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Reprint Address: Jason T. Nomura, md, rdms, Department of Emergency Medicine, Christiana Care Health System, 4755 Ogletown Stanton Road, Newark, DE 19720
Affiliations
Department of Emergency Medicine, Value Institute, Christiana Care Health System, Newark, Delaware
A 60-year-old woman with breast cancer with brain and bone metastases presented to
the emergency department with complaints of cough, progressive dyspnea, and hemoptysis.
Initial vitals signs revealed a heart rate of 80 beats/min, respiratory rate of 26
breaths/min, blood pressure of 120/80 mm Hg, and room air pulse oxygenation of 88%.
The patient also noted pain and swelling in her right lower extremity. When measured,
the right lower extremity had a 4 cm greater diameter compared to the left. Because
of the leg swelling, dyspnea, tachypnea, and an electrocardiogram (ECG) showing right
heart strain, a transthoracic echocardiogram was performed at the bedside to evaluate
for possible pulmonary embolism (Figure 1, Figure 2, Video 1).
Figure 1(A) Apical four-chamber view demonstrating thrombus (arrows) in the right and left
atria crossing the inter-atrial septum through the patent foramen ovale during systole.
(B) Apical four-chamber view demonstrating thrombus (arrows) in the right and left
atria crossing the inter-atrial septum through the patent foramen ovale during diastole.
Surgical or medical treatment for thrombus straddling the patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature review.
The therapeutic dilemma faced by Provenzal et al. reflects the uncertainty regarding the choice between surgical embolectomy, routine anticoagulation, or thrombolysis for the treatment of impending paradoxical embolism (1–3).
