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Serpentine Thrombus Traversing the Foramen Ovale: Paradoxical Embolism Shown by Transesophageal Echocardiography

Sandra I. Barbour, MD; Keith F. Izban, MD; Cesar V. Reyes, MD; Thomas L. McKiernan, MD; and Eric K. Louie, MD
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From Loyola University Medical Center, Maywood, Illinois. Requests for Reprints: Eric K. Louie, MD, Division of Cardiology, Loyola University Medical Center, Building 110, Room 6228, 2160 South First Avenue, Maywood, IL 60153. Current Author Addresses: Dr. Barbour: The Permanente Medical Group, Inc., Department of Cardiology, 2025 Morse Avenue, Sacramento, CA 95825-2115.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(2):111-113. doi:10.7326/0003-4819-125-2-199607150-00006
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Paradoxical embolism is a rare cause of myocardial infarction. We describe a patient in whom morbid obesity obscured clinical examination and rendered invasive diagnostic evaluation by angiography unfeasible. Transesophageal echocardiography showed the pathophysiologic basis for respiratory decompensation (pulmonary thromboembolism) and myocardial infarction (paradoxical embolism to a coronary artery) after transthoracic echocardiography and computed axial tomography had failed to distinguish among the initial differential diagnostic possibilities. These possibilities included left ventricular systolic dysfunction, pulmonary embolism, pulmonary sepsis, and acute decompensation of chronic pulmonary disease caused by morbid obesity.

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Grahic Jump Location
Figure 1. Diastolic stop-frame images ( ) and accompanying schematic line drawings ( ). Orienting arrows point from posterior ( ) to anterior ( ), from patient's left ( ) to right ( ), and from the basal portion (B) to the apical portion (A) of the heart. Transverse plane transesophageal echocardiogram of the four chambers of the heart. A multilobed mass (stippled structures) is seen in the right atrium (RA), prolapsing across the tricuspid valve into the right ventricle (RV). The same right atrial mass traverses a patent foramen ovale and is seen in the left atrium (LA) crossing the mitral valve. Longitudinal plane transesophageal echocardiogram of the aorta (Ao), left ventricular outflow tract, and left atrium. A portion of the same mass (stippled structures) shown in the top panels is seen in the left atrium traversing the aortic valve. Longitudinal plane transesophageal echocardiogram (with marked lateral tip flexion) of the right atrium and fossa ovalis. The same multilobed mass (stippled structures) is seen in the right atrium traversing a patent foramen ovale ( ) from right atrium to left atrium. LV = left ventricle.
Transesophageal echocardiogram of paradoxical embolism.left panelsright panelsPALRTop.Middle.Bottom.arrow
Grahic Jump Location
Grahic Jump Location
Figure 2. Posterior aspect of the autopsied heart with the left and right ventricular apices at the bottom of the picture and the free walls of the right ventricle (RV) and right atrium (RA) open and reflected toward the right. The solid white triangle shows the cross-section of the left ventricular cavity. The two large white arrows show a thrombus that originates in the right atrium and extends across the tricuspid valve into the right ventricle. Autopsied heart showing the opened right atrium and right ventricle. A probe has been placed through the patent foramen ovale. LA = left atrium.
The heart after the patient's death, showing intracardiac thrombus and patent foramen ovale. Top.Bottom.
Grahic Jump Location




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