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Case Reports
. 2014 Aug;5(3-4):112-117.
doi: 10.14740/cr335w. Epub 2014 Jul 20.

Paradoxical Thromboembolism/ST-Elevation Myocardial Infarction via a Patent Foramen Ovale in Sub-Massive Pulmonary Embolism Following an Upper Extremity Deep Venous Thrombosis: Is It Time for a Change in the Standard of Care?

Deepali Nivas Tukaye  1 , Rodrigo Silva Cavallazzi  2
Affiliations
Case Reports

Paradoxical Thromboembolism/ST-Elevation Myocardial Infarction via a Patent Foramen Ovale in Sub-Massive Pulmonary Embolism Following an Upper Extremity Deep Venous Thrombosis: Is It Time for a Change in the Standard of Care?

Deepali Nivas Tukaye et al. Cardiol Res. 2014 Aug.

Abstract

The objective of this case study is to discuss a rare case of proven paradoxical thromboembolism captured in-transit. A 23-year-old female with a diagnosis of right internal jugular deep vein thrombus who developed acute onset chest pain, dyspnea and hypotension, was selected for the study. Sub-massive PE and STEMI were diagnosed. Transthoracic echocardiogram revealed a left ventricular (LV) mass moving across the aortic valve. Soon after, the patient developed numbness of right extremities with non-palpable pulses. A transesophageal echocardiogram revealed absent LV mass, PFO, left atrial mass entering through the PFO and emboli in bilateral pulmonary arteries. We report a case of sub-massive PE and paradoxical proven coronary and upper extremity embolism, captured in-transit, following destabilization of an UEDVT in a patient with PFO.

Keywords: Paradoxical thromboembolism; STEMI; Sub-massive pulmonary embolism; Upper extremity DVT.

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Figures

Figure 1
Figure 1
(A) CT angiogram of head and neck demonstrating the right internal jugular vein thrombus. (B) Baseline EKG in normal sinus rhythm no ST-T changes. (C) Transthoracic ECHO 4-chamber view of the heart with no thrombus during first hospitalization. (D) CT PE protocol revealing emboli in right and left PAs (arrows). (E) Transthoracic ECHO 4-chamber view of the heart revealing thrombus in the LV cavity extending across the mitral valve with point of origin in the LA (arrow). (F) EKG demonstrating ST elevation in II, III and aVF.
Figure 2
Figure 2
Transesophageal ECHO. (A) Serpiginous thrombus in the LA. (B) Thrombus straddling across the PFO (broad arrow). (C) Color Doppler demonstrating flow across the inter-atrial septum via the PFO (broad arrow). (D) Embolus in the PA (arrow).
Figure 3
Figure 3
Paradoxical thromboembolism. (A) CT angiogram of lower extremities with emboli (filling defects; dotted circle) in the right illio-femoral arteries. (B) CT angiogram of upper extremities with emboli (filling defects; dotted circle) in the right subclavian artery. Cardiac catheterization, (C) left coronary artery; (D) right coronary artery.
See this image and copyright information in PMC

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