Korean Circ J.  2017 Sep;47(5):776-785. 10.4070/kcj.2016.0295.

Systematic Review of Treatment for Trapped Thrombus in Patent Foramen Ovale

• Seo WW
• Kim SE
• Park MS
• Lee JH
• Park DG
• Han KR
• Oh DJ

• KMID: 2389610
• DOI: http://doi.org/10.4070/kcj.2016.0295

Abstract

BACKGROUND AND OBJECTIVES
Trapped thrombus in patent foramen ovale (PFO) is a rare complication of pulmonary embolism that may lead to tragic clinical events. The aim of this study was to identify the optimal treatment for different clinical situations in patients with trapped thrombus in a PFO by conducting a literature review.
SUBJECTS AND METHODS
A PubMed database search was conducted from 1991 through 2015, and 194 patients (185 articles) with trapped thrombus in a PFO were identified. Patient characteristics, paradoxical embolic events, and factors affecting 60-day mortality were analyzed retrospectively.
RESULTS
Among all patients, 112 (57.7%) were treated with surgery, 28 with thrombolysis, and 54 with anticoagulation alone. Dyspnea (79.4%), chest pain (33.0%), and syncope (17.5%) were the most common presenting symptoms. Pretreatment embolism was found in 37.6% of cases, and stroke (24.7%) was the most common event. Surgery was associated with fewer post-treatment embolic events than were other treatment options (p=0.044). In the multivariate analysis, initial shock or arrest, and thrombolysis were independent predictors of 60-day mortality. Thrombolysis was related with higher 60-day mortality compared with surgery in patients who had no initial shock or arrest.
CONCLUSION
This systematic review showed that surgery was associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality in patients with trapped thrombus in a PFO. In patients without initial shock or arrest, thrombolysis was related with a higher 60-day mortality compared with surgery.

Keyword

Foramen ovale, patent; Pulmonary embolism; Review, systematic

MeSH Terms

Chest Pain
Dyspnea
Embolism
Foramen Ovale, Patent*
Humans
Incidence
Mortality
Multivariate Analysis
Pulmonary Embolism
Retrospective Studies
Shock
Stroke
Syncope
Thrombosis*

Figure

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  Figure 1 Echocardiographic images of trapped thrombi in the PFO. (A) Initial transthoracic echocardiography shows a large hypermobile mass that was consistent with a thrombus trapped in a PFO. (B) Transesophageal echocardiography obtained 1 day after thrombolysis with intravenous alteplase shows a small remnant thrombus trapped in the PFO. (C) Repeat transesophageal echocardiography obtained after 1-month of oral anticoagulation therapy confirmed complete resolution of the thrombus trapped in the PFO, and (D) agitated saline test shows a positive result for the PFO. PFO = patent foramen ovale.

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  Figure 2 Mortality rate according to treatment options published from 1991 through 2015.

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  Figure 3 Treatment-related mortality rate according to publication year (A) from 1991 to 2005, and (B) from 2006 to 2015.

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  Figure 4 Mortality rate according to treatment options, with or without cardiogenic shock. HR = hazard ratio; IVC = inferior vena cava. *Shock means initially presented with cardiogenic shock or cardiac arrest, †Result of the multivariate analysis after adjustment for age, sex, pre-embolization, cause of pulmonary embolism, and IVC filter replacement.

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