Patent foramen ovale with a riding vermicular thrombus arising from a pacemaker lead
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IMAGES IN CARDIOVASCULAR ULTRASOUND
Patent foramen ovale with a riding vermicular thrombus arising from a pacemaker lead Mehmet Ali Astarcioglu • Mehmet Ozkan Ozan Gursoy • Altug Tuncer
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Received: 15 October 2012 / Revised: 17 March 2013 / Accepted: 19 March 2013 Ó Japanese Society of Echocardiography 2013
A 57-year-old woman was admitted to our hospital with tachycardia and progressive dyspnea. The patient had a DDDR permanent pacemaker that was implanted 10 years ago because of complete AV block. A procoagulant state and lower limb venous thrombosis were not reported. Twodimensional transthoracic echocardiography revealed a mobile mass in the right and left atria, attached to the atrial pacemaker lead. Two-dimensional transesophageal echocardiography (2D-TEE) visualized a vermicular thrombus trapped in the patent foramen ovale (PFO) with floating parts in both atria and partially prolapsing into both ventricles during diastole (Fig. 1, videos 1 and 2 in the Supplementary Material). There was no evidence of thrombus in the pulmonary arteries. Computed tomography (CT) scan showed no pulmonary embolism. Neurologic examination and lower venous Doppler ultrasound imaging showed no abnormality. Anticoagulation therapy with unfractionated heparin was started and the patient was referred to the cardiac surgery department. Biatrial thromboembolectomy and surgical removal of the endocardial lead were successfully performed, and the foramen ovale was closed by primary suture (Fig. 2). The patient’s postoperative course was uneventful. Since there was no history of atrial fibrillation and procoagulant disease, oral Electronic supplementary material The online version of this article (doi:10.1007/s12574-013-0174-0) contains supplementary material, which is available to authorized users.
anticoagulation was initiated and prescribed for 6 months. Although atrial thrombi have previously been reported in the presence of PFO [1–4], this unusual occurrence of a pacemaker lead crossing a PFO is unique. This is the first example of thrombus originating from a pacemaker lead and extending to the left atrium via the PFO. Conflict of interest All the authors contributed to the submitted work and preparation of the manuscript and read and approved the manuscript. Our article is not under consideration elsewhere and none of the contents of the manuscript has been published elsewhere. We declare no conflicts of interest with respect to the authorship and/or publication of this article. The authors received no financial support for the research and/or authorship of this article.
References 1. Celik T, Kursaklioglu H, ˙Iyisoy A, et al. Huge atrial thrombus causing massive pulmonary and paradoxical embolism via patent foramen ovale. Tex Heart Inst J. 2005;32:612–3. 2. Webb ST, Falter F. Use of transoesophageal echocardiography in impending paradoxical embolism due to thrombus straddling a patent foramen ovale. Eur J Anaesthesiol. 2007;24:383–5. 3. Sibbing D, Overbeck M, Schmidt R, et al. Patent foramen ovale with a riding vermicular th
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