Abstract
Patent foramen ovale (PFO) in the setting of venous thromboembolism is associated with paradoxical embolization. We describe a patient who presented with pulmonary embolism, underwent pulmonary embolectomy, and postoperatively developed paradoxical embolization to the lower extremity.
A 27‐year‐old African American male presented to the hospital with shortness of breath and midsternal chest pain along with neck vein distention. A CT scan with contrast showed the presence of a saddle embolus in both pulmonary arteries. The next day, the patient developed right ventricular failure and hypotension. The patient was taken to the operating room for a pulmonary embolectomy. Postoperatively, the patient developed acute left lower extremity ischemia. The origin of the embolus was suspected to be cardiac. A transesophageal echocardiogram (TEE) revealed thrombus on the mitral valve and a PFO with right to left shunt. At this point vascular surgery for revascularization of the left lower extremity was performed. Two days later, the patient was taken for a repeat cardiac surgery and the left‐sided thrombus was removed along with a closure of the PFO.
This case signifies the importance of complete TEE and a search for PFO in patients with massive pulmonary embolism especially prior to surgical embolectomy because hemodynamic disturbances of pulmonary embolism and surgical embolectomy may cause migration of the thrombus from the right side to the left side of the heart. Copyright © 2009 Wiley Periodicals, Inc.
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References
- 1. Boyden EA. Segmental Anatomy of the Lungs: Study of the Patterns of the Segmental Bronchi and Related Pulmonary Vessels. New York, NY: McGraw‐Hill; 1955; 23–32. [Google Scholar]
- 2. Wharton LR, Pierson JW. Minor forms of pulmonary embolism after abdominal operations. JAMA 1922; 79: 1904–1910. [Google Scholar]
- 3. Hara et al. Patent foramen ovale: current pathology, patho‐ physiology, and clinical status. J Am Coll Cardiol 2005 Nov 1; 46(9): 1768–1776. [DOI] [PubMed] [Google Scholar]
- 4. Shan Guo, Ingram Roberts, and Jose Missri. Paradoxical embolism, deep vein thrombosis, pulmonary embolism in a patient with patent foramen ovale: a case report. J Med Case Reports 2007; 1: 104. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Roby D Rakhit Patent foramen ovale (PFO) and paradoxical embolism Heart 2003; 89: 1362. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Gibson, NS , Sohne, M , Buller, HR . Prognostic value of echocardiography and spiral computed tomography in patients with pulmonary embolism. Curr Opin Pulm Med 2005; 11: 380. [DOI] [PubMed] [Google Scholar]
- 7. Goldhaber SZ, Echocardiography in the management of pul‐ monary embolism. Ann Intern Med 2002 May 7; 136(9): 691–700. [DOI] [PubMed] [Google Scholar]
- 8. Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on transesophageal echocardiography. Anesthesiology 1996; 84: 986–1006. [PubMed] [Google Scholar]
- 9. Peter Rosenberger, Stanton K. Shernan, Simon C . Body, and Holger K. Eltzschig. Utility of Intraoperative Transesophageal Echocardiography for Diagnosis of Pulmonary Embolism. Anesth Analg 2004; 99: 12–16. [DOI] [PubMed] [Google Scholar]
- 10. Chant, H ; McCollum, C . Stroke in young adults: the role of paradoxical embolism. Thromb Haemost 2001; 85: 22–29. Review. [PubMed] [Google Scholar]
- 11. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002; 121: 877–905. [DOI] [PubMed] [Google Scholar]
- 12. Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads–80 case reports. G_Chest 1997 Mar; 111(3): 537–43. [DOI] [PubMed] [Google Scholar]
- 13. Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation 2002 Mar 26; 105(12): 1416–9. [DOI] [PubMed] [Google Scholar]
- 14. Holmes DR Jr, Cabalka, A . Was your mother right–do we always need to close the door?. Circulation 2002; 106: 1034. [DOI] [PubMed] [Google Scholar]