Page 19 - Delaware Medical Journal July 2015
P. 19
CASE REPORT
PFO can be challenging.8 Review of the reported case deemed a 21 percent mortality risk despite early diagnosis and management. Three therapeutic options are available including surgical removal, thrombolytic therapy, and/or anticoagulation.3,7,8 The choice among these options depends on the risk of surgery and co-morbidities. In reviewing all 88 cases reported in the literature apparently all patients received anticoagulation.8 Thrombolysis emergency surgery with thrombectomy and PFO closure. Patients treated with heparin and thrombolysis were older than those treated with surgery.8 The group treated with heparin had more frequent strokes. Most authors chose surgical treatment as the because of important associated comorbidities including hemodynamic instability, stroke, advanced age.8
Therefore, surgical intervention should be the treatment of choice in all low to intermediate risk patients, as it will offer better long- term outcomes with fewer complications of recurrent embolic events than both thrombolysis and anticoagulation.2,3 Those who are hemodynamically unstable or have associated comorbidities that make the surgical option a high risk should get thrombolysis with or without anticoagulation. If the patient is not a candidate for thrombolysis, then anticoagulation should be used.2,3
(Figure 5) shows a simple algorithm to choose the appropriate management depending on patients’ status.
REFERENCES
CONCLUSION
TEE is essential in identifying thrombus in transient in patients with DVT presenting with symptoms suggesting potential systemic emboli. Surgical intervention in low to intermediate risk patients is the option associated with fewest complications of recurrent embolic events compared with both thrombolysis and anticoagulation.
CONTRIBUTING AUTHORS
■ ZAHER FANARI, MD is a Cardiology Fellow at Christiana Care Health System in Newark, Del.
■ SUMAYA HAMMAMI, MD, MPH is associated with the Department of Cardiology at Christiana Care Health System in Newark, Del.
■ USMAN CHOUDHRY DO, MPH is a Cardiology Fellow at Christiana Care Health System in Newark, Del.
■ ASIM A. MOHAMMED, MBBS is a Cardiology Fellow at Christiana Care Health System in Newark, Del.
■ MARK ZWEBEN, MD is a Cardiologist at Christiana Care Health System in Newark, Del.
■ WASIF QURESHI, MD Is a Cardiologist at Christiana Care Health System in Newark, Del.
1. Lee BI, Nam HS, Heo JH, Kim DI. Yonsei Stroke Registry. Analysis of 1,000 patients with acute cerebral infarctions. Cerebrovasc Dis. 2001;12:145-151.
2. Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol. 1985;5:1002-1004.
3. Aboyans V, Lacroix P, Ostyn E, Cornu E, Laskar M. Diagnosis and management of entrapped embolus through a patent foramen ovale. Eur J Cardiothorac Surg. 1998;14:624-628.
4. Srivastava TN, Payment MF. Images in clinical medicine. Paradoxical embolism — thrombus in transit through a patent foramen ovale. N Engl J Med. 1997;337:681.
5. Cakir C, Duygu H, Eren NK, Akyildiz ZI, Nazli C, Ergene O. Witnessing a rare event — thrombus seeking its route in the right atrium: ‘thrombus-in-transit’. J Cardiovasc Med (Hagerstown). 2008;9:1166-1168
6. Pepi M, Evangelista A, Nihoyannopoulos P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography. Eur J Echocardiogr. 2010;11:461-476.
7. Baydoun H, Barakat I, Hatem E, Chalhoub M, Mroueh A. Thrombus in transit through patent foramen ovale. Case Reports in Cardiology. Available at : http://dx.doi.org/10.1155/2013/395879.
8. Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovasc Dis. 2008;101:637-644.
Del Med J | July 2015 | Vol. 87 | No. 7 211
