Cardiology Letters 2017, 26(3):164-169

What is a thrombus wedged in the patent foramen ovale capable of?

Böhm A¹, Hricák V¹, Kozlovský M¹, Sumbal J¹, Majerčík M², Tomašovič B¹, Baranová E¹, Péč J³

¹ Oddelenie akútnej kardiológie, Národný ústav srdcových a cievnych chorôb, a.s., Bratislava

² Oddelenia rádiológie, Národný ústav srdcových a cievnych chorôb, as., Bratislava

³ Oddelenia invazívnej kardiológie, Národný ústav srdcových a cievnych chorôb, a.s., Bratislava, Slovenská republika

Case description: A 49-year-old male was transferred to CCU with recent massive, but hemodynamically stable, pulmonary embolism (PE) followed by symptomatic embolic stroke 3 days before the CCU admission. TEE echocardiography showed thrombus in foramen ovale (PFO), CCD Ultrasonography showed thrombi in the right popliteal vein. Emergent surgical thrombectomy and PFO closure were successfully performed. However the postoperative period was complicated by hemodynamic instability requiring ECMOECLS, recurrent massive PE, infection with disseminated intravascular coagulopathy and diffuse bleeding on continual heparin treatment. After multiple surgical revisions, hemotherapy and antibiotic treatment bleeding was stabilized and the infection subsided. The patient was discharged with minimal neurologic deficit and hemodynamically stabilized.

Discussion: There were 3 possible therapeutic-preventive approaches: surgery, thrombolysis or solo-anticoagulation. We chose surgery because the patient was stable, with no comorbidities and had already suffered a stroke. The cause of the post-operative need for ECMO implantation might be in right ventricular (RV) failure. Therefore pre-operative RV dysfunction should be considered as an important prognostic factor for surgical therapy. To prevent the recurrent PE in the presence of residual deep vein thrombosis, a retrievable vena cava filter should be inserted.

Conclusions: Thrombus in PFO is a rare but severe event that was in our case successfully managed by surgery. As current guidelines don't provide necessary answers, the optimal treatment is still a matter of discussion.

Keywords: thromboembolic disease; thrombus in transit; patent foramen ovale; surgical thrombectomy; vena cava filter

Published: March 1, 2017  Show citation