European Heart Journal Advance Access originally published online on October 16, 2007
European Heart Journal 2008 29(5):648; doi:10.1093/eurheartj/ehm436
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Pulmonary thromboembolism and ‘temporary’ patent foramen ovalis: ischaemic stroke due to paradox embolism
Department of Cardiology, Santa Rita Clinical Institute, Via Catalani 4, 20131 Milan, Italy
* Corresponding author. Tel: +39 02 23933020, Fax: +39 02 23933087, Email: heart{at}casadicura-santarita.it, gianfrancoaprigliano{at}hotmail.com
An 80-year-old woman was admitted to the orthopaedic department of our hospital for elective right hip prosthesis implantation after recent fracture of the right femore. The first day after surgery, the patient became symptomatic for dyspnoea. Haemo-gas analysis showed hypoxia with hypocapnia. Slight elevation of D-dimer (14.5 mcg/mL) and normal ECG was found out. An echocardiogram revealed right ventricle (RV) dilatation with free wall hypokinesis and massive tricuspidal valve regurgitation secondary to pulmonary hypertension (Panel A). A floppy interatrial septum was also evidenced. Lower limb echo-Doppler showed left iliac vein thrombosis. Based on this evidence, pulmonary angiography was performed and bilateral thromboembolism diagnosed (Panels B and C). Loco-regional pulmonary thrombolysis and low molecular weight heparin at full dosage were started. During the second day, the patient became symptomatic for left-side emiparesis and afasia. Sovra-aortic trunks duplex scan, colour flow Doppler, and CT brain scan were negative. Transoesophageal echocardiography revealed a floppy aneurismatic interatrial septum (Type C), patent foramen ovalis with right to left shunt in basal conditions and positive micro bubble test (Panel D). Forty-eight hours later, the patient repeated the CT brain scan, showing major ischaemic stroke in right temporal lobe (Panel E). Subsequently, a caval filter was placed. One month later, a transoesophageal echocardiogram revealed aneurismatic floppy interatrial septum without right to left shunt even after Valsalva manoeuvre, and normal pulmonary pressure (Panel F). It seems plausible that the unexpected increase of pulmonary pressure secondary to pulmonary thromboembolism opened the foramen ovalis permitting right to left embolism.
Panel A. Transthoracic echocardiogram showing severe tricuspidal insufficiency. LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle; TV, tricuspidal valve.
Panel B. The red arrow points to massive embolism of the right pulmonary artery (RPA).
Panel C. The red arrow points to massive embolism of left pulmonary artery (LPA).
Panel D. Transoesophageal echocardiogram showing patent foramen ovalis with right-to-left shunting (red arrow).
Panel E. CT brain scan showing ischaemic area in the right temporal lobe (red arrow).
Panel F. Transoesophageal echocardiogram showing floppy interatrial septum without evidence of right-to-left shunting after Valsalva manoeuvre.
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