Manes Taylor J, Mohiuddin Zain, Bage Michael
Cardiology, A.T. Still University, Kirksville College of Osteopathic Medicine, Kirksville, USA.
Internal Medicine, Western Reserve Hospital, Cuyahoga Falls, USA.
Cureus. 2022 Mar 10;14(3):e23026. doi: 10.7759/cureus.23026. eCollection 2022 Mar.
A pulmonary embolism (PE) is an obstruction in a pulmonary artery, and a saddle PE occurs when the obstruction is lodged in the main pulmonary trunk and spans the left and right pulmonary arteries. The current case study describes complications of a thrombus in transit across a patent foramen ovale (PFO). A 35-year-old female presented to the emergency department after a nontraumatic syncopal fall. She had recently returned from a cross-country flight 10 days before and had noticed left calf tenderness when exiting the plane. Vitals were notable for sinus tachycardia at 120 bpm. An electrocardiogram indicated an S1Q3T3 pattern, and chest computed tomographic angiography was positive for a saddle PE. A 2D (two-dimensional) transthoracic echocardiogram showed right ventricular free wall hypokinesis and McConnell's sign. Echocardiogram findings were concomitant with a thrombus in transit across the interatrial septum, indicating a possible PFO. An emergency pulmonary embolectomy with cardiopulmonary bypass and closure of her PFO was performed the following morning and complicated by cardiogenic shock and subsequent cardiac arrest. The patient was resuscitated in the operating room but failed to be removed from cardiopulmonary bypass, requiring low-dose inotropic support and venoarterial extracorporeal membrane oxygenation flow at 4 L/min. After a repeat right pulmonary artery thrombectomy and two subsequent transesophageal echocardiograms indicated stable right ventricular systolic function, decannulation was performed. The patient was discharged on day 17 with long-term anticoagulation and home healthcare. In the current case report, the patient's unstable and deteriorating condition was complicated by unusual findings of a thrombus in transit across a PFO. These additional echocardiogram findings represented an unusual case that warranted surgical treatment instead of systemic thrombolysis therapy because of the increased risk of systemic clot embolization.
肺栓塞（PE）是指肺动脉内的阻塞，当阻塞位于主肺动脉干并横跨左右肺动脉时，就会发生骑跨性肺栓塞。本病例研究描述了血栓通过未闭卵圆孔（PFO）时的并发症。一名35岁女性在非创伤性晕厥跌倒后被送往急诊科。她10天前刚结束一次跨国飞行，下飞机时注意到左小腿压痛。生命体征显示窦性心动过速，心率为120次/分钟。心电图显示S1Q3T3模式，胸部计算机断层血管造影显示骑跨性肺栓塞呈阳性。二维经胸超声心动图显示右心室游离壁运动减弱及麦康奈尔征。超声心动图检查结果显示有血栓通过房间隔，提示可能存在PFO。次日上午进行了急诊体外循环下肺栓子切除术并封闭PFO，但出现了心源性休克及随后的心脏骤停等并发症。患者在手术室进行了复苏，但未能脱离体外循环，需要低剂量的血管活性药物支持及4L/分钟的静脉-动脉体外膜肺氧合血流。在再次进行右肺动脉血栓切除术并随后两次经食管超声心动图显示右心室收缩功能稳定后，拔除了体外循环插管。患者在第17天出院，接受长期抗凝治疗及家庭医疗护理。在本病例报告中，患者不稳定且不断恶化的病情因血栓通过PFO这一不寻常发现而变得更加复杂。这些额外的超声心动图检查结果代表了一个不寻常的病例，由于全身血栓栓塞风险增加，需要进行手术治疗而非全身溶栓治疗。
