Correspondence Letter by Myers and Kalangos Regarding Article, “Fluttering Thrombus in Patent Foramen Ovale With Paradoxical and Cerebral Embolism” To the Editor: We read with great interest the article by Bonanni et al1 containing images of a patient with a fluttering thrombus in a patent foramen ovale. This entity has more frequently been called impending paradoxical embolism,2,3 because the thrombus is found trapped within the atrial septum on its way to a paradoxical systemic embolism.4 It would be interesting to understand why the authors chose to treat this fluttering thrombus by anticoagulation alone in a young patient (56 years old) with apparently no major previous medical or surgical history. In a systematic review of the literature including 174 patients with impending paradoxical embolism published between 1985 and 2008,5 we previously reported a 30-day mortality of 15.5% (27 of 174) and systemic embolism after treatment initiation of 6.8% (12 of 174) in this patient population. Both of these end points were significantly increased in patients treated with anticoagulation (early mortality, 25.6%; systemic embolism after diagnosis, 13%) compared with surgical embolectomy (10.6%, P=0.04; and 2%, P=0.001, respectively). In multivariable analysis, surgical embolectomy improved survival and freedom from systemic embolism after treatment initiation (odds ratio, 0.26; 95% confidence interval, 0.11–0.60; P=0.001) compared with anticoagulation. This review was, admittedly, limited by selection bias because only interesting cases would have been reported. It is particularly of interest, given that the patient described by Bonanni et al presented clinical symptoms and with magnetic resonance imaging evidence of stroke after initiation of anticoagulation,

although he was later discharged alive and well. Could the authors comment on why they choose anticoagulation and whether they would continue such treatment after their experience?

Disclosures None. Patrick O. Myers, MD Afksendiyos Kalangos, MD, PhD Cardiovascular Surgery Geneva University Hospitals and School of Medicine Geneva, Switzerland

References 1. Bonanni L, Serafini F, Dalla Vestra M, Cutolo A, Grolla E, Presotto F. Fluttering thrombus in patent foramen ovale with paradoxical and cerebral embolism. Circulation. 2014;129:e343–e344. 2. Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol. 1985;5:1002–1004. 3. Myers P, Fassa A, Panos A, Licker M, Bounameaux H, Zender HO, Kalangos A. Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale. J Card Surg 2008;23:376–378. 4. Maron BA, Shekar PS, Goldhaber SZ. Paradoxical embolism. Circulation. 2010;122:1968–1972. 5. Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137:164–170.

(Circulation. 2014;130:e163.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.114.009728

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Letter by Myers and Kalangos Regarding Article, ''Fluttering Thrombus in Patent Foramen Ovale With Paradoxical and Cerebral Embolism'' Patrick O. Myers and Afksendiyos Kalangos Circulation. 2014;130:e163 doi: 10.1161/CIRCULATIONAHA.114.009728 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539

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