Ménager C, Bui H T, Rubin S, Nazeyrollas P, Metz D
Service de cardiologie, CHU Robert-Debré, rue du Général-Koenig, 51090 Reims cedex, France.
Ann Cardiol Angeiol (Paris). 2013 Dec;62(6):438-41. doi: 10.1016/j.ancard.2011.05.009. Epub 2011 May 25.
This observation relates to the discovery of native coronary paradoxical embolism secondary to thrombus adherent to the right atrium through a patent foramen ovale (PFO). A patient of 64 years, with a history of mitral regurgitation not followed, was hospitalized for acute respiratory distress due to a mitral insufficiency (MI) with a ruptured chordae and pulmonary embolism. Coronary angiography was performed and revealed two typical images of coronary embolism associated to a non-atheromatous coronary tree. The patient underwent a mitral valve replacement. After the establishment of cardiopulmonary bypass, adherent fibrin and cruoric thrombus of the right atrium and a PFO were found. The analysis of the valves did not reveal any arguments for infective endocarditis. A CT scan, performed as the patient remained unconscious after surgery, showed several cerebral infarcts. Paradoxical embolism coronary was diagnosed in front of the combination of adherent thrombus in the right atrium, pulmonary embolism and systemic coronary and cerebral embolism with a PFO. Coronary embolism rarely happens. It is mainly due to three causes: iatrogenic origin in most cases, direct causes due to micro emboli, particularly from infectious endocarditis and paradoxical embolic origin. There are two types of right atrial thrombus; the most common is the mobile thrombus from the peripheral venous system. The other one, which is more rare, is the adherent thrombus, which occurs in situ. Coronary embolism of paradoxical origin represents a small proportion of the causes of coronary embolism. However, this diagnosis must be considered.
该观察结果与通过卵圆孔未闭（PFO）附着于右心房的血栓继发的原发性冠状动脉矛盾栓塞的发现有关。一名64岁的患者，有未接受治疗的二尖瓣反流病史，因二尖瓣腱索断裂伴二尖瓣关闭不全（MI）和肺栓塞导致急性呼吸窘迫而住院。进行了冠状动脉造影，显示出与非动脉粥样硬化冠状动脉树相关的两个典型冠状动脉栓塞图像。该患者接受了二尖瓣置换术。建立体外循环后，发现右心房有附着的纤维蛋白和凝血血栓以及一个卵圆孔未闭。瓣膜分析未发现感染性心内膜炎的证据。由于患者术后仍昏迷，进行了CT扫描，显示有多处脑梗死。鉴于右心房附着血栓、肺栓塞以及伴有卵圆孔未闭的系统性冠状动脉和脑栓塞同时存在，诊断为冠状动脉矛盾栓塞。冠状动脉栓塞很少发生。其主要由三个原因引起：大多数情况下为医源性起源，微栓子直接导致，特别是来自感染性心内膜炎，以及矛盾栓塞起源。右心房血栓有两种类型；最常见的是来自外周静脉系统的移动血栓。另一种较罕见的是原位形成的附着血栓。矛盾起源的冠状动脉栓塞在冠状动脉栓塞原因中占比很小。然而，必须考虑这种诊断。
