Caught in the Act: Paradoxical Emboli

Abstract

A 29-year-old woman who had factor V Leiden thrombophilia and an indwelling venous catheter for chronic pain therapy presented with dyspnea, fever, and abdominal pain. Computed tomography revealed septic pulmonary emboli with surrounding consolidation and thrombus extending from the superior vena cava to the right atrium (Fig. 1), as well as wedge-shaped splenic infarcts (Fig. 2). Blood cultures grew Staphylococcus aureus. A transesophageal echocardiogram (TEE) showed a large patent foramen ovale (PFO); severe right-to-left shunting (>20 microbubbles); and a mobile, stalked thrombus in the right atrium, extending into the left atrium (Fig. 3).The patient later had an acute ischemic stroke. No atrial thrombus was detected on repeat TEE. Antibiotic therapy and anticoagulation improved her symptoms. She later underwent percutaneous PFO closure with use of a 25-mm Gore ® Cardioform Septal Occluder (W.L. Gore & Associates, Inc.) (Fig. 4). Results of repeat color-f low Doppler imaging and a bubble study revealed no interatrial shunting. Images in Cardiovascular Medicine