Emergency. 2018; 6 (1): e50

CA S E RE P O RT

Paradoxical Embolism in a Patient with Patent Foramen
Ovale; a Case Report
Mohammad Khani1, Fariba Bayat1, Atoosheh Rohani2∗, Mehdi Pishgahi 3

1. Department of Cardiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

2. Department of Cardiology, Mashhad University of Medical Sciences, Mashhad, Iran.

3. Department of Cardiology, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Received: June 2018; Accepted: July 2018; Published online: 8 August 2018

Abstract: Patent foramen ovale (PFO) is usually asymptomatic; however, it could be quite dangerous for patients with
right side clot in which thrombus can transmit the PFO and paradoxically emboli to systemic circulation. Here
we present a patient with ankle fracture and paradoxical embolus to the brain, who was successfully treated
with emergent thrombectomy, inferior vena cava (IVC) filter placement and anticoagulation therapy. Despite
the high rate of mortality in these patients, fortunately our patient survived with surgical treatment.

Keywords: Venous thrombosis; pulmonary embolism; embolism, paradoxical; patent foramen ovale; thrombolytic therapy

© Copyright (2018) Shahid Beheshti University of Medical Sciences

Cite this article as: Khani M, Bayat F, Rohani A, Pishgahi M. Paradoxical Embolism in a Patient with Patent Foramen Ovale; a Case Report.

Emergency. 2018; 6 (1): e50.

1. Introduction:

Simultaneous occurrences of cerebrovascular accident and

pulmonary embolism (PE) demonstrates the presence of

paradoxical embolism according to the Johnson criteria (1).

In 25–30 percent of individuals presenting with paradoxical

embolism a patent foramen ovale (PFO) could be detected

(2). Inter-atrial septum has two parts; septum primum and

secundum. There is a slit-like opening between the two

parts called a PFO. Because of low pressure in both atria and

anatomical position of the septum secundum there is no sig-

nificant left-to-right shunting and little shunting in general;

however, when the right atrial pressure rises during a phys-

iological condition like as straining, Valsalva maneuver or

coughing this slit like flap separates and allows right to left

shunting, this type of shunting may become more marked in

cases with raised right atrial (RA) pressure due to pathologic

conditions such as PE. There is also a “so-called” “flow phe-

nomenon” that describes a preferential blood flow from the

inferior vena cava towards the atrial septum as a part of the

fetal circulation.

∗Corresponding Author: Atoosheh Rohani; Department of cardiol-
ogy, Mashhad University of Medical Sciences, Mashhad, Iran. Email:
mp_cr1@yahoo.com Tel/Fax: 00989123387486

Far less than 1% have a stroke or other outcome that results

in the need to have the PFO closed. There are some case re-

ports of coexistence of paradoxical emboli with PE systemic

embolism and DVT, especially in patients with “hybrid de-

fect”, which is defined as fenestrated secundum atrial septal

defect with septal aneurysm (3).

2. Case presentation:

A 60-year-old female was admitted to our hospital for left

ankle and right knee fracture. She underwent orthopedic

surgery and was discharged in stable medical condition with

administration of low molecular weight heparin (LMWH) on

a daily basis. She was asymptomatic and was in healthy med-

ical condition, she denied any symptoms such as dyspnea as-

sociated with postural change. She was bed ridden at home,

with irregular LMWH injection. Forty five days later she pre-

sented with convulsion, right side hemiplegia, aphasia and

decreased level of consciousness. Her past medical history

included systemic hypertension and she was not on any reg-

ular medication.

On admission she was confused, had tachypnea and tachy-

cardia and a pulse rate of 120 beats per minute. Her blood

pressure was 105/75 mmHg. The oxygen saturation was re-

duced at 85% in room air. She had total loss of strength in

right upper and lower extremities and was aphasic. A neuro-

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M. Khani et al. 2

Figure 1: Clot straddled in patent foramen ovale in trans-

esophageal echocardiography (TEE) bicaval view.

logical examination showed aphasia and Babinski’s sign on

the right side. Heart and lung examination were unremark-

able. Electrocardiogram showed right axis deviation and in-

verted T waves in the anterior leads (V1-V3).

Echocardiography imaging revealed mild right ventricular

(RV ) dilatation and mild impaired RV systolic function and

large thrombus crossing the RA to the left atrium (LA) via

inter-atrial septum. A trans-esophageal echocardiogram re-

vealed a large RA clot extending through a PFO into the LA,

entrapped in foramen ovale as well as right pulmonary artery

thrombus (Figure 1). Atrial septal aneurysm and pulmonary

hypertension with pulmonary arterial pressure of 45mmHg

were evident. The chest computed tomography (CT) angiog-

raphy showed a massive thrombus in the main right and left

pulmonary artery. Doppler study of her lower legs showed

signs of deep vein thrombosis in right superficial femoral

and anterior tibialis vein. Brain CT scan demonstrated hypo-

density in left frontal, temporal and parietal lobes consis-

tent with middle cerebral artery related stroke. Patient un-

derwent emergent surgical removal of RA, LA, right and left

pulmonary arteries and surgical closure of PFO. To reduce

the risk of further emboli, the temporary IVC filter was re-

placed. She had an uneventful postoperative course and was

discharged eight days after surgery. Our patient is alive but

aphasic and hemiplegic one year after surgery. Patient had

signed informed consent to be presented as case report.

3. Discussion

Less than 2% of all cases of systemic arterial emboli are para-

doxical (4). As high as 35% of the general population have

a PFO, which is the most common cardiac defect in asso-

ciation with paradoxical embolism (5). There are some re-

ports, which demonstrate that presence of PFO is an im-

portant predictor of adverse outcome and LA dysfunction,

which leads to thrombi formation in LA (6, 7). When a patient

presents with multi-vascular arterial embolism, not only the

transthoracic echo, but also the trans-esophageal and even

intra-cardiac echocardiography is essential to differentiate

between PFO, flat ASD and hybrid defects.

There are no clear guidelines based on randomized trials

for treatment of paradoxical embolism. Surgical embolec-

tomy with exploration of the right chambers and the pul-

monary arteries under complete cardiopulmonary bypass

is the classic treatment; however, there are reports (7-9) of

successful medical treatment of RA and LA clot question-

ing whether mechanical closure of PFO should be indicated.

Since older patients are more prone to rapid change of right

heart pressure, we decided to send our patient to the oper-

ating room considering the large clot burden, contraindica-

tions to thrombolytic, her age, and the risk of relapse. Ac-

cording to previous reports, in-hospital mortality is as high

as 44.7 % (10-12).

4. Conclusion:

We described the diagnosis and successful surgical treatment

of a severe form of venous thromboembolic disease with

thrombi in transit getting complicated by paradoxical embo-

lus to cerebral arteries in an aged woman. However, there are

no clear guidelines based on randomized trials for therapy

of paradoxical embolism. Clot removal by cardiopulmonary

bypass surgery as shown in our case, could be considered in

treatment of paradoxical embolism.

5. Appendix

5.1. Acknowledgements

None.

5.2. Author’s contribution

All authors passed the four criteria for authorship contribu-

tion based on recommendations of the International Com-

mittee of Medical Journal Editors.

5.3. Conflict of interest

None.

5.4. Funding

None.

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	Introduction:
	Case presentation:
	Discussion
	Conclusion:
	Appendix
	References