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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
- 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.
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.
Case Report
A 48-year-old man presented with progressive dyspnea and no history of other difficulties. Three weeks before admission, he had lost consciousness briefly and had had associated numbness in both hands and chest pain radiating to the left shoulder. The chest pain had resolved rapidly but had recurred intermittently over the following 3 days.
The patient weighed 177 kg; his body temperature was 38.5 °C, his respiratory rate was 30 breaths/min, his heart rate was 116 beats/min, and his blood pressure was 160/100 mm Hg. Breath sounds were diffusely diminished, and rales were heard bilaterally throughout the lower third of the thorax. Cardiac rhythm was rapid and regular and was associated with biventricular third heart sounds. Pitting …
