Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary embolism

Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary... 358 Image Focus IMAGE FOCUS doi:10.1093/ehjci/jex256 Online publish-ahead-of-print 27 October 2017 ................................................................................................................................................... Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary embolism Ahmad Awada, Didier de Cannie`re, Paul-Gael Silance, and Philippe Unger* Department of Cardiology, Universite´ Libre de Bruxelles (ULB), CHU Saint-Pierre, 322 rue Haute, B-1000 Brussels, Belgium * Corresponding author. Tel: 1322 5353350; Fax: 1322 5353362. E-mail: punger@ulb.ac.be A 74-year-old woman presented with a 3-day history of increasing dyspnoea. She had undergone left hip arthro- plasty following a car accident 5 weeks previously, resulting in prolonged bed rest. The patient was tachypnoeic, and blood pressure was 140/60 mmHg. Besides sinus tachycardia, the electro- cardiogram revealed an S1Q3 pattern. NT-proBNP (4849 pg/ml) and D- dimers (3964 ng/ml) were increased. Transthoracic echocardiography (Panel A; RA: right atrium; LA: left atrium, see Supplementary data online, Video S1) demonstrated a thrombus (*) straddling a patent fora- men ovale (PFO), confirmed by transoesophageal echocardiography (TEE) (Panels B and C,see Supplemen tary data online, Videos S2 and S3) which, in addition, detected another thrombus (**) in the right pulmonary artery (PA) (Panel D,see Supplemen tary data online, Video S4). Computed tomography pulmonary angiogram showed multiple bilateral pulmonary emboli (Panel E). Emergent surgical thrombectomy and pulmonary embo- lectomy were performed (Panel F), followed by gradual clinical improve- ment under unfractionated heparin. Heparin-induced thrombocytopenia complicated by left popliteal artery thrombosis was diagnosed on the tenth postoperative day. Danaparoid sodium was initiated after thrombectomy. Thrombus entrapped in the PFO is an uncommon finding in the setting of pulmonary embolism. Anticoagulation and surgical thrombec- tomy are considered the therapeutic mainstay, although the optimal approach remains unclear. Associated pulmonary embolism is the rule, but there is only one single previous report of straddling thrombus and PA clot simultaneously detected by TEE, also originating from our group. We hereby speculate that TEE might allow detecting more frequently PA thrombi in patients with straddling thrombi than what is actually reported in the literature, and emphasize the critical role of echocardiography in allowing early diagnosis. Supplementary data are available at European Heart Journal – Cardiovascular Imaging online. References 1. Najem B, Lefrancq E, Unger P. Thrombus trapped in patent foramen ovale and bilateral pulmonary embolism: a one-stop shop ultrasound diagnosis. Circulation 2008;118:e154–5. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/19/3/358/4568991 by Ed 'DeepDyve' Gillespie user on 22 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal – Cardiovascular Imaging Oxford University Press

Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary embolism

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Oxford University Press
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.
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2047-2404
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10.1093/ehjci/jex256
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Abstract

358 Image Focus IMAGE FOCUS doi:10.1093/ehjci/jex256 Online publish-ahead-of-print 27 October 2017 ................................................................................................................................................... Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary embolism Ahmad Awada, Didier de Cannie`re, Paul-Gael Silance, and Philippe Unger* Department of Cardiology, Universite´ Libre de Bruxelles (ULB), CHU Saint-Pierre, 322 rue Haute, B-1000 Brussels, Belgium * Corresponding author. Tel: 1322 5353350; Fax: 1322 5353362. E-mail: punger@ulb.ac.be A 74-year-old woman presented with a 3-day history of increasing dyspnoea. She had undergone left hip arthro- plasty following a car accident 5 weeks previously, resulting in prolonged bed rest. The patient was tachypnoeic, and blood pressure was 140/60 mmHg. Besides sinus tachycardia, the electro- cardiogram revealed an S1Q3 pattern. NT-proBNP (4849 pg/ml) and D- dimers (3964 ng/ml) were increased. Transthoracic echocardiography (Panel A; RA: right atrium; LA: left atrium, see Supplementary data online, Video S1) demonstrated a thrombus (*) straddling a patent fora- men ovale (PFO), confirmed by transoesophageal echocardiography (TEE) (Panels B and C,see Supplemen tary data online, Videos S2 and S3) which, in addition, detected another thrombus (**) in the right pulmonary artery (PA) (Panel D,see Supplemen tary data online, Video S4). Computed tomography pulmonary angiogram showed multiple bilateral pulmonary emboli (Panel E). Emergent surgical thrombectomy and pulmonary embo- lectomy were performed (Panel F), followed by gradual clinical improve- ment under unfractionated heparin. Heparin-induced thrombocytopenia complicated by left popliteal artery thrombosis was diagnosed on the tenth postoperative day. Danaparoid sodium was initiated after thrombectomy. Thrombus entrapped in the PFO is an uncommon finding in the setting of pulmonary embolism. Anticoagulation and surgical thrombec- tomy are considered the therapeutic mainstay, although the optimal approach remains unclear. Associated pulmonary embolism is the rule, but there is only one single previous report of straddling thrombus and PA clot simultaneously detected by TEE, also originating from our group. We hereby speculate that TEE might allow detecting more frequently PA thrombi in patients with straddling thrombi than what is actually reported in the literature, and emphasize the critical role of echocardiography in allowing early diagnosis. Supplementary data are available at European Heart Journal – Cardiovascular Imaging online. References 1. Najem B, Lefrancq E, Unger P. Thrombus trapped in patent foramen ovale and bilateral pulmonary embolism: a one-stop shop ultrasound diagnosis. Circulation 2008;118:e154–5. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/19/3/358/4568991 by Ed 'DeepDyve' Gillespie user on 22 March 2018

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European Heart Journal – Cardiovascular ImagingOxford University Press

Published: Mar 1, 2018

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