Page 18 - Delaware Medical Journal July 2015
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Thrombus in Transient Through PFO
Is the Patient Low to Intermediate Risk for Surgery?
High Risk for Surgery?
Any Contraindication for Fibrinolysis?
NO
ticoagulation Alone
of an embolus passing from the venous to the arterial system through an atrial septal abnormality (either PFO or an ASD). Although PFO has a high incidence of around 27 percent,2 the incidence of paradoxical embolism is rare and requires a higher right than left atrial pressure, which happens in the context of pulmonary embolism (PE) or pulmonary hypertension.5
Echocardiography is the diagnostic test of choice for the detection of cardiac source of stroke. TTE with agitated saline through a PFO, an atrial septal defect, or an atrial septal aneurysm.6
TEE is superior to TTE for imaging the interatrial septum and
YES
YES: Proceed to Surgery
Proceed with Thrombolysis and Anticoagulation
FIGURE 5
Simple algorithm to choose the appropriate management of thrombus in transit depending on patients’ status.
suboptimal images (e.g., in patients with chest wall deformities, lung disease, or other causes for poor acoustic windows). The use of TEE is indicated as well in patients with known DVT
or PE who are presenting with signs of systemic embolization including stroke or TIA.7 TIT through PFO with a TEE is a very rare event.7
In a review of the 88 reported cases in the literature, 50 percent of the patients presented with an association between PE and systemic embolism before treatment.8 Two cases of paradoxical embolism occurred after treatment. The most frequent site
of systemic embolism was cerebral; other sites of systemic embolism were the coronary arteries, kidneys, the spleen, and the inferior or superior limbs. Management of TIT through a
A
Ant
DISCUSSION
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Del Med J | July 2015 | Vol. 87 | No. 7
