RESUMEN
BACKGROUND: Paradoxical embolism is a rare cause of acute arterial occlusion. This phenomenon arises when embolic material travels from the venous system crosses an abnormal shunt such as patent foramen ovale, atrial septal defects, ventricular septal defects, or pulmonary arteriovenous malformations, into the arterial system. Impending paradoxical embolism refers to the presence of an entrapped thrombus in the patent foramen ovale. CASE PRESENTATION: We report a case of a 68-year-old female patient who presented with an impending paradoxical embolism, alongside both concomitant pulmonary embolism and myocardial infarction with ST-segment elevation. Swiftly addressed through emergency cardiac surgery and systemic anticoagulation, the patient's condition was effectively treated. CONCLUSIONS: While the ideal treatment strategy for impending paradoxical embolism remains a topic of debate due to limited and inconclusive evidence, emergent open surgery should be contemplated in patients as it signifies a critical clinical emergency.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Infarto del Miocardio , Embolia Pulmonar , Femenino , Humanos , Anciano , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/cirugía , Embolia Paradójica/complicaciones , Embolia Paradójica/cirugía , Ecocardiografía Transesofágica , Embolia Pulmonar/complicaciones , Embolia Pulmonar/cirugía , Infarto del Miocardio/complicaciones , Infarto del Miocardio/cirugíaRESUMEN
Paradoxical embolism occurs when a thrombus crosses an intracardiac defect into the systemic circulation. Here, we present the case of a 35-yearold male kidney transplant recipient with a cerebral paradoxical embolism associated with a spontaneous venous thromboembolism. This patient had recurrent deep venous thrombosis and showering emboli to the lung and paradoxically to the brain through patent foramen ovale, and we treated him successfully. The role of bubble echocardiography was essential in diagnosis to avoid contrast-induced nephropathy. This is the first successfully managed case of a kidney transplant recipient with recurrent idiopathic deep vein thrombosis, pulmonary embolism, and cerebral paradoxical embolism. Bubble echocardiography was an excellent alternative to contrast angiography to avoid nephrotoxicity. Vitamin K antagonists are superior to direct oral anticoagulants, especially among nonadherent/noncompliant patients.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Trasplante de Riñón , Embolia Pulmonar , Trombosis de la Vena , Humanos , Masculino , Adulto , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/etiología , Embolia Paradójica/cirugía , Trasplante de Riñón/efectos adversos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/tratamiento farmacológico , Embolia Pulmonar/etiología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/tratamiento farmacológico , Trombosis de la Vena/etiología , Foramen Oval Permeable/complicaciones , Anticoagulantes/uso terapéuticoRESUMEN
A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.
Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Embolia Pulmonar , Trombosis , Masculino , Humanos , Persona de Mediana Edad , Trombosis/cirugía , Choque Cardiogénico/etiología , Embolia Paradójica/diagnóstico , Embolia Paradójica/cirugía , Trombectomía/métodos , Embolia Pulmonar/complicaciones , Embolia Pulmonar/cirugíaRESUMEN
Although a patent foramen ovale (PFO) is relatively common, confirmed reports of thrombus entrapped within a PFO are uncommon. Management of impending paradoxical embolism (IPE), also called a thrombus in transit, lacks consensus but includes systemic anticoagulation (e.g., heparin), systemic thrombolysis, or surgical thrombectomy. We present a case of IPE diagnosed with intraoperative transesophageal echocardiography (TEE) as well as a novel en bloc approach to atrial septal aneurysmectomy to minimize embolism and facilitate repair of the interatrial septum. Timely use of intraoperative TEE may aid in diagnosis and help guide the surgical approach to minimize embolic risk with an IPE.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Defectos del Tabique Interatrial , Embolia Pulmonar , Trombosis , Ecocardiografía Transesofágica , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/prevención & control , Embolia Paradójica/cirugía , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico por imagen , Foramen Oval Permeable/cirugía , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/cirugía , Humanos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/prevención & controlRESUMEN
Background and Purpose: The Risk of Paradoxical Embolism (RoPE) score stratifies patients with stroke according to the probability of having a patent foramen ovale (PFO), which (through Bayes theorem and simple assumptions) can be used to estimate the probability that a PFO is pathogenic in a given subgroup of patients with specific features (ie, a given RoPE score value): a higher PFO prevalence corresponds to a higher probability that a PFO is pathogenic. Among alternative mechanisms in embolic stroke of undetermined source (ESUS), the actual stroke cause may be covert atrial fibrillation. We aimed to validate the RoPE score in a large ESUS population and investigate the rate of stroke recurrence and new incident atrial fibrillation during follow-up according to PFO status and RoPE score. Methods: We pooled data of consecutive patients with ESUS from 3 prospective stroke registries. We assessed RoPE score's calibration and discrimination for the presence of PFO (and consequently for the probability that it is pathogenic). Multivariate logistic regression analysis was performed to identify factors associated with PFO. Results: Among 455 patients with ESUS (median age 59 years), 184 (40%) had PFO. The RoPE score's area under the receiver operating characteristic curve was 0.75. In addition to RoPE score variables, absence of left ventricular hypertrophy, absence of atherosclerosis, and infratentorial lesions were independently associated with PFO. In patients with PFO and RoPE 7 to 10, PFO and RoPE 0 to 6, and without PFO, new incident atrial fibrillation rate was 3.1%, 20.5%, and 31.8%, respectively (log-rank test=6.28, P=0.04). Stroke recurrences in patients with likely pathogenic PFO were not statistically different from other patients. Conclusions: This multicenter study validates the RoPE score to predict the presence/absence of PFO in patients with ESUS, which strongly suggests that RoPE score is helpful in identifying patients with ESUS with pathogenic versus incidental PFOs. Left ventricular hypertrophy, atherosclerosis, and infratentorial stroke may further improve the score. Low RoPE scores were associated with more incidental atrial fibrillation during 10-year follow-up.
Asunto(s)
Fibrilación Atrial , Accidente Cerebrovascular Embólico , Embolia Paradójica , Foramen Oval Permeable , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/etiología , Fibrilación Atrial/mortalidad , Fibrilación Atrial/cirugía , Accidente Cerebrovascular Embólico/etiología , Accidente Cerebrovascular Embólico/mortalidad , Accidente Cerebrovascular Embólico/cirugía , Embolia Paradójica/etiología , Embolia Paradójica/mortalidad , Embolia Paradójica/cirugía , Femenino , Estudios de Seguimiento , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/mortalidad , Foramen Oval Permeable/cirugía , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Factores de RiesgoRESUMEN
We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Embolia Pulmonar , Anciano , Embolectomía , Embolia Paradójica/tratamiento farmacológico , Embolia Paradójica/cirugía , Femenino , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico por imagen , Foramen Oval Permeable/tratamiento farmacológico , Humanos , Isquemia/tratamiento farmacológico , Embolia Pulmonar/cirugía , Terapia TrombolíticaRESUMEN
Impending paradoxical embolism is a rare but potentially life-threatening complication of venous thromboembolism that is usually associated with acute pulmonary embolism and a right to left atrial shunt. Patients may have associated right ventricular pressure or volume overload with subsequent failure. Transesophageal echocardiography is the preferred diagnostic test of choice in this patient group. Definitive management has yet to be clearly defined. However, emergent surgical removal of the entrapped intracardiac blood thrombus may be necessary. In this article, we review a case of impending paradoxical embolism managed surgically and describe the perioperative anesthetic considerations in this patient population, along with the role of intraoperative transesophageal echocardiography.
Asunto(s)
Ecocardiografía Transesofágica/métodos , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/cirugía , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/cirugía , Atención Perioperativa/métodos , Angiografía por Tomografía Computarizada/métodos , Embolia Paradójica/complicaciones , Defectos del Tabique Interatrial/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/cirugíaAsunto(s)
Embolia Paradójica/diagnóstico por imagen , Atrios Cardíacos/diagnóstico por imagen , Leiomiomatosis/diagnóstico por imagen , Vena Cava Inferior/diagnóstico por imagen , Diagnóstico Diferencial , Embolia Paradójica/patología , Embolia Paradójica/cirugía , Femenino , Atrios Cardíacos/patología , Atrios Cardíacos/cirugía , Humanos , Histerectomía , Leiomiomatosis/patología , Leiomiomatosis/cirugía , Persona de Mediana Edad , Salpingooforectomía , Neoplasias Uterinas/patología , Neoplasias Uterinas/cirugía , Vena Cava Inferior/patología , Vena Cava Inferior/cirugíaRESUMEN
A severely obese patient with dyspnea and weighing 197 kg presented to us. He experienced an impending paradoxical embolism in the left ventricle caused by a deep vein thrombosis passing through a patent foramen ovale, as well as an acute massive pulmonary thromboembolism. Emergency thromboembolectomy from the right atrium and the bilateral pulmonary arteries was successfully performed. This is an extremely rare case of a severely obese patient with a body mass index of 66.6 kg/m2 who required emergency cardiac surgery by a cardiopulmonary bypass.
Asunto(s)
Embolia Paradójica , Foramen Oval Permeable , Embolia Pulmonar , Tromboembolia Venosa , Embolia Paradójica/diagnóstico , Embolia Paradójica/etiología , Embolia Paradójica/cirugía , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico por imagen , Foramen Oval Permeable/cirugía , Humanos , Masculino , Obesidad/complicaciones , Embolia Pulmonar/etiología , Embolia Pulmonar/cirugía , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologíaRESUMEN
Impending paradoxical embolism (IPDE) is the presence of a thrombus in the patent foramen ovale. Usually, IPDE is diagnosed by echocardiography or a multislice computed tomography scan and is performed during the evaluation of a patient presenting with suspected pulmonary embolism. We report 2 patients who presented with IPDE and were successfully treated with cardiac surgery and thrombolytic therapy. Thus, we focus our discussion on the diagnosis and treatment modalities of this rare entity.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Embolia Paradójica/cirugía , Foramen Oval Permeable/complicaciones , Embolia Pulmonar/cirugía , Ecocardiografía Transesofágica , Embolia Paradójica/diagnóstico , Embolia Paradójica/etiología , Femenino , Foramen Oval Permeable/diagnóstico , Foramen Oval Permeable/cirugía , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector/métodos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologíaAsunto(s)
Embolia Paradójica/etiología , Endocarditis Bacteriana/diagnóstico , Foramen Oval Permeable/complicaciones , Válvula Tricúspide/cirugía , Adulto , Antibacterianos/uso terapéutico , Ecocardiografía Transesofágica , Embolia Paradójica/cirugía , Endocarditis Bacteriana/terapia , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Staphylococcus aureus/aislamiento & purificación , Válvula Tricúspide/microbiologíaRESUMEN
OBJECTIVE: Paradoxical embolism represents a rare condition occurring when a thrombus originating from venous system produces pulmonary embolism and systemic embolization through an intracardiac or pulmonary shunt. The evidence of a thrombus entrapped in a patent foramen ovale (PFO) is an even more rare condition. There is uncertainty about the optimal treatment strategy. PATIENTS AND METHODS: A 58-year-old male patient was admitted to our Internal Medicine Unit with the diagnosis of bilateral bronchopneumonia. During hospitalization, the co-occurrence of chest pain and amaurosis led us to hypothesize a paradoxical embolism. RESULTS: Transthoracic echocardiography showed the presence of a thrombus stuck over the interatrial septum. A contrast-enhanced chest CT scan showed multiple pulmonary embolisms and brain CT scan documented a hypodense area, of ischemic significance, in the left occipital lobe near tentorium. In order to prevent further embolization, emergency cardiac surgery (right atriotomy, removal of thrombus and closure of the PFO, pulmonary thrombectomy) was performed without complications. CONCLUSIONS: Although rare, the evidence of a thrombus stuck in a patent foramen ovale represents a clinical emergency. The optimal therapeutic approach is still debated. The surgical correction seems to be a safe and effective option for these patients.
Asunto(s)
Embolia Paradójica/cirugía , Foramen Oval Permeable/complicaciones , Trombosis/cirugía , Ecocardiografía , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/etiología , Humanos , Masculino , Persona de Mediana Edad , Trombosis/diagnóstico por imagen , Trombosis/etiología , Tomografía Computarizada por Rayos XRESUMEN
Abstract: Patent Foramen Ovale (PFO) is one of the most frequent congenital defects in adults. Its prevalence in middle-aged adults is close to 25-30% and may cause paradoxical embolic phenomena. We report a 45 years old male admitted for an ischemic stroke with an occlusion of the left terminal internal carotid artery. A thrombectomy was performed. Searching for possible sources of emboli, a patent foramen ovale was detected in an echocardiography, with an hypoechogenic examination image passing through it. Anticoagulant therapy was started and the patient had an uneventful evolution.
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Embolia Paradójica/etiología , Foramen Oval Permeable/complicaciones , Ecocardiografía , Arterias Carótidas , Factores de Riesgo , Resultado del Tratamiento , Trombectomía/métodos , Embolia Paradójica/cirugía , Embolia Paradójica/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Foramen Oval Permeable/diagnóstico por imagenRESUMEN
Paradoxical embolism through a patent foramen ovale is a very unusual event considering that this cardiac anomaly may be present in as much as 26% of the general population. We describe the case of a 68-year-old man with a pulmonary and paradoxical coronary embolism in the presence of a patent foramen ovale. The finding of a worm-shaped thrombus though the atrial septum together with the risk of further embolization through the atrial septum prompted surgical treatment.
Asunto(s)
Oclusión Coronaria/etiología , Embolia Paradójica/etiología , Foramen Oval Permeable/complicaciones , Embolia Pulmonar/etiología , Trombosis/complicaciones , Anciano , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/cirugía , Ecocardiografía , Embolectomía , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/cirugía , Foramen Oval Permeable/diagnóstico por imagen , Foramen Oval Permeable/cirugía , Humanos , Masculino , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/cirugía , Trombectomía , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Resultado del TratamientoAsunto(s)
Embolia Paradójica/diagnóstico , Foramen Oval Permeable/diagnóstico , Insuficiencia Respiratoria/etiología , Choque/etiología , Accidente Cerebrovascular/etiología , Anciano , Embolia Paradójica/complicaciones , Embolia Paradójica/cirugía , Femenino , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/cirugía , HumanosRESUMEN
Patent Foramen Ovale (PFO) is one of the most frequent congenital defects in adults. Its prevalence in middle-aged adults is close to 25-30% and may cause paradoxical embolic phenomena. We report a 45 years old male admitted for an ischemic stroke with an occlusion of the left terminal internal carotid artery. A thrombectomy was performed. Searching for possible sources of emboli, a patent foramen ovale was detected in an echocardiography, with an hypoechogenic examination image passing through it. Anticoagulant therapy was started and the patient had an uneventful evolution.
Asunto(s)
Embolia Paradójica/etiología , Foramen Oval Permeable/complicaciones , Arterias Carótidas , Ecocardiografía , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/cirugía , Foramen Oval Permeable/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Accidente Cerebrovascular/etiología , Trombectomía/métodos , Resultado del TratamientoAsunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Embolia Paradójica/diagnóstico por imagen , Foramen Oval Permeable/diagnóstico por imagen , Embolia Pulmonar/etiología , Trombectomía/métodos , Anciano , Artroplastia de Reemplazo de Cadera/métodos , Disnea/diagnóstico , Disnea/etiología , Ecocardiografía/métodos , Ecocardiografía Transesofágica/métodos , Embolia Paradójica/etiología , Embolia Paradójica/cirugía , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Angiografía por Resonancia Magnética/métodos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/cirugía , Medición de Riesgo , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
Paradoxical embolization is the mechanism for patent foramen ovale (PFO)-associated cryptogenic stroke and transcatheter closure of PFO may prevent recurrent ischemic stroke. Mechanical thrombectomy is promising to treat acute ischemic stroke due to high rates of reperfusion and reduced intracranial hemorrhage complications. We report the case of a 27-year-old woman with a massive cerebral infarction but no evidence for any atherosclerosis, who received an urgent mechanical thrombectomy with a Solitaire device. In order to ascertain the etiology of stroke, transcranial Doppler (TCD) and transesophageal echocardiograph (TEE) were conducted. TCD showed severe right-to-left shunting (shower effect) after Valsalva maneuver and bubble test and TEE identified a PFO. Therefore, the patient had suffered a paradoxical stroke associated with PFO. After two weeks of the stroke onset, transcatheter PFO closure with Cardio-O-Fix occluder was also performed successfully. During 1-year of follow-up, no recurrence of stroke occurred. Our case demonstrates that mechanical thrombectomy using a Solitaire device and transcatheter PFO closure can be safely and successfully performed to treat acute paradoxical stroke and prevent its recurrence.