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Thrombus formation in a patent foramen ovale
Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) e79–e80
Letter to editor Thrombus formation in a patent foramen ovale Thrombose d’une foramen ovale perme´able
A R T I C L E I N F O
Keywords: Patent foramen ovale Thrombus Treatment Mots cle´s: Foramen ovale perme´able Thrombus Traitement
A 79-year-old man was transferred to intensive care unit with septic shock 2 days after he developed a pneumonia. He quickly presented ARDS and severe disseminated intravascular coagulation (DIC) without bleeding. Arterial saturation of oxygen remained low despite optimal mechanical ventilation. Transoesophageal echocardiography using color-Doppler revealed a patent
foramen ovale (PFO) (Fig. 1A). A few hours later, hemodynamic state worsened. A new transoesophageal echocardiography revealed an acute cor pulmonale with thrombus in the right pulmonary artery and a thrombus trapped in the PFO (Fig. 1B). The patient subsequently developed bi-atrial thrombus straddling the PFO. As long as the PFO acted as a pressure relief valve, hemodynamic state was stabilized despite ARDS and pulmonary embolism related pulmonary hypertension. When the thrombus occluded PFO, right ventricular overpressure raised, inducing irrecoverable cardiogenic shock. Despite treatment with heparin and thrombolysis, vasopressors, inotropes, and nitric oxide, the patient developed refractory cardiogenic shock with multi organ failure, and died 1 day later. PFO’s prevalence in autopsy studies of general population is 25 to 30% [1]. Higher prevalence has been reported in conditions with elevated right-heart pressures [2]. In the presence of low cardiac output and stasis, co-existence of DIC may have a paradoxical effect of enhancing thrombus formation [3]. This type of non-mobile thrombi (in opposition to mobile thrombi resulting from peripheral venous thrombosis) are normally less likely to cause pulmonary embolism and decrease with anticoagulant therapy [4,5]. Unfortunately things were different for our patient. There are no clear recommendations regarding treatment of entrapped thrombi in PFO. Surgical embolectomy, frequently proposed, might be impossible in case of severe multiorgan failure. Anticoagulant therapy may be an alternative treatment [6]. In case of failure and cardiogenic shock, thrombolysis should probably be considered, even in the presence of DIC.
Fig. 1. A. Multiplane TEE (638). Visualizationof right to left shunt with color-doppler. Ao: indicates ascending aorta; IAS: interatrial septum; LA: left atrium; RA: right atrium. B. Multiplane TEE (1248). Thrombus trapped in a patent foramen ovale. SVC indicates superior vena cava; LA: left atrium; RA: right atrium.
0750-7658/$ – see front matter ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.annfar.2013.02.018
e80
Letter to editor / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) e79–e80
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
[5] Chapoot L, Tassigny C, Nazeyrollas P, Poismans P, Maillier B, Maes D, et al. Pulmonary embolism and thrombi of the right heart. Arch Mal Coeur Vaiss 1995;88:1723–8. [6] Wirtz SP, Schmidt C, Hammel D, Hoffmeier A, Berendes E. Crossing atrial thrombus in a patient with recurrent pulmonary embolism. Crit Care Med 2002;30:1902–5.
References [1] Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. [2] Shanoudy H, Soliman A, Raggi P, Liu JW, Russell DC, Jarmukli NF. Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 1998;113:91–6. [3] Lo SS, Sutton GC. Right atrial thrombus presenting in a patient with heart failure and disseminated intravascular coagulation. Eur Heart J 1996;17:1605–6. [4] The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989;10:1046–59.
L. Franck, S. de Rudnicki, N. Libert* De´partement d’anesthe´sie-re´animation, hoˆpital d’instruction des Arme´es de Val-de-Graˆce, 74, boulevard de Port-Royal, 75005 Paris, France *Corresponding author. E-mail address : [email protected] (N. Libert)
Letter to editor Thrombus formation in a patent foramen ovale Thrombose d’une foramen ovale perme´able
A R T I C L E I N F O
Keywords: Patent foramen ovale Thrombus Treatment Mots cle´s: Foramen ovale perme´able Thrombus Traitement
A 79-year-old man was transferred to intensive care unit with septic shock 2 days after he developed a pneumonia. He quickly presented ARDS and severe disseminated intravascular coagulation (DIC) without bleeding. Arterial saturation of oxygen remained low despite optimal mechanical ventilation. Transoesophageal echocardiography using color-Doppler revealed a patent
foramen ovale (PFO) (Fig. 1A). A few hours later, hemodynamic state worsened. A new transoesophageal echocardiography revealed an acute cor pulmonale with thrombus in the right pulmonary artery and a thrombus trapped in the PFO (Fig. 1B). The patient subsequently developed bi-atrial thrombus straddling the PFO. As long as the PFO acted as a pressure relief valve, hemodynamic state was stabilized despite ARDS and pulmonary embolism related pulmonary hypertension. When the thrombus occluded PFO, right ventricular overpressure raised, inducing irrecoverable cardiogenic shock. Despite treatment with heparin and thrombolysis, vasopressors, inotropes, and nitric oxide, the patient developed refractory cardiogenic shock with multi organ failure, and died 1 day later. PFO’s prevalence in autopsy studies of general population is 25 to 30% [1]. Higher prevalence has been reported in conditions with elevated right-heart pressures [2]. In the presence of low cardiac output and stasis, co-existence of DIC may have a paradoxical effect of enhancing thrombus formation [3]. This type of non-mobile thrombi (in opposition to mobile thrombi resulting from peripheral venous thrombosis) are normally less likely to cause pulmonary embolism and decrease with anticoagulant therapy [4,5]. Unfortunately things were different for our patient. There are no clear recommendations regarding treatment of entrapped thrombi in PFO. Surgical embolectomy, frequently proposed, might be impossible in case of severe multiorgan failure. Anticoagulant therapy may be an alternative treatment [6]. In case of failure and cardiogenic shock, thrombolysis should probably be considered, even in the presence of DIC.
Fig. 1. A. Multiplane TEE (638). Visualizationof right to left shunt with color-doppler. Ao: indicates ascending aorta; IAS: interatrial septum; LA: left atrium; RA: right atrium. B. Multiplane TEE (1248). Thrombus trapped in a patent foramen ovale. SVC indicates superior vena cava; LA: left atrium; RA: right atrium.
0750-7658/$ – see front matter ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.annfar.2013.02.018
e80
Letter to editor / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) e79–e80
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
[5] Chapoot L, Tassigny C, Nazeyrollas P, Poismans P, Maillier B, Maes D, et al. Pulmonary embolism and thrombi of the right heart. Arch Mal Coeur Vaiss 1995;88:1723–8. [6] Wirtz SP, Schmidt C, Hammel D, Hoffmeier A, Berendes E. Crossing atrial thrombus in a patient with recurrent pulmonary embolism. Crit Care Med 2002;30:1902–5.
References [1] Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. [2] Shanoudy H, Soliman A, Raggi P, Liu JW, Russell DC, Jarmukli NF. Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 1998;113:91–6. [3] Lo SS, Sutton GC. Right atrial thrombus presenting in a patient with heart failure and disseminated intravascular coagulation. Eur Heart J 1996;17:1605–6. [4] The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989;10:1046–59.
L. Franck, S. de Rudnicki, N. Libert* De´partement d’anesthe´sie-re´animation, hoˆpital d’instruction des Arme´es de Val-de-Graˆce, 74, boulevard de Port-Royal, 75005 Paris, France *Corresponding author. E-mail address : [email protected] (N. Libert)