Intensive Care Med (2014) 40:891–892 DOI 10.1007/s00134-014-3283-y

Roshen Mathew Winnie E. Roy


Paradoxical massive pulmonary embolism with a straddling thrombus across a patent foramen ovale

Received: 24 March 2014 Accepted: 31 March 2014 Published online: 16 April 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014 R. Mathew ()) Division of Pulmonary Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA e-mail: [email protected] W. E. Roy KBN Institute of Medical Sciences, Gulbarga, India e-mail: [email protected]

Fig. 2 Transesophageal echo during cardiac massage showing a

A 52-year-old male patient with no significant past history PFO presented with dyspnea on exertion and some chest tightness while shoveling snow. He had some sinus

Fig. 1 Clot (C) in the right (RA) and left atrium (LA) passing Fig. 3 Massive saddle pulmonary embolus in main pulmonary through a patent foramen ovale arteries with subsegmental defects


Fig. 4 Possible RA clot seen in the right atrium

left atrium (Fig. 1), through a patent foramen ovale (PFO) was seen (Fig. 2). Chest computed tomography with contrast showed a saddle embolus with extensive clot burden (Figs. 3 and 4). Thrombectomy was planned. Thrombolytics were given. Within the next hour the patient developed hypoxia, hypotension, and asytolic cardiac arrest and could not be resuscitated. A thrombus entrapped between right and left atrium (straddling thrombus) can cause a life-threatening paradoxical pulmonary embolism [1]. Their management has no clear consensus. Thrombolytics are fast, mostly effective, and can be a bridge to surgical intervention. Surgical embolectomy with clot extraction from the right chambers and the pulmonary arteries, with closure of patent foramen ovale is the surgical treatment. Interventional techniques for clot removal with catheters have been described when surgery is contraindicated [2, 3].

tachycardia. His oxygen saturations were 100 % on 2-l Conflicts of interest None. nasal cannula. His EKG showed new right bundle bunch Ethical standard statement All persons gave their informed block and T wave inversions in inferior leads. A bedside echo showed right ventricle strain and consent for submission. hypokinesis. A clot extending from the right atrium to the

References 1. Charier L, Bera J, Delomez M, Asseman 2. Digonnet A, Moya-Plana A, Aubert S, Flecher E, Bonnet N, Leprince P et al P, Thery C (1999) Free floating thrombi (2007) Acute pulmonary embolism: a in right heart, diagnosis, management current surgical approach. Interact and prognostic indicators in 38 Cardiovasc Thorac Surg 6(1):27–29 consecutive patients. Circulation 99:2779–2783. doi: 10.1161/01.CIR.99.21.2779

3. Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A (2010) Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest 137(1):164–170

Paradoxical massive pulmonary embolism with a straddling thrombus across a patent foramen ovale.

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