doi:10.1378/chest.07-0100
(Chest. 2007; 132:1358-1360)
© 2007 American College of Chest Physicians
Impending Paradoxical Embolism Presenting as a Pulmonary Embolism, Transient Ischemic Attack, and Myocardial Infarction*
Scott L. Willis, MD;
Timothy S. Welch, MD;
John P. Scally, MD;
Michael W. Bartoszek, MD;
Lance E. Sullenberger, MD;
Jeremy C. Pamplin, MD and
Oleh W. Hnatiuk, MD, FCCP
* From the Department of Internal Medicine (Drs. Willis and Bartoszek), the Cardiology Service (Drs. Welch, Scally, and Sullenberger), and Pulmonary and Critical Care Services (Drs. Pamplin and Hnatiuk), Walter Reed Army Medical Center, Washington, DC.
Correspondence to: Scott L. Willis, MD, Department of Internal Medicine, Walter Reed Army Medical Center, Washington, DC 20307-5001; e-mail: scott.willis2{at}na.amedd.army.mil.
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Abstract
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A 25-year-old man presented with complaints of nonpleuritic, substernal chest pain, dyspnea, and decreasing exercise tolerance. His vital signs were normal, with the exception of an oxygen saturation level of 93% while breathing room air. During his assessment, he developed transient left facial droop, left arm and leg weakness, and an ataxic gait, which lasted 15 min then resolved spontaneously. Cardiac enzyme levels were elevated, and an ECG revealed T-wave inversion in leads III, aVF, V1, and V2 with evolving ST-segment elevation in leads V3 through V5. The findings of a CT scan and MRI of the head were negative; a Doppler ultrasound of the right lower extremity revealed a thrombus extending from the common femoral vein to the popliteal vein. Cardiac catheterization revealed no evidence of epicardial coronary artery disease. CT pulmonary angiography revealed bilateral pulmonary emboli. Transesophageal echocardiography (TEE) showed a 4-cm, dumbbell-shaped mass lodged in a patent foramen ovale, confirming the diagnosis of an impending paradoxical embolism. The patient was started on therapy with unfractionated heparin, and his thrombus resolved spontaneously by hospital day 5. An impending paradoxical embolism is rare but should be suspected in anyone presenting with evidence of both venous and arterial emboli. The therapeutic options include anticoagulation, thrombolysis, and surgical embolectomy. We would propose that initial treatment with anticoagulation therapy and following with serial TEEs may be appropriate therapy in an otherwise stable patient, with surgical embolectomy or thrombolysis reserved for the treatment of thrombi that do not resolve with anticoagulation therapy or for patients with clinical deterioration.
Key Words: anticoagulation; • pulmonary embolism; • thrombosis
A 25-year-old man presented with complaints of nonpleuritic, substernal chest pain, dyspnea, and decreasing exercise tolerance. His vital signs were normal, with the exception of an oxygen saturation level of 93% while breathing room air. Physical examination findings were remarkable for a 2/6 systolic ejection murmur at the left sternal border. During his initial assessment he developed transient left facial droop, left arm and leg weakness, and an ataxic gait. These symptoms lasted 15 min then resolved spontaneously. Cardiac enzyme levels were elevated, with a creatine kinase level of 1,021 U/L, a creatine kinase-MB level of 105 ng/mL, and a troponin T level of 3.86 ng/mL. An ECG revealed T-wave inversion in leads III, aVF, V1, and V2, with evolving ST-segment elevation in leads V3 through V5. The findings of a CT scan and MRI of the head were negative; a Doppler ultrasound of the right lower extremity revealed a thrombus extending from the common femoral vein to the popliteal vein. The patient was subsequently started on therapy with unfractionated heparin and admitted to the medical ICU. The findings of a transthoracic echocardiogram were notable for the presence of biatrial masses near the fossa ovalis and distal anteroseptal hypokinesis. Cardiac catheterization revealed no evidence of epicardial coronary artery disease. A transesophageal echocardiography (TEE) showed a 4-cm, dumbbell-shaped mass lodged in a patent foramen ovale (PFO), communicating between the right and left atria (Fig 1
). The decision was made to continue anticoagulation therapy and to repeat a TEE on hospital day 3, with the anticipation of performing surgical embolectomy if no resolution of the thrombus was seen or to administer thrombolytic agents if the patient decompensated clinically. The patient remained asymptomatic, and a repeat TEE on hospital day 3 revealed resolution of the left atrial portion of the thrombus (Fig 2
). A TEE on hospital day 5 showed near complete resolution of the right atrial thrombus (Fig 3
). The patient was discharged from the hospital to receive 6 months of therapy with oral warfarin and was referred for percutaneous closure of his PFO.
A PFO is common, occurring in up to 35% of the general population.1 A paradoxical embolism, or embolism through a PFO, is quite rare, however, accounting for < 2% of all arterial emboli.2 Furthermore, an impending paradoxical embolism is exceedingly rare, with < 70 cases having been reported in the literature to date. Criteria for the diagnosis of a paradoxical embolism include the presence of a venous thrombus, an arterial embolus, a predisposing intracardiac defect enabling communication between the right and left heart, and a transient reversal of an intracardiac shunt.2 An impending paradoxical embolism serves as a constant source for arterial embolization with the potential for devastating consequences to the cerebral, renal, peripheral, mesenteric, and coronary vasculature. In fact, the mortality rate is estimated to be 21%.3 For this reason, the diagnosis should be promptly considered in anyone presenting with signs of both arterial and venous embolization. The vast majority of patients present with symptoms of pulmonary embolism (82%) or arterial embolism (25%).3 Only 16% of patients present with findings suggestive of both venous and arterial embolism.4
We believe that this is the first reported case of an impending paradoxical embolism presenting as a pulmonary embolism, transient ischemic attack, and myocardial infarction. Echocardiography remains the diagnostic modality of choice with a diagnostic accuracy of 92%. Therapeutic options include surgical embolectomy, thrombolysis, and anticoagulation. Overall survival appears to be equivalent among the three therapeutic options, although more complications relating to arterial and pulmonary embolization occur with anticoagulation and thrombolysis.234 For this reason, anticoagulation followed by surgical embolectomy has been recommended as the optimal therapy. While awaiting surgical consultation, our patient responded well to anticoagulation therapy alone. We would propose that initial treatment with anticoagulation and following that with serial TEEs may be appropriate therapy in an otherwise stable patient, with surgical embolectomy or thrombolysis reserved for the treatment of thrombi that do not resolve with anticoagulation therapy or for patients with clinical deterioration. In cases in which surgery is contraindicated, thrombolysis with anticoagulation therapy would be an appropriate alternative.
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Footnotes
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Abbreviations: PFO = patent foramen ovale; TEE = transesophageal echocardiography
The opinions or assertions contained herein are those of the authors and should not be construed as reflecting the views of the Department of the Army or the Department of Defense.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Received for publication January 11, 2007.
Accepted for publication April 2, 2007.
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References
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- d’Audiffret, A, Pillai, L, Dryjski, M (1999) Paradoxical emboli: the relationship between patent foramen ovale, deep vein thrombosis and ischemic stroke. Eur J Vasc Endovasc Surg 17,468-471[CrossRef][ISI][Medline]
- Ward, R, Jones, D, Haponik, EF Paradoxical embolism: an underrecognized problem. Chest 1995;108,549-558[Abstract/Free Full Text]
- Aboyans, V, Lacroix, P, Ostyn, E, et al Diagnosis and management of entrapped embolus through a patent foramen ovale. Eur J Cardiothorac Surg 1998;14,624-628[Abstract/Free Full Text]
- Chow, B, Johnson, C, Turek, M, et al Impending paradoxical embolism: a case report and review of the literature. Can J Cardiol 2003;19,1426-1432[ISI][Medline]
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