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Thrombus-in-transit and paradoxical embolism
Thrombus-in-Transit and Paradoxical Embolism Kul Aggarwal, MD, MRCP(UK), FACC, Vinod K. Jayam, MD, Michael A. Meyer, MD, Atasu K. Nayak, MD, FACC, and Sriram Nathan, MD, Columbia, Missouri
Paradoxical embolism is an uncommon but clinically important phenomenon. Elements of diagnosis include the presence of: (1) a venous thrombus, (2) an arterial embolus, (3) a communication between the right and left heart, and (4) a thrombus traversing such a communication. Unfortunately, all of these elements can be rarely demonstrated in each case but the probability should be considered in any patient with 2 or more present. It should be
Thromus-in-transit across the interatrial septum
through a patent foramen ovale is rarely seen as it is usually a transient phenomenon. However, when visualized, it serves to confirm the mechanism of an arterial embolic event and presents a challenging management problem for the clinician. This case highlights the value of echocardiography in the detection of such a case.
suspected in patients who have evidence of systemic arterial emboli without apparent cause. A transesophageal echocardiogram with contrast should be considered in cases where paradoxical embolism is a possibility. We present a case in which a “thrombus-in-transit” was imaged across the interatrial septum in a patient with a patent foramen ovale, deep venous thrombosis, and an embolic cerebrovascular stroke. (J Am Soc Echocardiogr 2002;15:1021-2.)
vena cava. The patient was then taken to the operating room for removal of the intracardiac thrombus. The patient was anesthetized and intubated. A transesophageal probe was introduced and images obtained. These images showed that the thrombus was no longer present (Figure 2). A microbubble contrast study was positive for crossover of bubbles from the right atrium to the left atrium through a patent foramen ovale. The patient was returned to the intensive care department without opening his chest. He gradually recovered without further events.
CASE REPORT A 75-year-old man underwent abdominal operation uneventfully. Three days after surgery, he was noted to have frequent supraventricular ectopy. Shortly thereafter, he had a cerebrovascular stroke with right-sided weakness and speech impairment. Magnetic resonance imaging showed findings consistent with an embolic stroke. A transthoracic echocardiogram was obtained that showed mobile masses in the right atrium, left atrium, and left ventricular outflow tract. A transesophageal echocardiogram (TEE) was performed that revealed a mobile thrombus in the right atrium traversing the interatrial septum and extending into the left atrium (Figure 1). A microbubble contrast study produced negative findings. An ultrasound study of the lower extremities showed evidence of deep vein thrombosis. Intravenous heparin was started and a Greenfield filter was placed in the inferior
From the University of Missouri Health Sciences Center, Columbia. Reprint requests: Kul Aggarwal, MD, FACC, University Hospital and Clinics, MC312 Cardiology, One Hospital Dr, Columbia, MO 65212 (E-mail: [email protected]). Copyright 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 ⫹ 0 27/4/121279 doi:10.1067/mje.2002.121279
DISCUSSION Paradoxical embolism is an uncommon but clinically very important condition. To prove paradoxical embolism as being the cause of a clinical condition, the following elements usually need to be present: (1) a thrombus in the systemic venous circulation, (2) a communication between the left and right heart such as an atrial septal defect or a patent foramen ovale, (3) a thrombus in the systemic arterial circulation, and (4) evidence that the thrombus traversed through the communication between the right and left heart. Of these 4 elements, the thrombus traversing through the communication is the most difficult to establish because it is usually transient in nature. Therefore, there is a paucity of reported cases of such thrombi being seen.1 In our case report, all elements are present making the diagnosis a definite one. The condition should be clinically suspected in cases in which there is unexplained arterial thromboemboli in the setting of a venous thrombus. In such cases a transthoracic echocardiogram with color Doppler and agitated saline contrast or a TEE may help establish the diagnosis of atrial septal
1021
1022 Aggarwal et al
Figure 1 Transesophageal echocardiographic image showing thrombus in right atrium extending into left atrium through patent foramen ovale.
defect, patent foramen ovale, or an atrial septal aneurysm thereby suggesting the probability of a paradoxical embolus. In cases in which there is an arterial thromboembolic phenomenon without an obvious cause, the incidence of patent foramen ovale has been shown to be higher than in control subjects.2 In such cases, however, only 2 of the 4 elements mentioned above are established, making the diagnosis possible but not proven. This point is especially relevant because of the reported high incidence of patent foramen ovale in otherwise “normal” hearts. In a necropsy study,3 the incident was 27.3%. A TEE study with color Doppler and contrast echocardiography is the most sensitive diagnostic technique for diagnosing patent foramen ovale.4 Once the diagnosis of paradoxical embolism has been made, decisions regarding management for that particular episode and then prevention of future episodes need to be made. Anticoagulation is obviously an important part in managing the severe episode. Consideration to thrombolysis, caval filters, and operation depends on the clinical situation. Prevention of further events is a complex issue.
Journal of the American Society of Echocardiography September 2002
Figure 2 Transesophageal echocardiographic image showing right and left atria with thrombus no longer seen.
Prevention of deep venous thrombosis is clearly very important and oral anticoagulation should be considered if feasible. The decision to close the interatrial communication percutaneously or surgically has to be individualized. Likelihood of recurrence of deep venous thrombosis, recurrence of thromboembolic events, risks of oral anticoagulation, patient preferences, and degree of residual neurologic deficit from the index event should all be taken into consideration in arriving at a decision. REFERENCES 1. Meacham RR III, Headley AS, Bronze MS, Lewis JB, Rester MM. Impending paradoxical embolism. Arch Intern Med 1998;158:438-48. 2. Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. Stroke 1993;24:1865-73. 3. 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. 4. Hausmann D, Mugge A, Becht I, Daniel WG. Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events. Am J Cardiol 1992;70:668-72.
Paradoxical embolism is an uncommon but clinically important phenomenon. Elements of diagnosis include the presence of: (1) a venous thrombus, (2) an arterial embolus, (3) a communication between the right and left heart, and (4) a thrombus traversing such a communication. Unfortunately, all of these elements can be rarely demonstrated in each case but the probability should be considered in any patient with 2 or more present. It should be
Thromus-in-transit across the interatrial septum
through a patent foramen ovale is rarely seen as it is usually a transient phenomenon. However, when visualized, it serves to confirm the mechanism of an arterial embolic event and presents a challenging management problem for the clinician. This case highlights the value of echocardiography in the detection of such a case.
suspected in patients who have evidence of systemic arterial emboli without apparent cause. A transesophageal echocardiogram with contrast should be considered in cases where paradoxical embolism is a possibility. We present a case in which a “thrombus-in-transit” was imaged across the interatrial septum in a patient with a patent foramen ovale, deep venous thrombosis, and an embolic cerebrovascular stroke. (J Am Soc Echocardiogr 2002;15:1021-2.)
vena cava. The patient was then taken to the operating room for removal of the intracardiac thrombus. The patient was anesthetized and intubated. A transesophageal probe was introduced and images obtained. These images showed that the thrombus was no longer present (Figure 2). A microbubble contrast study was positive for crossover of bubbles from the right atrium to the left atrium through a patent foramen ovale. The patient was returned to the intensive care department without opening his chest. He gradually recovered without further events.
CASE REPORT A 75-year-old man underwent abdominal operation uneventfully. Three days after surgery, he was noted to have frequent supraventricular ectopy. Shortly thereafter, he had a cerebrovascular stroke with right-sided weakness and speech impairment. Magnetic resonance imaging showed findings consistent with an embolic stroke. A transthoracic echocardiogram was obtained that showed mobile masses in the right atrium, left atrium, and left ventricular outflow tract. A transesophageal echocardiogram (TEE) was performed that revealed a mobile thrombus in the right atrium traversing the interatrial septum and extending into the left atrium (Figure 1). A microbubble contrast study produced negative findings. An ultrasound study of the lower extremities showed evidence of deep vein thrombosis. Intravenous heparin was started and a Greenfield filter was placed in the inferior
From the University of Missouri Health Sciences Center, Columbia. Reprint requests: Kul Aggarwal, MD, FACC, University Hospital and Clinics, MC312 Cardiology, One Hospital Dr, Columbia, MO 65212 (E-mail: [email protected]). Copyright 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 ⫹ 0 27/4/121279 doi:10.1067/mje.2002.121279
DISCUSSION Paradoxical embolism is an uncommon but clinically very important condition. To prove paradoxical embolism as being the cause of a clinical condition, the following elements usually need to be present: (1) a thrombus in the systemic venous circulation, (2) a communication between the left and right heart such as an atrial septal defect or a patent foramen ovale, (3) a thrombus in the systemic arterial circulation, and (4) evidence that the thrombus traversed through the communication between the right and left heart. Of these 4 elements, the thrombus traversing through the communication is the most difficult to establish because it is usually transient in nature. Therefore, there is a paucity of reported cases of such thrombi being seen.1 In our case report, all elements are present making the diagnosis a definite one. The condition should be clinically suspected in cases in which there is unexplained arterial thromboemboli in the setting of a venous thrombus. In such cases a transthoracic echocardiogram with color Doppler and agitated saline contrast or a TEE may help establish the diagnosis of atrial septal
1021
1022 Aggarwal et al
Figure 1 Transesophageal echocardiographic image showing thrombus in right atrium extending into left atrium through patent foramen ovale.
defect, patent foramen ovale, or an atrial septal aneurysm thereby suggesting the probability of a paradoxical embolus. In cases in which there is an arterial thromboembolic phenomenon without an obvious cause, the incidence of patent foramen ovale has been shown to be higher than in control subjects.2 In such cases, however, only 2 of the 4 elements mentioned above are established, making the diagnosis possible but not proven. This point is especially relevant because of the reported high incidence of patent foramen ovale in otherwise “normal” hearts. In a necropsy study,3 the incident was 27.3%. A TEE study with color Doppler and contrast echocardiography is the most sensitive diagnostic technique for diagnosing patent foramen ovale.4 Once the diagnosis of paradoxical embolism has been made, decisions regarding management for that particular episode and then prevention of future episodes need to be made. Anticoagulation is obviously an important part in managing the severe episode. Consideration to thrombolysis, caval filters, and operation depends on the clinical situation. Prevention of further events is a complex issue.
Journal of the American Society of Echocardiography September 2002
Figure 2 Transesophageal echocardiographic image showing right and left atria with thrombus no longer seen.
Prevention of deep venous thrombosis is clearly very important and oral anticoagulation should be considered if feasible. The decision to close the interatrial communication percutaneously or surgically has to be individualized. Likelihood of recurrence of deep venous thrombosis, recurrence of thromboembolic events, risks of oral anticoagulation, patient preferences, and degree of residual neurologic deficit from the index event should all be taken into consideration in arriving at a decision. REFERENCES 1. Meacham RR III, Headley AS, Bronze MS, Lewis JB, Rester MM. Impending paradoxical embolism. Arch Intern Med 1998;158:438-48. 2. Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. Stroke 1993;24:1865-73. 3. 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. 4. Hausmann D, Mugge A, Becht I, Daniel WG. Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events. Am J Cardiol 1992;70:668-72.