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Ann Thorac Surg 1995;59:1559-1561
© 1995 The Society of Thoracic Surgeons

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Case Report

Surgical Treatment of Impending Paradoxical Embolism Through Patent Foramen Ovale

Departments of Cardiac Surgery and Cardiology, University Hospital of Ghent, Ghent, Belgium

Accepted for publication October 14, 1994.

	Abstract

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We describe the case of a patient with deep venous thrombosis who had cerebral and extremity paradoxical emboli and an intracardiac thrombus crossing a patent foramen ovale identified by echocardiography. He was treated successfully with immediate intracardiac embolectomy and closure of the patent foramen ovale.

	Introduction

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Paradoxical embolism (PE) can be presumed in the presence of the following triad: (1) venous thrombosis in the systemic circulation with or without pulmonary embolism; (2) abnormal right-to-left shunt (usually cardiac, rarely pulmonary); and (3) arterial embolism. To be ``proven,'' a venous thrombus should be found lodged in the intracardiac shunt [1]. First described by Cohnheim [2] in 1877, PE remained a postmortem finding until 1930. Since that time, a number of cases have been recognized during life by both invasive and noninvasive methods [3–5]. Surgical treatment has generally been limited to peripheral embolectomy with or without interruption of the inferior vena cava [3]. Intracardiac embolectomy and concomitant closure of the defect has been used in only 2 cases of patent foramen ovale (PFO) [5, 6] and 1 case of atrial septal defect [7] with proven PE but to an extracerebral site. We report the case of a patient with peripheral and cerebral PE and an embolus that was overriding a PFO and was detected by echocardiography and successfully removed surgically.

A 42-year-old man, the victim of a minor car accident, was admitted to a community hospital with a right-sided hemiplegia and aphasia but no other traumatic lesions. Cerebral computed tomographic scan 3 days later confirmed a left-sided temporal infarction. The neurologic deficit resolved partially. The patient also had a large, ulcerated perianal and intergluteal mass, which proved after biopsy to be a well-differentiated epidermoid epithelioma.

Two days after admission, he was heparinized for a deep venous thrombosis in the right leg, confirmed by duplex Doppler echography. The next day, the right leg became ischemic because of an occlusion of the right common iliac artery. He underwent arterial embolectomy, concomitant venous thrombectomy, and biopsy of enlarged inguinal lymph nodes. Histologic examination revealed recent mixed thrombus in the arterial and venous surgical specimens and aspecific lymphadenitis without tumoral invasion. One day later, conventional transthoracic echocardiography showed a mass in the right atrium, and the patient was transferred to University Hospital Ghent.

Examination on admission showed an obese, hemiparetic, and dysphasic man in stable hemodynamic condition and without respiratory distress. A large, ulcerated perianal mass and a substantial, painful edema of the right leg were noted. Electrocardiogram showed sinus rhythm and incomplete right bundle-branch block. Chest roentgenogram was normal apart from large hila. The creatine kinase level was 12,379 IU/L. Transesophageal echocardiography (Vingmed CFM 750; Horten, Norway) revealed an elongated mass straddling a PFO with the right end floating in the inferior vena cava and the opposite, frayed end in the left atrium (Fig 1).

View larger version (74K): [in this window] [in a new window]   Fig 1. . Transesophageal echocardiograms showing (A) the part of the thrombus (arrow) in the right atrium (RA) and (B) the thrombus (arrow) crossing the foramen ovale into the left atrium (LA).

View larger version (0K): [in this window] [in a new window]   Fig 2. . Surgical specimen of the thrombus. (Tape is marked in centimeters.)

	Comment

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The deep venous thrombosis in this patient presumably was of paraneoplastic origin and led to successive cerebral and extremity arterial embolism, the two most common locations of PE [4]. The patient had a PFO, which is the predominant intracardiac shunt in cases of PE [3, 4]. On clinical grounds, although not confirmed by ventilation/perfusion pulmonary scan or pulmonary angiography, he had no pulmonary embolus, which has been described in 60% of surviving patients [3] and in up to 85% of autopsy cases [1]. Until the advent of echocardiography, PE could only be suspected during life on the basis of indirect criteria [3] and could be proven only at postmortem examination [8]. This report confirms that conventional and especially transesophageal echocardiography permits definite diagnosis of an impending PE through a PFO [4–6] or an atrial septal defect [7] and expedites its management. Surgical intracardiac embolectomy and closure of the PFO seemed the most logical approach in our patient to prevent further systemic or potentially fatal pulmonary embolism [3, 4]. Although in the presence of a recent cerebral infarct, cardiopulmonary bypass might theoretically be hazardous because of the need of total-body heparinization and possible localized low-flow states, contradictory reports [9] exist. A heparin-coated cardiopulmonary bypass circuit requiring only low-dose systemic heparin has been suggested as a useful alternative in recent stroke patients [10]. On the other hand, the presence of the recent cerebral infarct and the operative interventions contraindicated a recently reported therapeutic alternative consisting of thrombolysis followed by PFO closure using a percutaneous transcatheter device [11].

	Footnotes

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Address reprint requests to Dr Caes, Department of Cardiac Surgery, University Hospital of Ghent, De Pintelaan 185, B-9000 Ghent, Belgium.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Johnson BI. Paradoxical embolism. J Clin Pathol 1951;4: 316–32.
2. Cohnheim J. Thrombose und embolie. Vorl Allg Pathol 1877;1:143–4.
3. Leonard RCF, Neville E, Hall RJC. Paradoxical embolism. A review of cases diagnosed during life. Eur Heart J 1982;3: 362–70.[Abstract/Free Full Text]
4. Loscalzo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J 1986;112:141–5.[Medline]
5. Barnard SP, Kulatilake ENP, Azzu AA, Ikram S. Straddle embolus-imminent paradoxical embolus diagnosed by echocardiography and treated surgically. Eur J Cardio-thorac Surg 1991;5:105–7.[Abstract]
6. Nelson CW, Snow FR, Barnett M, McRoy L, Wechsler AS, Nixon JV. Impending paradoxical embolism: echocardiographic diagnosis of an intracardiac thrombus crossing a patent foramen ovale. Am Heart J 1991;122:859–62.[Medline]
7. Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol 1985;5:1002–4.[Abstract]
8. Sardesai SH, Marshall RJ, Mourant AJ. Paradoxical systemic embolization through a patent foramen ovale [Letter]. Lancet 1989;1:732–3.[Medline]
9. Beall AC Jr, Jones JW, Guinn GA, Svensson LG, Nahas C. Cardiopulmonary bypass in patients with previously completed stroke. Ann Thorac Surg 1993;55:1383–5.[Abstract]
10. Jones DR, Hill RC, Vasilakis A, et al. Safe use of heparin-coated bypass circuits incorporating a pump-oxygenator. Ann Thorac Surg 1994;57:815–9.[Abstract]
11. Movsowitz C, Podolsky LA, Meyerowitz CB, Jacobs LE, Kotler MN. Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology? J Am Soc Echocardiogr 1992;5:259–70.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yves V. Van Belleghem Guido J. Van Nooten Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Caes, F. L. Articles by Van Nooten, G. J. Search for Related Content PubMed PubMed Citation Articles by Caes, F. L. Articles by Van Nooten, G. J.