A 40-year-old male experienced intermittent heart palpitations and chest pain for 2 years was unconscious 20 h ago before being admitted to our hospital. In addition, a month prior to this incident, the patient had fractured his left calcaneus during an accident. Echocardiography revealed a large thrombus (39 mm × 18 mm) crossing the midst of the atrial septum, swinging in the right ventricular inflow tract with cardiac cycle (Panel A) (see Supplementary material online, Videos S1 and S2). Dual-source computed tomography (CT) showed a continuous low-density shadow in the left atrium (16.7 mm × 9.9 mm) and right atrium (41.4 mm × 14.4 mm), and a filling defect shadow was found in the bifurcation of the pulmonary arteries in both lungs and distal lumen (large bilateral pulmonary embolism, with a thrombosis index of ∼75%) (Panel B). Brain CT showed a low-density C-shaped patchy shadow on the right parietal lobe (Panel C), which indicated encephalomalacia. Colour-coded Doppler flow image showed no blood flow in the left distal popliteal veins, indicating a thrombo-embolism (Panel D). The patient underwent a pulmonary artery embolectomy to remove the pulmonary thrombus (Panel E), followed by a pathological examination. The presence of red blood cells, platelets, and fibrin confirmed that the tissue was a thrombus.
To our knowledge, this is the first time that a thrombus has been observed straddling the PFO. This discovery provides direct evidence for a paradoxical embolism, and lays out a foundation for PFO intervention.
S.X. performed statistical analysis. Q.Q. handled funding and supervision. D.L., C.Z., J.Y., C.X. and R.L. acquired the data. X.S., G.Z., D.L. conceived and designed the research. D.L. and L.W. drafted the manuscript. Q.Q. and H.Z. made critical revision of the manuscript for key intellectual content.
Funding
Funding to pay the Open Access publication charges for this article was provided by Wuhan Asia Heart Hospital (Hubei, China).
Supplementary material is available at European Heart Journal online.
Supplementary Material
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.