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Paradoxical Embolism with Thrombus Stuck in a Patent Foramen Ovale: a Review of Treatment Strategies

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Paradoxical Embolism with Thrombus Stuck in a Patent Foramen Ovale: a Review of Treatment Strategies European Review for Medical and Pharmacological Sciences 2018; 22: 8885-8890 Paradoxical embolism with thrombus stuck in a patent foramen ovale: a review of treatment strategies A. MIRIJELLO1, M.M. D’ERRICO1, S. CURCI1, P. SPATUZZA2, D. GRAZIANO1, M. LA VIOLA1, V. D’ALESSANDRO1, M. GRILLI1, G. VENDEMIALE3, M. CASSESE2, S. DE COSMO1 1Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy 2Department of Cardiovascular Sciences, Cardiac Surgery Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy 3Internal Medicine and Geriatrics Residency School, University of Foggia, Foggia, Italy Antonio Mirijello and Maria Maddalena D’Errico equally contributed to the manuscript Abstract. – OBJECTIVE: Paradoxical embo- Introduction lism represents a rare condition occurring when a thrombus originating from venous system pro- Paradoxical embolism is defined as a ve- duces pulmonary embolism and systemic em- nous thrombosis producing systemic embolism bolization through an intracardiac or pulmonary 1 shunt. The evidence of a thrombus entrapped in through an intracardiac or pulmonary shunt . a patent foramen ovale (PFO) is an even more ra- The most common cause of intracardiac shunt is re condition. There is uncertainty about the op- represented by patent foramen ovale (PFO). This timal treatment strategy. last can be found in about a quarter of the adult PATIENTS AND METHODS: A 58-year-old population2 and it is generally asymptomatic3. male patient was admitted to our Internal Medi- However, it could predispose to cryptogenic cine Unit with the diagnosis of bilateral broncho- stroke4 due to systemic embolism. On the con- pneumonia. During hospitalization, the co-oc- currence of chest pain and amaurosis led us to trary, the exact incidence of paradoxical embo- hypothesize a paradoxical embolism. lism is not known. RESULTS: Transthoracic echocardiography The evidence of a thrombus entrapped in a showed the presence of a thrombus stuck over PFO is even more rare and it constitutes a clinical the interatrial septum. A contrast-enhanced emergency due to the risk of massive systemic chest CT scan showed multiple pulmonary em- embolization. Given the rarity of this condition, bolisms and brain CT scan documented a hy- there are no standardized guidelines for the treat- podense area, of ischemic significance, in the 5 left occipital lobe near tentorium. In order to ment of these patients . The aim of the present prevent further embolization, emergency cardi- review is to focus on this condition and to discuss ac surgery (right atriotomy, removal of thrombus the available treatment strategies. and closure of the PFO, pulmonary thrombecto- my) was performed without complications. CONCLUSIONS: Although rare, the evidence of Case Report a thrombus stuck in a patent foramen ovale rep- resents a clinical emergency. The optimal thera- peutic approach is still debated. The surgical cor- A 58-year-old male patient presented to the rection seems to be a safe and effective option Emergency Department (ED) because of the per- for these patients. sistence, for about two weeks, of fever (maximum 38°C), dry cough and arthralgia. The appearance Key Words of chest pain – elicited by breathing – represented Embolism, Thrombosis, Pulmonary embolism, Stroke, Patent foramen ovale. the reason for ED referral. At home he had tak- en aspirin, paracetamol and antibiotics without Corresponding Author: Antonio Mirijello, MD; e-mail: [email protected] 8885 A. Mirijello, M.M. D’Errico, S. Curci, P. Spatuzza, D. Graziano, et al. effect. Patient’s medical history was significant and NT-pro-BNP (2435 ng/l, n.v. 0-125 pg/ml). for arterial hypertension and chronic obstructive This symptom together with pleuritic chest pain pulmonary disease. He was an active smoker (20 and tachycardia drew our attention to the possi- pack/year). His home therapy consisted of rami- bility of thromboembolism. pril and carvedilol. Diagnosis Blood and Instrumental Tests Transthoracic echocardiography showed the At the ED, blood pressure was normal (125/80 presence of hypoechoic masses in both right mmHg), pulse rate was 120 bpm, oxygen sat- and left atria moving over the interatrial septum uration in room air was 94%, temperature was (Video 1). 38.5°C. Lab tests showed mild leukocytosis Contrast-enhanced chest CT scan showed a (WBC 11280/μl, Neu 80.9%). An electrocardio- saddle embolus at the bifurcation of the main pul- gram (ECG) showed sinus tachycardia. Chest monary artery, multiple opacification defects in X-ray showed thin and circumscribed basal opac- main branches, lobar and segmental branches of ities bilaterally (Figure 1a-b). Thus, the patient pulmonary arteries, and the presence of bilateral was admitted to our Internal Medicine Unit with basal subpleural thickening (Figure 2 a-b-c). No the diagnosis of bilateral bronchopneumonia. In masses or venous thrombosis in the abdominal our ward, after cultural exams (blood, sputum CT-scans. Brain CT scan documented a hypodense and urine), treatment with levofloxacin was start- area of ischemic significance in the left occipital ed. The day after the admission, the patient lobe near tentorium (Figure 3). Doppler ultraso- complained of right hemianopsia lasting about nography of lower extremities wWas negative for 2 hours. Laboratory results showed significantly thrombus. Anticoagulation with enoxaparin was elevated D-dimer (19351 ng/ml, n.v. 0-500.0 ng/ started and the patient was evaluated and under- ml), troponin (0.211 ng/ml, n.v. 0-0.045 ng/ml) went emergency cardiac surgery. A B Figure 1 A-B. Chest X-ray showing thin and circumscribed bilateral basal opacities. 8886 Paradoxical embolism with thrombus stuck in a patent foramen ovale A Figure 3 Brain CT scan showing a hypodense area, of isch- emic significance, in the left occipital lobe near tentorium. B was removed, and the patent foramen ovale was occluded by direct suture (Figure 4). Left atrium was opened and explored: no further thrombotic lesions were identified. Pulmonary artery was opened: inside the main pulmonary artery and the left pulmonary trunk, up to left lobar arteries, a huge amount of coarse thrombotic material was identified and removed. Outcome Screening for thrombophilic state showed high homocysteine levels and methylene tetrahydrofo- late reductase (MTHFR) homozygous mutation. Thus, it is conceivable that a transient minor in- C fection acted as pro-thrombotic cause in an active Figure 2 A-C. Contrast-enhanced chest CT scan showing smoker with hyperhomocysteinemia due to the opacification defects in the main branches of the pulmonary homozygous mutation of MTHFR. The patient arteries. was discharged on the seventh post-operative day with a 6-months edoxaban prescription, folic acid supplementation and indication to quit smoking. Treatment: Surgical Procedure Through a median sternotomy and extracor- Discussion poreal circulation, a right atriotomy was per- formed, and a big fresh thrombus was visualized The present case shows the occurrence of neu- inside the right atrium, crossing, via a patent fo- rological symptoms in a patient admitted for fe- ramen ovale, inside the left atrium. The thrombus ver and chest pain. The diagnosis of paradoxical 8887 A. Mirijello, M.M. D’Errico, S. Curci, P. Spatuzza, D. Graziano, et al. the diagnosis of pneumonia requires suggestive clinical features of respiratory system infection, demonstrable infiltrate by chest radiograph or oth- er imaging technique, with or without supporting microbiological data7. Raised inflammatory index- es (e.g., leukocytosis), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), are not helpful to differentiate bronchopneumonia from pulmonary embolism. However, leukocytes and ESR are modestly increased in pulmonary embo- lism, while significantly higher in patients with bronchopneumonia8. Moreover, in our patient, procalcitonin levels were normal. The diagnosis of pneumonia could also be supported by the presence of opacities at bilateral basis of the lungs, which may also indicate infarcted pulmonary ar- eas (Hampton hump sign)9. In our case, the small opacities observed at X-ray, could be attributable to pulmonary embolism complicated with lung infarction, as showed by chest CT-scan (Figure 2c). The patient had no known risk factor for, nor history of, thromboembolism. According to Well’s score10, the patient should be considered at low-risk for pulmonary embolism. D-dimer, tro- ponin and NT-pro-BNP have not been performed in ED. D-dimer could be elevated in presence of inflammatory state, and probably could not be Figure 4. Picture of the thrombus stuck in the patent fora- helpful to discriminate the diagnosis11. However, men ovale and removed from the right atrium during surgical procedure. elevated troponin and NT-pro-BNP, associated to electrocardiographic findings of sinus tachycar- dia12 could support the suspicion of PE. Proba- embolism was based on clinical features and CT bly, hemodynamic stability, fever, leukocytosis, evidence of both stroke and pulmonary embolism, cough, chest pain and the absence of risk factors together with the echocardiographic evidence of a for thromboembolism directed towards a typical thrombus stuck in PFO. The choice was to treat bronchopneumonia picture. After admission, the patient by emergency cardiac surgery, in order association between chest/respiratory symptoms, to reduce the risk of massive re-embolism, with tachycardia and hemianopsia drew our attention subsequent anticoagulation.
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