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doi:10.1093/eurheartj/ehv045 Online publish-ahead-of-print 6 March 2015
Thrombus trapped in patent foramen ovale Pavan Chandrala*, Kate Johnson, and Hisham Hallani Department of Cardiology, Nepean Hospital, Derby St, Kingswood, NSW, Australia
A 63-year-old man was hospitalized with 2 days of increasing dyspnoea and presyncope. He had developed confusion, dysarthria, and a left-sided facial droop that morning. Three weeks previously the patient had suffered a urinary tract infection and had taken prolonged bed rest. His only background was hypertension. Clinical assessment revealed tachypnoea, sinus tachycardia, and a mild left-sided motor deficit. Laboratory testing revealed elevated high-sensitivity troponin (5122 ng/L), positive D dimer and elevated urea (20 mmol/L), and creatinine (420 mmol/L). Transoesophageal echocardiography (TOE) illustrated a mobile mass crossing the interatrial septum and present in both atria and ventricles. Doppler ultrasound revealed a right lower limb deep vein thrombosis (DVT). Brain magnetic resonance imaging demonstrated multiple small strokes. Thrombophilia screening was negative. He was diagnosed with a thrombus straddling a patent foramen ovale (PFO) causing coronary, pulmonary, renal, and cerebral embolism. The patient was heparinized and surgical thombectomy was arranged for the subsequent day. However, preoperative TOE showed the thrombus was no longer present. The patient was transitioned to warfarin therapy. His dyspnoea, neurological signs, and renal function gradually improved. He remains well 1 month after discharge and is due for percutaneous PFO closure as soon as possible. Both PFO and DVT are relatively common. Thrombus entrapped in a PFO is an uncommon finding with potentially devastating consequences. Usually pulmonary embolism elevates right heart pressures facilitating thrombus entering a PFO where it becomes entrapped and propagates. Ideal treatment is unknown due to its low incidence; however, anticoagulation and surgical thrombectomy are the mainstay. Thrombolysis can be attempted if in extremis. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected]
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* Corresponding author. Tel: +61 2 4734 1719, Fax: +61 2 4734 3066, Email: [email protected]