Asian Journal of Research in Cardiovascular Diseases

A Large Thrombus in Transit within a Patent Foramen Ovale with Massive Pulmonary Embolism : A Rare Case Report

H. Charif *

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.

I. Rezzouk

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.

B. E. Ovaga

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.

D. Jama

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.

S. Elmazozi

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco.

M. Haboub

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco.

S. Arous

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco.

Med G. Benouna

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco.

A. Drighil

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco.

R. Habbal

Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco and Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco.

*Author to whom correspondence should be addressed.

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Abstract

Reports of thrombi straddling the patent foramen ovale (PFO) are uncommon occurrences. The development of thrombi within the cardiac chambers poses a greater risk of mortality compared to pulmonary embolism (PE) alone and may necessitate a change in treatment strategy [1]. In this case, we describe a rare scenario involving a 53-year-old patient who presented with massive pulmonary embolism. Echocardiography revealed a large thrombus trapped within the patent foramen ovale, protruding into the left heart chambers and causing increased pulmonary artery pressure—a highly unusual and critical condition. Echocardiography emerges as a valuable and safe tool in demonstrating the size, location, and extent of a thrombus, playing a crucial role in the prompt diagnosis and evaluation of treatment options for individuals with a thrombus trapped within a PFO alongside concurrent pulmonary embolism. Our patient received treatment with thrombolysis and anticoagulation, ultimately achieving an uneventful recovery. While the treatment in this case yielded satisfactory results, it may not be universally applicable. Given the rarity of this diagnosis and the limited available data, there is no formally established treatment guideline. Nevertheless, in patients deemed suitable for surgery, studies have indicated improved outcomes with surgical embolectomy compared to anticoagulation alone or thrombolysis. Anticoagulant therapy may represent an acceptable therapeutic alternative, especially for patients with comorbidities at high surgical risk or those with small PFOs. Notably, thrombolysis is associated with the highest mortality, potentially explained by the severity of the patient's initial presentation.

Keywords: Patent foramen ovale, massive pulmonary embolism, thrombus

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References

Emir Derviş et al. A large biatrial thrombus entrapped by patent foramen ovale in a case with massive pulmonary embolism Masif, 2018;26(1):150-152

Shepherd F, White-Stern A, Rahaman O, et al. Saddle pulmonary embolism with thrombus in transit across a patent foramen Ovale. Case Rep Cardiol. 2017;2017:6752709.

Vidya Suratkal et al. Right atrial thrombus and challenges in its management. 2018 Dec;66(12):65-68.

Nellessen U, Daniel WG, Matheis G. Impending paradoxical embolism from atrial thrombus: Correct diagnosis by transesophageal echocardiography and prevention by surgery. Journal of the American College of Cardiology. 1985; 5(4):1002–1004.

Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: Systematic review of prognostic factors and treatment. Chest. vol. 2010;137(1):164–170.

Kilic A, Shah AS, Conte JV, et al. Nationwide outcomes of surgical embolectomy for acute pulmonary embolism. J Torac Cardiovasc Surg. 2013;145:373–377.

Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in pulmonary embolism: Results from the international cooperative pulmonary embolism registry. Journal of the American College of Cardiology. 2003; 41(12):2245–2251,.

Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002;121(3) 806–814.

Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. Journal of the American College of Cardiology. 1985; 5(4):1002–1004.

Aboyans V, Lacroix P, Ostyn E, Cornu E, Laskar M. Diagnosis and management of entrapped embolus through a patent foramen ovale. European Journal of Cardio-Thoracic Surgery. 1998;14(6):624–628.

Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: Systematic review of prognostic factors and treatment. Chest. 2010;137(1):164–170.

Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015;28:910–958.

Kucukseymen S, Bayar N, Koklu E, et al. Successful lysis in massive pulmonary embolism with thrombus entrapped in PFO. Am J Emerg Med. 2017;35:198.e3–198.e5. DOI: 10.1016/j.ajem.2016.07.039.

Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002;121: 806–814.

Fauveaua E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: Impending paradoxical embolism? Report of four clinical cases and literature review. Archives of Cardiovascular Diseases. 2008;101(10) :637–644.

Lu C, Li J, Wang W, Gong K, Zhao L, Fu X. Large thrombus-in-transit within a patent foramen ovale in a patient with pulmonary embolism: A case report. Journal of International Medical Research. 2018 Oct;46(10):4332-7.