Correspondence Article Type Response to Letter Regarding Article “Fluttering Thrombus in Patent Foramen Ovale With Paradoxycal and Cerebral Embolism” We thank Myers and Kalangos for their interest in our case, and we would like to reply to the issue they raised in their letter. As they report in their article, the management and treatment options of impending paradoxycal embolism are a subject of debate.1 For the American Heart Association, in its statement for the management of massive and submassive pulmonary embolism, the optimal treatment for these patients remains unclear: the surgical thrombectomy may result in the lowest rate of stroke, but with a low level of evidence (Class IIb, Evidence C).2 Also in the literature there is a high heterogeneity of treatments because of the complexity of clinical and echographic presentation of these patients.3 Because the “Images in Cardiovascular Medicine” Section is not intended as a primary vehicle for case reports, we didn’t report anamnestic and clinical data of our patient. The medical history was positive for a cancer of the kidney previous treated with surgery and chemotherapy. When he came to our attention, there was evidence of a tumor’s relapse for which he was candidated to a second-line of chemotherapy. For this comorbidity we decided to avoid the surgical thrombectomy and to start promptly the anticoagulation therapy alone.4 Waiting for prospective and randomized trials to clarify the best treatment option, we think that the surgical thrombectomy should always be considered as first-line therapy for impending paradoxycal embolism, but only in patients without high surgical risk or associated comorbidities.

Disclosures None. Luca Bonanni, MD Francesco Serafini, MD Michele Dalla Vestra, MD, PhD

Department of Internal Medicine Ospedale dell’Angelo Mestre (Venezia), Italy Ada Cutolo, MD Elisabetta Grolla, MD Department of Cardiology Ospedale dell’Angelo Mestre (Venezia), Italy Fabio Presotto, MD, PhD Department of Internal Medicine Ospedale dell’Angelo Mestre (Venezia), Italy

References 1. 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. 2. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788–1830. 3. Baydoun A, Barakat I, Hatem E, Chalhoub M, Mroueh A. Thrombus in transit through Paten Foramen Ovale. Case Report in Cardiology 2013; 2013: 395879. 4. 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.

(Circulation. 2014;130:e164.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.114.012352

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Response to Letter Regarding Article ''Fluttering Thrombus in Patent Foramen Ovale With Paradoxycal and Cerebral Embolism'' Luca Bonanni, Francesco Serafini, Michele Dalla Vestra, Ada Cutolo, Elisabetta Grolla and Fabio Presotto Circulation. 2014;130:e164 doi: 10.1161/CIRCULATIONAHA.114.012352 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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Response to letter regarding article "fluttering thrombus in patent foramen ovale with paradoxycal and cerebral embolism".

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