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(Circulation. 1996;93:387-391.)
© 1996 American Heart Association, Inc.

Articles

Impending Paradoxical Embolus

Barry P. Rosenzweig, MD; Lawrence Glassman, MD; Itzhak Kronzon, MD

From the Departments of Medicine and Surgery (L.G.), New York University School of Medicine, NY.

Correspondence to Itzhak Kronzon, MD, 560 First Ave, HW 228, New York, NY 10016.

	Introduction

 
The diagnosis of paradoxical embolization typically requires evidence of acute systemic arterial occlusion, systemic venous thrombosis, and a pathway for the thromboembolus to bypass the pulmonary vasculature. However, even when all of these findings are present, they cumulatively represent only a "smoking gun" from which a diagnosis is inferred. It is rare that one captures the actual process of paradoxical embolization "red-handed."

These transthoracic and transesophageal echocardiographic images demonstrate a thrombus traversing the patent foramen ovale of a 76-year-old woman (Fig 1). She had presented with syncope, and a ventilation-perfusion lung scan revealed a segmental abnormality strongly suggestive of pulmonary embolus. Emergency surgery confirmed the echocardiographic diagnosis and may have saved her the devastation of systemic arterial occlusion. The thrombus that was extricated from the atria and the patent foramen ovale is shown in Fig 2.

View larger version (183K): [in this window] [in a new window]   Figure 1. Top left, Transthoracic echocardiographic image obtained from the apical view. A long thrombus (arrows) is seen within both atria apparently traversing the interatrial septum in its midportion. In real time, its ends were wildly mobile and even entered the atrioventricular valve orifices during diastole. LA indicates left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle. Bottom left, Transesophageal echocardiographic image in the longitudinal plane. A thrombus (C) extends from the right atrium (RA) across the interatrial septum via a patent foramen ovale (arrow) into the left atrium (LA). The full length of the thrombus and its extent into the left atrium as well as its wild motion . . . [Full Text of this Article]

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