Poster No. 040 Traversing boundaries inside the heart

Abstract

Abstract An 84-year-old man with previous pulmonary embolism (PE) was admitted to hospital for acute dyspnea. He was normotensive, but tachypneic and tachycardic. Non-relevant findings on auscultation. ECG showed sinus tachycardia and blood tests depicted elevated D-dimers and troponin I. Angio-CT diagnosed a PE. Echocardiogram (echo) showed an enlarged right ventricle with depressed function, a flattened septum with paradoxical movement, preserved left ventricular function, no intracavitary masses. Enoxaparin was started. Days later he developed new left sided hemiparesis. Acute ischemic cerebral lesion on CT scan. Echo disclosed a new hyperechogenic highly mobile mass attached to the interatrial septum moving from the right to the left atrium, suggestive of thrombus. Anticoagulation was maintained and on new echo evaluation days later there were no intracardiac masses. Agitated saline echo testing disclosed the presence of a patent foramen ovale, supporting the previous notion that a thrombus was moving between interatrial chambers. Oncological screening and prothrombotic evaluation were not completed due to unfavorable clinical evolution. Paradoxical embolism (PaE) is usually a presumptive diagnosis. It is rarely found in clinical practice, though its prevalence may be underestimated due to the transient nature of the phenomenon and the difficulty in identifying a venous thrombus-in-transit through a cardiac defect and subsequent arterial embolism. The presence of a thrombus-in-transit modifies the treatment strategy, requiring urgent management due to the impeding risk of PaE, with treatment options comprising anticoagulation, thrombolysis and thrombectomy. Although no consensus exists regarding optimal strategy, surgical embolectomy is the favored approach in most published cases.