Biatrial Thromboembolism with Paradoxical Embolism Through Persistent Foramen Ovale

AbstractWe present a case of a biatrial thrombus penetrating through the PFO against the background of massive bilateral pulmonary thromboembolism in a 75-year-old patient. Because of the rare condition, there are no literature data on consensus treatment. Due to the patient’s clinical status and the results of the diagnostic tests, for the specific clinical case was made a decision for emergency surgical thrombectomy with PFO closure.

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Management of straddling thrombus through patent foramen ovale complicating pulmonary embolism

BMJ Case Reports ◽

10.1136/bcr-2020-240957 ◽

2021 ◽

Vol 14 (4) ◽

pp. e240957

Author(s):

Vijeth Bhat ◽

Stuart lane ◽

Sam Orde

Keyword(s):

Pulmonary Embolism ◽

Patent Foramen Ovale ◽

Treatment Options ◽

Treatment Strategies ◽

Rare Condition ◽

Bleeding Risk ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Haemodynamic Stability ◽

Surgical Thrombectomy

A 60-year-old man was admitted to intensive care unit with the diagnosis of pulmonary embolism. Bedside transthoracic echocardiography revealed the extension of the thrombus into left atrium and ventricle through patent foramen ovale (PFO). A straddling thrombus also described as impending paradoxical embolism is a rare condition when thrombus embolised to the heart gets caught in PFO. Morbidity is extremely high in case of systemic embolisation. Due to rarity, the treatment options are mainly individualised and no guidelines exist. There are few treatment strategies described in literature from surgical to interventional radiology to conservative approach. Treatment strategy should take individual parameters such as patient’s age, haemodynamic stability, bleeding risk and comorbidities into consideration. Our patient successfully underwent emergency surgical thrombectomy.

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285Arrhythmias after transcatheter closure of persistent foramen ovale are related to the type and size of the implanted device

European Heart Journal ◽

10.1093/eurheartj/ehz747.0089 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Komar ◽

T Przewlocki ◽

P Prochownik ◽

U Gancarczyk ◽

B Sobien ◽

...

Keyword(s):

Atrial Fibrillation ◽

Lower Risk ◽

Transcatheter Closure ◽

Supraventricular Arrhythmias ◽

Foramen Ovale ◽

Av Conduction ◽

Persistent Foramen Ovale ◽

Premature Beats ◽

Pfo Closure

Abstract Transient supraventricular arrhythmias may occur in patients following persistent foramen ovale (PFO) closure. Therefore, the aim of the study was to prospectively perform 24-hour ECG monitoring to assess the electrocardiographic effects of transcatheter closure of PFO depending on the type of implanted devices. Material and methods 351 consecutive adult subjects (196 F, 155M; mean age: 40.9±15.3) were enrolled into the study to undergo PFO closure with an Amplatzer Septal Occluder - ASO (157 pts: 117 occluders – size 25; 40 pts – size 30), and Cardia device (194 pts: 163 occluders – size 25; 31 – size 30). Holter monitoring was performed on all patients before, at 1 and 12 months after the procedure. Results The success rate of PFO closure was 97.8% (351 cases from 359 qualified in TEE), in 8 cases the PFO tunnels were too small to be forced by a catheter, in one case the PFO device caused an injury of the septum and an ASD Amplatzer device was implanted. During the procedure in 3 (0.85%) cases transient supraventricular arrhythmia and in 1 (0.28%) case bradycardia to 27 bpm occurred. At 1 month: in 7 (2%) pts changes in AV conduction occurred: 1 pt (0.28%) had complete AV dissociation, 6 (1.7%) pts intermittent first degree AV block; paroxysmal atrial fibrillation (pAF) occurred in 6 (1.7%) pts, 2 of whom had pAF prior to closure. A significant increase in the number of SVE premature beats/24h was noted at 1 month after the procedure: 1167.9±409 (27–9976) compared to baseline data 60.2±44 (0–601) (p<0.0001), at 12 months the SVE number decreased to 57.2±51 (7–752) and did not differ significantly from the baseline data. There was no change in the mean number of ventricular arrhythmias/24h after the procedure. There was a significant correlation between SVE premature beats/24h at 1 month after the procedure and device size (p<0.001 r=97211). Pts with ASO device had a significantly higher number of SVE ectopy at 1 month after PFO closure (19123.9±70) compared to pts with Cardia device (811.9±324), p<0.0001. Conclusions 1. Transcatheter closure of PFO is associated with a transient increase in supraventricular premature beats and a small risk of AV conduction abnormalities and paroxysmal atrial fibrillation in the early follow-up. There is regression of periprocedural arrhythmias after 12 months of PFO closure. 2. Transcatheter closure of PFO with Cardia device is related to a lower risk of supraventricular arrhythmias in the early follow-up. 3. The smaller device is implanted the lower risk of periprocedural arrhythmias is expected.

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Acute Hypoxic and Refractory Respiratory Failure Induced by an Underlying PFO: An Unusual Case of Platypnea Orthodeoxia and Transient Complication after Transcatheter Closure

Case Reports in Critical Care ◽

10.1155/2017/4397163 ◽

2017 ◽

Vol 2017 ◽

pp. 1-4

Author(s):

Carlos Salazar ◽

Romeo A. Majano

Keyword(s):

Respiratory Failure ◽

Unusual Case ◽

Transcatheter Closure ◽

Air Embolism ◽

Hemodynamic Instability ◽

Foramen Ovale ◽

St Segment Elevation ◽

St Segment ◽

Persistent Foramen Ovale ◽

Pfo Closure

Platypnea orthodeoxia (PO) is an infrequent condition of dyspnea with hypoxemia, increased by adopting an upright position and is relieved in decubitus. This condition may occur in patients with hidden intracardiac shunts, usually across a persistent foramen ovale (PFO). The incidence of PFO in general population is quite common, around 27%; however, the concurrent presentation with PO, especially in acute refractory respiratory failure, is extremely rare. PFO closure in this setting is still the treatment of choice with significant improvement or complete resolution of symptoms after closure with an overall periprocedural complication in the first 24 hours of approximately less than 5%. A transient ST-segment elevation in the inferior leads is present in extremely rare occasions and most likely is induced by either an air embolism or a mechanically provoked spasm of coronary arteries. We report a case of an 83-year-old woman in acute hypoxic and refractory respiratory failure in whom PO was identified, most likely induced by a hidden PFO. The patient underwent percutaneous transcatheter closure and developed immediate chest pain, transient hemodynamic instability, and ST-segment elevation in the inferior leads; nevertheless, our patient recovered completely with rapid resolution of respiratory failure with no adverse clinical sequelae.

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Pulmonary thromboembolism along with an impending paradoxical embolism across patent foramen ovale

Journal of Echocardiography ◽

10.1007/s12574-019-00434-z ◽

2019 ◽

Vol 18 (4) ◽

pp. 258-259

Author(s):

Rajesh Vijayvergiya ◽

Kewal Kanabar ◽

Sudhanshu Budakoty ◽

Vivek Guleria ◽

Navjyot Kaur ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Pulmonary Thromboembolism ◽

Paradoxical Embolism ◽

Foramen Ovale

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Multiorgan paradoxical embolism consequent to acute pulmonary thromboembolism with patent foramen ovale: a case report

Cases Journal ◽

10.4076/1757-1626-2-8358 ◽

2009 ◽

Vol 2 (1) ◽

pp. 8358 ◽

Cited By ~ 4

Author(s):

Giorgio Caretta ◽

Debora Robba ◽

Ivano Bonadei ◽

Melissa Teli ◽

Benedetta Fontanella ◽

...

Keyword(s):

Case Report ◽

Patent Foramen Ovale ◽

Pulmonary Thromboembolism ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Acute Pulmonary Thromboembolism

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Closure of persistent foramen ovale with the BioSTAR biodegradable PFO closure device: Feasibility and long-term outcome

Scandinavian Cardiovascular Journal ◽

10.3109/14017431.2011.591819 ◽

2011 ◽

Vol 45 (5) ◽

pp. 267-272 ◽

Cited By ~ 5

Author(s):

Alexia Karagianni ◽

Putte Abrahamsson ◽

Eva Furenäs ◽

Peter Eriksson ◽

Mikael Dellborg

Keyword(s):

Closure Device ◽

Foramen Ovale ◽

Term Outcome ◽

Long Term Outcome ◽

Persistent Foramen Ovale ◽

Pfo Closure

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Development of severe intrapulmonary shunting in a patient with carcinoid heart disease after closure of a persistent foramen ovale: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab494 ◽

2021 ◽

Author(s):

Dominik Schüttler ◽

Konstantinos Mourouzis ◽

Christoph J Auernhammer ◽

Konstantinos D Rizas

Keyword(s):

Heart Disease ◽

Symptomatic Therapy ◽

Carcinoid Heart Disease ◽

Foramen Ovale ◽

Residual Shunt ◽

Selective Internal Radiotherapy ◽

Intrapulmonary Shunting ◽

Persistent Foramen Ovale ◽

One Year ◽

Pfo Closure

Abstract Background Neuroendocrine tumors (NETs) can affect the cardiopulmonary system causing carcinoid heart disease and valve destruction. Persistent foramen ovale (PFO) occlusion is indicated in patients with carcinoid heart disease and shunt-related left-heart valve involvement. Case Summary We report the case of a 54-year-old female patient with metastatic NET originating from the small bowel. The patient was on medication with octreotide and telotristat. One year after diagnosis, cardiac involvement of carcinoid developed with regurgitation of right-sided and, due to PFO, left-sided heart valves. Closure of PFO was performed (Occlutech 16/18 mm). One year later she presented with recurrent severe dyspnoea. The PFO-occluder was in situ without residual shunt. Valvular heart disease, including left-sided disease, and metastatic spread of NET were stable. Blood gas analysis revealed arterial hypoxemia (pO2 = 44 mmHg/5.87 kPa), which was related to extensive intrapulmonary shunting (31% shunt fraction) confirmed using contrast-enhanced echocardiography. The patient was prescribed long-term oxygen supplementation as symptomatic therapy and anti-tumoral therapy was intensified with selective internal radiotherapy of the liver metastases in order to improve biochemical control of the carcinoid syndrome. Discussion An echocardiographic assessment of the presence of a PFO is recommended in patients with NET as PFO closure minimizes the risk of left-sided carcinoid valve disease. Deterioration of symptomatic status in metastasized NET might also be due to a hepatopulmonary-like physiology with intrapulmonary shunting and arterial desaturation thought to be caused by vasoactive substances secreted by the tumor. This is a rare case describing the development of this syndrome after PFO closure.

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Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management

Indonesian Journal of Cardiology ◽

10.30701/ijc.1144 ◽

2021 ◽

Vol 42 (3) ◽

Author(s):

Dhanang Ali Yafi ◽

Azmi Azmi

Keyword(s):

Patent Foramen Ovale ◽

Adult Population ◽

Management Strategies ◽

Cryptogenic Stroke ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Arterial Circulation ◽

Systemic Embolization ◽

The Relationship ◽

Pfo Closure

A patent foramen ovale (PFO) is a common disorder that affects between 20-34% of the adult population. This condition is a benign finding for most people. However, In some the PFO can open widely and enabling paradoxical embolism to transit from venous to arterial circulation, which is associated with stroke and systemic embolization. There are still unclear to date regarding the effectiveness of pharmacological anticoagulant therapy, defined as antithrombin or antiplatelet therapy, which has proven to be more beneficial for patients with PFO and cryptogenic stroke. In addition, surgical and transcutaneous PFO closure has been proposed for secondary prevention of stroke in patients with cryptogenic stroke with PFO. Both catheter-based and surgical modes of closure have been shown to reduce the incidence of subsequent embolism substantially. This review will discuss the evidence regarding the relationship between PFO and cryptogenic stroke and decision making for management strategies.

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Surgical Patent Foramen Ovale Closure for Prevention of Paradoxical Embolism–Related Cerebrovascular Ischemic Events

Circulation ◽

10.1161/circ.100.suppl_2.ii-171 ◽

1999 ◽

Vol 100 (suppl_2) ◽

Author(s):

Joseph A. Dearani ◽

Baran S. Ugurlu ◽

Gordon K. Danielson ◽

Richard C. Daly ◽

Christopher G. A. McGregor ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Univariate Analysis ◽

Significant Risk ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Surgical Closure ◽

Ischemic Events ◽

Pfo Closure

Background —The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results —We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n=82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n=1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with 1 caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2% at 1 year and 83.4±6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis ( P =0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions —Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.

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Saddle Pulmonary Embolus Caught in Transit across a Patent Foramen Ovale

Case Reports in Pulmonology ◽

10.1155/2019/5747598 ◽

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.

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