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Zuin M, Rigatelli G, Bilato C, Bongarzoni A, Zonzin P, Casazza F, Roncon L. Risk of early clinical deterioration and 30-day mortality in pulmonary embolism intermediate-high-risk patients with patent foramen ovale. Intern Emerg Med 2024; 19:1637-1644. [PMID: 38822190 DOI: 10.1007/s11739-024-03657-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/24/2024] [Indexed: 06/02/2024]
Abstract
We assess the prognostic role of patent foramen ovale (PFO) for the estimation of 30-day mortality and risk of 48-h clinical deterioration since admission, in intermediate-high-risk pulmonary embolism (PE) patients. A post-hoc analysis of intermediate-high-risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. The entire cohort was divided according to the presence or absence of PFO after transthoracic echocardiography (TTE) evaluation. Among 450 intermediate-high-risk PE patients (mean age 71.4 ± 13.8 years, 298 males), PFO was diagnosed in 68 (15.1%) cases. A higher mortality rate (29.4% vs. 3.1%, p < 0.001) as well as occurrence of clinical deterioration within 48 h from admission (38.2% vs. 3.6%, p < 0.001) were observed in intermediate-high-risk PE patients with PFO compared to those without multivariate Cox regression analysis showed that the presence of a PFO predicts 30-day mortality (HR: 3.21, 95% CI 3.16-3.27, p < 0.001) and was also associated with a significantly higher risk of 48-h clinical deterioration [HR: 2.24 (95% CI 2.20-2.29), p < 0.0001] in intermediate-high-risk PE patients. The presence of a PFO in intermediate-high-risk PE patients is associated with a higher risk of clinical deterioration within 48 h from admission and 30-day mortality.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, 44124, Ferrara, Italy.
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy.
| | | | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Amedeo Bongarzoni
- Department of Cardiology, ASST Santi Paolo E Carlo, University of Milan, Milan, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, Milan, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria Della Misericordia Hospital, Rovigo, Italy
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Sera S, Okazaki Y, Kashiwa K, Ichiba T. A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus. Cureus 2024; 16:e52535. [PMID: 38371032 PMCID: PMC10870038 DOI: 10.7759/cureus.52535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.
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Affiliation(s)
- Satoshi Sera
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
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Calthrop A, Shabbir A, Raffles M, Hogarth K. Acute neurological deficit with submassive pulmonary emboli. BMJ Case Rep 2022; 15:e247923. [PMID: 35292546 PMCID: PMC8928298 DOI: 10.1136/bcr-2021-247923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
Pulmonary embolism (PE) is frequently encountered in the emergency department. Syncope, often as a consequence of impending haemodynamic collapse, is associated with increased mortality. While loss of consciousness owing to cerebral hypoperfusion and reduced left ventricular preload is a common cause of collapse with large volume PE, other syndromes can also cause neurological deficit in thromboembolic disease. Here, we describe a case of a woman in her 60s, presenting to the emergency department with features of high-risk PE. During clinical examination, the patient collapsed and became unresponsive with a Glasgow Coma Scale of 4/15 despite normal haemodynamics. Neurological signs were noted and CT revealed evidence of a large territory cerebral infarction. Further cardiovascular investigations identified a grade 4 patent foramen ovale. We describe a challenging case of established venous thromboembolism complicated by paradoxical embolism, highlighting the importance of thorough clinical examination and investigation and discuss the current evidence base of treatments.
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Affiliation(s)
| | - Asad Shabbir
- Royal Berkshire NHS Foundation Trust, Reading, UK
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Thrombus straddling a patent foramen ovale: Also a myocardial infarction matter? Int J Cardiol 2021; 340:24-25. [PMID: 34375708 DOI: 10.1016/j.ijcard.2021.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 11/22/2022]
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Suenaga H, Tsurukiri J, Kato T, Matsunaga K, Ogawa N, Oiwa A, Otake N, Numata J. Paradoxical Cerebral Embolization Caused by Thrombus-In-Transit via a Patent Foramen Ovale in a Patient with Symptomatic Pulmonary Embolism: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:805-810. [PMID: 37502001 PMCID: PMC10370931 DOI: 10.5797/jnet.cr.2021-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/15/2021] [Indexed: 07/29/2023]
Abstract
Objective Acute pulmonary embolism (PE) is a life-threatening cardiovascular event associated with high mortality and morbidity. The presence of a patent foramen ovale (PFO) in patients with acute PE represents a risk factor for mortality. Furthermore, a thrombus-in-transit via a PFO with impending paradoxical embolism carries a high mortality rate. Case Presentation An adult patient with ischemic stroke caused by paradoxical embolism following PE underwent mechanical thrombectomy and achieved successful recanalization. Initial CT pulmonary angiography (CTPA) showed not only pulmonary thromboemboli but also bilateral atrial thromboemboli. During hospitalization, transesophageal echocardiography (TEE) revealed the PFO with a right-to-left shunt. Two months after rehabilitation undergone by the patient, PE completely disappeared and PFO closure was conducted to reduce the recurrence risk of ischemic stroke. Conclusion Not only cardiologists but also interventional neurologists should understand that CTPA can demonstrate the thrombus-in-transit through the PFO and provides a reliable prediction of the sudden onset of ischemic stroke in patients with symptomatic PE. When identified, considering a case-by-case treatment approach by multidisciplinary teams is essential for preventing further life-threatening paradoxical embolization.
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Affiliation(s)
- Hiroki Suenaga
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takahisa Kato
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Kyosuke Matsunaga
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Naoko Ogawa
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Akito Oiwa
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Naruaki Otake
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Jushi Numata
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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Roy S, Le H, Balogun A, Caskey E, Tessitore T, Kota R, Hejirika J, Yu S, Nguyen L, Lazo AL, Yard C, Monaghan M, Dhingra M, Modi S, Hunter K. Risk of Stroke in Patients With Patent Foramen Ovale Who Had Pulmonary Embolism. J Clin Med Res 2020; 12:190-199. [PMID: 32231756 PMCID: PMC7092756 DOI: 10.14740/jocmr4094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background The presence of patent foramen ovale (PFO) alone does not increase the risk of ischemic stroke. Several prospective studies with a small number of patients have shown that the risk of ischemic stroke is higher in patients with PFO and pulmonary embolism (PE). We studied the association of ischemic stroke in the patients who had PFO with PE (PFOwiPE) and compared with the patients who had PFO without PE (PFOwoPE). Methods Electronic medical records of 154 adult patients in our internal medicine office were reviewed. Thirty-four patients had PFOwiPE and 120 had PFOwoPE. Independent t-test and Mann-Whitney U-test were used to compare the continuous variables between the two groups, while Chi-square tests were applied to compare the categorical variables between the two groups. Logistic regression was used for multivariate analysis. The dependent variable was stroke and the independent variable of interest was PFO with, or without PE. Results Mean age of patients with PFOwiPE was 54.8 years and patients with PFOwoPE was 57.8 years (P = 0.331). Mean body mass index (BMI) of the patients with PFOwiPE was significantly greater than the patients with PFOwoPE (32.5 ± 8.84 kg/m2 vs. 28.4 ± 6.99 kg/m2; P < 0.05). Mean left ventricular ejection fraction (LVEF) and red blood cell (RBC) count of patients with PFOwiPE was significantly lower than patients with PFOwoPE (LVEF 54.9 ± 13.01% vs. 59.6 ± 6.85%, P < 0.05; RBC 4.1 ± 1.203 × 106/µL vs. 4.5 ± 0.596 × 106/µL, P < 0.05). There was significantly higher association of congestive heart failure (CHF) in patients with PFOwiPE compared to patients with PFOwoPE (20.6% vs. 7.5%; P < 0.05). Association of ischemic stroke was 35.3% in patients with PFOwiPE and 39.2% in patients with PFOwoPE. The difference was not statistically significant (P = 0.682). Conclusions Association of ischemic stroke was similar in patients with PFOwiPE and patients with PFOwoPE. Association of significantly higher BMI, lower LVEF, lower RBC count, and higher frequency of CHF were associated with patients with PFOwiPE compared to the patients with PFOwoPE.
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Affiliation(s)
- Satyajeet Roy
- Department of Medicine, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, USA
| | - Han Le
- Department of Medicine, Cooper University Health Care, Camden, NJ, USA
| | | | - Elizabeth Caskey
- Department of Medicine, Cooper University Health Care, Camden, NJ, USA
| | | | - Rasagnya Kota
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Long Nguyen
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | | | | | - Menaka Dhingra
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sneha Modi
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, USA
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Al’Aref SJ, Mrsic Z, Feuchtner G, Min JK, Villines TC. The Journal of Cardiovascular Computed Tomography year in review - 2018. J Cardiovasc Comput Tomogr 2018; 12:529-538. [DOI: 10.1016/j.jcct.2018.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/18/2018] [Indexed: 12/24/2022]
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