (TIT) through a PFO is extremely rare. It’s a therapeutic challenge, and systemic anticoagulation, cardiac surgery or fibrinolysis should be considered. Case Summary A 43-year-old female was admitted with intermediate-high risk pulmonary embolism. Transthoracic echocardiogram revealed a large right atrial mobile mass that crossed the interatrial septum through a PFO, compatible with TIT, and the patient was started on unfractionated heparin. The diagnosis was confirmed by transesophageal echocardiogram (TEE). However, during TEE probe removal, the patient developed dyspnoea, sudoresis and peripheral desaturation, and new image acquisition revealed sudden mass disappearance. Due to the possibility of paradoxical embolization associated with Valsalva maneuver, fibrinolysis with alteplase was promptly started. The patient had no signs of embolic or hemorrhagic complications and remained clinically stable. She was discharged on warfarin and then underwent percutaneous transcatheter closure of PFO. Conclusion The treatment strategy of a TIT through a PFO is controversial, but surgery might be the most appropriate treatment for hemodynamically stable patients, while thrombolysis should be used in cases of hemodynamic instability. TEE is generally a safe procedure but pressure changes associated with Valsalva maneuver may induce embolization of a TIT and attention should be given to patient sedation and tolerance. After complete embolization of a TIT, emergent thrombolysis may be the only treatment option, in order to prevent disastrous consequences related to paradoxical embolism.

scholarly journals 137 Paradoxical Embolism Risk Increases with Atypical Right Atrial Blood Flow in the Presence of a Patent Foramen Ovale

Heart ◽  
2016 ◽  
Vol 102 (Suppl 6) ◽  
pp. A97.2-A98
Author(s):  
Victoria Stoll ◽  
Aaron Hess ◽  
Oliver Rider ◽  
Hayley Harvey ◽  
Alex Pitcher ◽  
...  
Keyword(s):  
Blood Flow ◽  
Patent Foramen Ovale ◽  
Paradoxical Embolism ◽  
Right Atrial ◽  
Foramen Ovale

scholarly journals Patent Foramen Ovale: A Fatal Trap

2019 ◽  
Author(s):  
Tahereh Davarpasand ◽  
Reza Mohseni Badalabadi ◽  
Soheil Mansourian ◽  
Zahra Rahnamoun
Keyword(s):  
Patent Foramen Ovale ◽  
Systolic Dysfunction ◽  
Anticoagulation Therapy ◽  
Right Atrial ◽  
Foramen Ovale ◽  
Blood Oxygen Saturation ◽  
Rare Type ◽  
Oxygen Saturation Level ◽  
Vein Thrombosis ◽  
In Transit

A 39-year-old man referred to us with a complaint of dyspnea and palpitation of 3 days’ duration.  The patient was tachycardic but normotensive with a normal blood oxygen saturation level of about 91%. His electrocardiogram showed a sinus rhythm with an incomplete right bundle branch block. There was no known risk factor for vein thrombosis in his past medical history. Transthoracic and then transesophageal echocardiography revealed a large, hypermobile elongated mass (about 10×1 cm) in the right atrium. The mass was in transit through a large patent foramen ovale (Figure 1, Video 1). There was also severe right ventricular dilation with moderate systolic dysfunction on echocardiography, suggestive of pulmonary thromboembolism (PTE). Consequently, multiple-detector computed tomography angiography was performed to determine mortality risk and help the decision-making regarding the duration of anticoagulation therapy. The angiographic procedure revealed massive bilateral PTE (Figure 2). The patient was referred for atriotomy and pulmonary embolectomy on cardiopulmonary bypass (Figure 3). A thrombus in transit is a life-threatening, albeit rare, type of right-heart thrombosis with mortality rates of 80-100% in untreated patients,1 necessitating urgent assessment and treatment. A thrombus in transit can result in catastrophic systemic embolism in a patient with PTE; therefore, taking heed of this issue in the presence of a right atrial mass is of great therapeutic significance. Meticulous imaging modalities in such patients are mandatory to prove the existence of a patent foramen ovale with a view to deciding on an emergent individualized therapeutic management of the patient’s condition.   

scholarly journals Saddle Pulmonary Embolus Caught in Transit across a Patent Foramen Ovale

2019 ◽  
Vol 2019 ◽  
pp. 1-6
Author(s):  
Aram Barbaryan ◽  
Stefania Bailuc ◽  
Travis Abicht ◽  
Sergey Barsamyan ◽  
Yonatan Gizaw ◽  
...  
Keyword(s):  
Pulmonary Embolus ◽  
Patent Foramen Ovale ◽  
Anticoagulation Therapy ◽  
Rare Condition ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Oral Contraceptive Pills ◽  
Contraceptive Pills ◽  
Systemic Embolization ◽  
In Transit

Impending paradoxical embolism (IPE) also described in the literature as thrombus straddling a patent foramen ovale (PFO) or paradoxical embolus in transit is a rare condition when thrombus (originating mostly in deep veins of lower extremities) embolized to the heart gets caught in PFO or in atrial septal defect without systemic embolization. We present a case of a 39-year-old female on oral contraceptive pills who presented to the emergency department with chief complaint of dyspnea and chest pain. She was found to have saddle pulmonary embolus (PE) extending through PFO to left atrium and into the left ventricle. Patient underwent emergent open pulmonary embolectomy, removal of right and left atrial thrombi, and closure of patent foramen ovale. She tolerated the surgery well and was discharged home on chronic anticoagulation therapy.

scholarly journals Prevalence of patent foramen ovale in the Greek population is high and impacts on the interpretation of the risk of paradoxical embolism (RoPE) score

2020 ◽  
Vol 13 ◽  
pp. 175628642096467
Author(s):  
Ioanna Koutroulou ◽  
Georgios Tsivgoulis ◽  
Dimitris Karacostas ◽  
Ignatios Ikonomidis ◽  
Nikolaos Grigoriadis ◽  
...  
Keyword(s):  
Healthy Subjects ◽  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Attributable Fraction ◽  
Greek Population ◽  
Foramen Ovale ◽  
International Consensus ◽  
Very High

Background: The risk of paradoxical embolism (RoPE) score calculates the probability that patent foramen ovale (PFO) is causally related to stroke (PFO attributable fraction, PFOAF), based on PFO prevalence in patients with cryptogenic stroke (CS) compared with that in the general population. The latter has been estimated at 25%; however, PFO prevalence in nonselected populations varies widely. Methods: Since PFO prevalence in Greece remains unknown, we evaluated it and we calculated PFOAF stratified by RoPE score in a cohort of patients with CS ⩽55 years old. PFO was detected according to the international consensus transcranial Doppler (TCD) criteria in 124 healthy subjects (H), in 102 patients with CS, and in 56 patients with stroke of known cause (nonCS). Each subject underwent unilateral middle cerebral artery recording after infusion of agitated saline, at rest, and after a controlled Valsalva maneuver. We characterized PFO as large (>20 microbubbles or curtain), moderate (11–20), and small (⩽10). Results: PFO was detected in 42.7% of H, 49% of CS, and 25% of nonCS ( p = 0.013). Large PFOs were numerically higher in CS [28.4% (29/102)] compared with H [19.3% (24/124); p = 0.1] and to nonCS [7.1% (4/56), p = 0.04]. The median RoPE score in patients with CS and PFO was seven. Even patients with very high RoPE score (9–10) had moderate PFOAF (57%). For any individual stratum up to RopE score 8, PFOAF was <33%. Conclusions: PFO prevalence in the Greek population is much higher than the widely accepted 25%. PFO may be the cause of stroke in one out of nine Greek patients with CS. Among Greek CS patients who harbor a PFO, the latter is causal in one out of five. The established RoPE score cutoff of ⩾7 for having a probable PFO-associated stroke may overestimate the probability in patients deriving from populations with high PFO prevalence.

scholarly journals Thrombus in Transit through Patent Foramen Ovale

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Hassan Baydoun ◽  
Iskander Barakat ◽  
Elie Hatem ◽  
Michel Chalhoub ◽  
Ali Mroueh
Keyword(s):  
Patent Foramen Ovale ◽  
Case Reports ◽  
Rare Event ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Surgical Risk ◽  
Transient Nature ◽  
Clinical Scenarios ◽  
High Surgical Risk ◽  
In Transit

A thrombus in transit through a patent foramen ovale (PFO) with impending paradoxical embolism is an extremely rare event. Due to its transient nature, it is unable to identify the thrombus, and most of the cases have been reported at autopsy. We are reporting a case of thrombus straddling the foramen ovale which was diagnosed by echocardiography and treated surgically. Through this personal case, an exhaustive review of the literature was performed. There were 88 cases reported. We concluded that there is no medical consensus about the best option for treatment. Nevertheless, surgery, which is associated with fewer complications of recurrent embolic events than those of thrombolysis and anticoagulation, appeared to be the best approach in patients who are not at a high surgical risk. Anticoagulant treatment appears to be an acceptable therapeutic alternative to surgery, particularly in patients with comorbidities who are at high surgical risk and for patients with small PFO. Thrombolysis is linked to the highest mortality, which could be explained by the severity of the patient’s initial presentation. In conclusion, and after the cumulative effects of these case reports, we propose a diagram consisting of the use of the three therapeutic options in the different clinical scenarios.

Abstract TP221: A Novel Ultrasound Probe Attached to the Cervix Can Precisely Detect Large Patent Foramen Ovale

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Hidetaka Mitsumura ◽  
Ayumi Arai ◽  
Kenichi Sakuta ◽  
Kenichiro Sakai ◽  
Yuka Terasawa ◽  
...  
Keyword(s):  
Temporal Bone ◽  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Interatrial Septum ◽  
Center Frequency ◽  
Foramen Ovale ◽  
Ultrasound Probe ◽  
Diagnostic Ability ◽  
Bone Window ◽  
The Right

Introduction: We developed a novel probe (paste-able soft ultrasound probe; PSUP) attached to the cervix for detection of right-to-left shunt (RLS), because insufficient temporal bone window interrupts the precise examination for diagnosis of RLS. Hypothesis: We assessed the hypothesis that diagnostic ability of PSUP for RLS detection is equal to those of transesophageal echocardiography (TEE). Methods: Subjects were patients with ischemic stroke and transient ischemic attack who underwent TEE. PSUP was a 2.0-MHz center frequency, which had an equal property with TCD, and the shape was thin, soft, and square modified for attachment to the neck. At first, we performed TEE with the echoscope at the level of the fossa ovalis after injection of saline agitated with air in the right antecubital vein. The procedure was performed with and without Valsalva maneuver. Visualization of microembolic signals (MES) induced contrast agent within the right atrium and crossing the interatrial septum was considered as positive patent foramen ovale (PFO). We divided PFO into two groups according to number of MES, such as small PFO (1-29 of MES) and large PFO (≥30 of MES). Then, monitoring using PSUP was performed at unilateral common carotid artery (CCA) using similar preparation and procedure to TEE. RLS by PSUP diagnosed when we found 1and more MES in CCA. We compared detectable rate by size of PFO between TEE and PSUP, and calculated accuracy of PSUP against TEE. Results: From May 2014 to July 2015, 62 patients (46 male, mean age of 61 years) were included in this study. We diagnosed 26 of 62 patients (42%) as PFO by TEE, whereas PSUP detected in 17 of them (27%). As a reference of TEE findings, diagnostic ability of PSUP was 58% of sensitivity, 94% of specificity, and 79% of accuracy. In TEE examination, large PFO was 11 patients and small was 15 patients. PSUP could evaluate large PFO (9 of 11 patients) more accurately than small one (6 of 15, 82% vs. 40%, p=0.05). Conclusion: PSUP should have a considerable accuracy of large PFO diagnosis. For patients with insufficient temporal bone window, PSUP may play an important role of detecting large PFO.

scholarly journals Patent foramen ovale closure review: decades of research and the evolution of the evidence

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Ayodipupo S Oguntade ◽  
Mayowa Sefiu Oguntade
Keyword(s):  
Atrial Fibrillation ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Safe Procedure ◽  
Foramen Ovale ◽  
Uncertain Significance ◽  
Perioperative Anticoagulation ◽  
Recurrent Strokes ◽  
Onset Atrial Fibrillation

Abstract Background A quarter of the population suffers from patent foramen ovale, a form of interatrial shunt. It has been linked to cryptogenic strokes and is a common cause of paradoxical embolism. Main text The benefit of closing the patent foramen ovale in cryptogenic stroke patients aged 18-60 years to prevent recurrent strokes, particularly in those with large shunts or associated atrial septal aneurysms, was recently demonstrated. It is a relatively safe procedure that necessitates post-operative anticoagulation, but it has been linked to new-onset atrial fibrillation of uncertain significance. The effectiveness of patent foramen closure depends on patient selection, and prediction scores such as the Risk of Paradoxical Embolism (RoPE) score should be used. Newer closure devices, such as bioabsorbable devices like the Biostar system and ‘device-less’ devices like the Noble Stitch, are becoming more common due to their lower operative risks. The use of such devices in future trials, as well as careful case selection, could improve the acceptability of patent foramen ovale closure in the general population, removing the need for perioperative anticoagulation. Conclusion Individuals aged 18-60 years with cryptogenic stroke who have adverse patent foramen ovale morphology on imaging should be offered patent foramen ovale closure, preferably using the newer closure devices. More studies are needed to determine the significance of periprocedural atrial fibrillation after device closure.

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