Thrombus straddling patent foramen ovale and massive pulmonary embolism
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CASE REPORT
Thrombus straddling patent foramen ovale and massive pulmonary embolism Nirmal Panthee 1 & Raamesh Koirala 1 & Nivesh Rajbhandari 1 & Sidhartha Pradhan 1 Received: 14 May 2020 / Revised: 24 June 2020 / Accepted: 25 June 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract A thrombus straddling the foramen ovale is rare; and optimal management is controversial. Most of the literature on this topic is available only in the form of case reports. Here, we present a case of 30-year-old female with recent history of fibular fracture and thrombus in transit through patent foramen ovale and massive pulmonary embolism who was successfully managed with pulmonary embolectomy, extraction of serpentine thrombus straddling patent foramen ovale, and closure of patent foramen ovale. Keywords Foramen ovale . Thrombus . Pulmonary embolism
Introduction Deep venous thrombosis is not so uncommon after fracture of lower limbs; which might easily be complicated by pulmonary embolism. Patent foramen ovale (PFO) is a common finding, occurring in up to 25% of people [1]. PFO is associated with a number of conditions which include cryptogenic stroke, decompression sickness, migraine, obstructive sleep apnea, paradoxical myocardial infarction, and other distal embolizations [2]. Thrombus straddling foramen ovale (TSFO) is a rare entity and management strategies include thrombolysis, anticoagulation, and surgical extraction, with no consensus over the superiority of one versus another [3]. Intracardiac thrombus in transit wedged in a PFO is associated with high mortality and morbidity [4]. The combination of a TSFO and acute pulmonary embolism significantly increases the likelihood of the occurrence of paradoxical embolism [5].
Case report A 30-year-old female was referred to us from another hospital with shortness of breath, cough, and palpitations for 6 days. * Raamesh Koirala [email protected] 1
Department of Cardiac Surgery, Shahid Gangalal National Heart Center, Bansbari, Kathmandu, Nepal
Significant past history included left posterior malleolar and proximal fibular fracture 1 month earlier, which was treated by applying circumferential cast. Clinical examination revealed a dyspneic patient with SpO2 of 94% at room air. Chest revealed bilateral crepitations; cardiovascular system examination was positive for soft systolic murmur in tricuspid area with loud P2. Other systemic examination was within normal limits. Local examination revealed circular cast in left leg below knee. Baseline hematology, biochemistry, and chest x-ray were within normal limits. Electrocardiogram (ECG) showed sinus tachycardia. Transthoracic echocardiography revealed dilated right atrium (RA), right ventricle (RV), and inferior vena cava (IVC), severe tricuspid regurgitation with estimated pulmonary artery systolic pressure (PASP) of 90 mmHg, and RV strain, although we did not measure tricuspid annular plane systolic excursion (TAPSE) to quantify RV dysfunction. Transesophageal echocardiography showed a thrombus in b
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