J Cardiovasc Ultrasound.  2011 Dec;19(4):196-198. 10.4250/jcu.2011.19.4.196.

Thrombus in Transit within a Patent Foramen Ovale: Gone with the Cough!

• Kim JH
• Kim YJ

• KMID: 1980382
• DOI: http://doi.org/10.4250/jcu.2011.19.4.196

Abstract

Pulmonary embolism and concomitant right atrial thrombus entrapped in a patent foramen ovale (PFO) is a rare, unusual finding in echocardiography. The diagnosis of paradoxical embolism is usually presumptive when PFO is detected by echocardiography. We herein reported a case of a 53-year-old patient presenting with pulmonary embolism in which a thrombusin-transit through a PFO was found and disappeared during transesophageal echocardiography.

Keyword

Pulmonary embolism; Thrombus in transit; Patent foramen ovale

MeSH Terms

Echocardiography
Echocardiography, Transesophageal
Embolism, Paradoxical
Foramen Ovale, Patent
Humans
Middle Aged
Pulmonary Embolism
Thrombosis

Figure

• 

  Fig. 1 Chest computed tomography shows multiple filling defects (white arrows) in both pulmonary arteries.

• 

  Fig. 2 A: Transthoracic echocardiography shows hypoechogenic mobile thrombus in right atrium extending into the left atrium through interatrial septum. B: Right ventricular pressure overload results in D-shaped left ventricle under pulmonary embolism. White arrow: mass suspecting thrombus, LA: left atrium, RA: right atrium, AV: aortic valve, RV: right ventricle, LV: left ventricle.

• 

  Fig. 3 Transesophageal echocardiography shows serpentine, hypermobile thrombus entraps in patent foramen ovale (A). But, thrombus in transit is disappeared after involuntary cough. The arrow indicates patent foramen ovale (B). (C) Color Doppler jet suggests right to left shunt (white arrow). LA: left atrium, RA: right atrium.

Reference

1. Loscalzo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J. 1986. 112:141–145.

2. Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998. 97:1946–1951.

3. 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.

4. Kim ES, Kim SH, Hur JW, Yook DS, Kim SM, Cha TJ, Joo SJ, Lee JW. A case of impending paradoxical embolus in a patient with acute pulmonary embolism. J Korean Soc Echocardiogr. 2002. 10:101–105.

5. Shah DK, Ritter MJ, Sinak LJ, Miller JA, Sundt TM 3rd. Paradoxical embolus caught in transit through a patent foramen ovale. J Card Surg. 2011. 26:151–153.

6. Can I, Altunkeser BB, Yavas O, Duzenli A, Ozdemir K, Gok H. Transit thrombus entrapped in patent foramen ovale resolved without clinical embolic events. J Am Soc Echocardiogr. 2006. 19:1074.e1–1074.e2.

7. Lee JH, Park JH. Role of Echocardiography in Patients with Acute Pulmonary Thromboembolism. J Cardiovasc Ultrasound. 2008. 16:9–16.

8. Stoddard MF, Keedy DL, Dawkins PR. The cough test is superior to the Valsalva maneuver in the delineation of right-to-left shunting through a patent foramen ovale during contrast transesophageal echocardiography. Am Heart J. 1993. 125:185–189.

9. Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008. 101:637–644.

10. Brianti V, Pattacini C, Rastelli G, Pini M. Paradoxical embolism and thrombus trapped in patent foramen ovale in an old woman: a case report. Intern Emerg Med. 2009. 4:517–518.

11. Hansen A, Kuecherer H. Caught in the act: entrapped embolus through a patent foramen ovale. Eur J Echocardiogr. 2008. 9:692–693.

12. Ozdogru I, Kaya MG, Dogan A, Inanc T, Yalcin A, Oguzhan A. Thrombus crossing through a patent foramen ovale. Int J Cardiol. 2009. 133:e55–e56.