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European Heart Journal Advance Access originally published online on December 7, 2007
European Heart Journal 2008 29(9):1117; doi:10.1093/eurheartj/ehm538
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Paradoxical embolism with an intact interatrial septum

Joris Schurmans1, Jan Vermeulen2 and Werner Budts1,*

1 Department of Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
2 Department of Cardiology, Sint Dimpna Hospital, Geel, Belgium

* Corresponding author. Tel: +32 16 344235, Fax: +32 344240, Email: werner.budts{at}uz.kuleuven.ac.be

A 71-year-old woman with a recent onset of recurrent transient ischaemic attacks was referred for further diagnostic assessment. Stroke occurred each time shortly after performing a Valsalva manoeuvre. The patient mentioned a stable dyspnoea NYHA II, a mildly reduced exercise capacity, and no history of palpitations.

Transoesophageal echocardiography could not detect an intracardiac right-to-left shunt, but showed a delayed appearance of a massive amount of contrast bubbles in the left atrium. By evaluating each pulmonary vein, the contrast flow originated only from the right superior pulmonary vein (Panel A). These findings suggested the presence of a pulmonary arterio-venous malformation in the right superior pulmonary lobe, causing recurrent paradoxical embolisms. The diagnosis was confirmed by a CT-scan of the chest. The fistula was located anteriorly in the right upper pulmonary lobe, with a hypertrophied supplying artery and draining vein (Panel B, arrow).

The patient was re-admitted for (selective) pulmonary angiography and fistula occlusion. The arterio-venous fistula was selectively cannulated and injected with contrast (Panel C). The fistula was successfully coiled with a COOK MWCE-8-PDA5 coil (William Cook, Europe). No residual shunt nor damage to the native, non-fistulous parenchyma, was present (Panel D). However, to prevent embolization of thrombus distal of the coil, a vitamin K-antagonist was initiated for a period of 6 months.

Formula


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This Article
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
29/9/1117    most recent
ehm538v1
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Right arrow Articles by Schurmans, J.
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