From the Abteilung Innere Medizin III—Kardiologie (S.K., A.G.,
L.B., H.J.), the Abteilung Medizinische Biometrie und Informatik (M.O.),
Universitaetsklinik Freiburg, and the St. Josefs Hospital (W.K.),
Wiesbaden—all in Germany.
Background—Right-to-left shunt
through a patent foramen ovale is frequently diagnosed by contrast
echocardiography and can be particularly prominent
in the presence of elevated pressures in the right side of the heart.
Its prognostic significance in patients with pulmonary
thromboembolism, however, is unknown.
Methods and Results—The present prospective study included
139 consecutive patients with major pulmonary embolism
diagnosed on the basis of clinical, echocardiographic,
and cardiac catheterization criteria. All patients
underwent contrast echocardiography at
presentation. The end points of the study were overall
mortality and complicated clinical course during the hospital stay
defined as death, cerebral or peripheral
arterial thromboembolism, major bleeding, or need for
endotracheal intubation or cardiopulmonary resuscitation.
Patent foramen ovale was diagnosed in 48 patients (35%). These
patients had a death rate of 33% as opposed to 14% in patients with a
negative echo-contrast examination (P=.015). Logistic
regression analysis demonstrated that the only independent
predictors of mortality in the study population were a patent foramen
ovale (odds ratio [OR], 11.4; P<.001) and
arterial hypotension at presentation (OR, 26.3;
P<.001). Patients with a patent foramen ovale also had
a significantly higher incidence of ischemic stroke (13%
versus 2.2%; P=.02) and peripheral
arterial embolism (15 versus 0%; P<.001).
Overall, the risk of a complicated in-hospital course was 5.2 times
higher in this patient group (P<.001).
Conclusions—In patients with major pulmonary embolism,
echocardiographic detection of a patent foramen ovale
signifies a particularly high risk of death and arterial
thromboembolic complications.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Patent Foramen Ovale Is an Important Predictor of Adverse Outcome in Patients With Major Pulmonary Embolism
Key Words: embolism • echocardiography • contrast media • shunts
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