Freeman Kirsten, Brinkley Lindsey, Azarrafiy Ryan, Jones Todd E, Beaver Thomas
Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Florida.
Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Florida;
J Vis Exp. 2025 Jul 3(221). doi: 10.3791/67682.
Hemodynamically significant pulmonary embolisms (PE) in the pulmonary artery or those crossing a patent foramen ovale (PFO) can become life-threatening emergencies requiring immediate removal. While cases of surgical management for a PE crossing a PFO have been reported, there are no documented cases of a PE extending across both the mitral and aortic valves. A 38-year-old female with a medical history of obesity, depression, and thalassemia minor was transferred from an outside hospital with hemodynamic compromise due to a large PE. Transesophageal echocardiography (TEE) revealed a PE crossing the PFO, extending across the mitral valve, and traversing the aortic valve into the ascending aorta. Cardiopulmonary bypass (CPB) was initiated using standard aortic cannulation distal to the known clot, along with bicaval venous cannulation. The heart was arrested, and the right and left atria were opened in a transeptal fashion. The clot, which extended from the PFO through the mitral and aortic valves, was identified and removed en bloc. A small aortotomy was performed, confirming a clear aorta. An additional clot was found in the right atrium crossing the tricuspid valve and was subsequently removed. Finally, the pulmonary artery was opened, and the bulk of the clot burden was extracted, completing the embolectomy. The patient was successfully weaned from CPB without complications and was extubated within 24 h post-surgery. She underwent inferior vena cava filter placement and was discharged on post-operative day seven. Extensive pulmonary emboli are life-threatening emergencies that require immediate intervention. This study presents an extensive clot burden crossing the PFO, mitral valve, and aortic valve. Prompt surgical intervention is crucial to preventing severe complications such as stroke, myocardial infarction, respiratory failure, death, and long-term sequelae, including pulmonary hypertension and future strokes.
肺动脉中具有血流动力学意义的肺栓塞（PE）或那些穿过卵圆孔未闭（PFO）的栓子可成为危及生命的紧急情况，需要立即清除。虽然已经报道了针对穿过PFO的PE进行手术治疗的病例，但尚无PE同时累及二尖瓣和主动脉瓣的文献记载病例。一名38岁女性，有肥胖、抑郁症和轻度地中海贫血病史，因大面积PE导致血流动力学不稳定，从外院转入。经食管超声心动图（TEE）显示一个PE穿过PFO，延伸至二尖瓣，并穿过主动脉瓣进入升主动脉。使用标准的主动脉插管在已知血栓远端建立体外循环（CPB），同时进行双腔静脉插管。心脏停搏后，以经房间隔的方式打开右心房和左心房。识别出从PFO延伸穿过二尖瓣和主动脉瓣的血栓，并将其整块取出。进行了一个小的主动脉切开术，确认主动脉通畅。在右心房发现另一个穿过三尖瓣的血栓，随后将其取出。最后，打开肺动脉，取出大部分血栓负荷，完成栓子切除术。患者成功脱离CPB，无并发症，并在术后24小时内拔管。她接受了下腔静脉滤器置入术，并于术后第7天出院。广泛的肺栓塞是危及生命的紧急情况，需要立即干预。本研究展示了一个穿过PFO、二尖瓣和主动脉瓣的广泛血栓负荷。及时的手术干预对于预防严重并发症如中风、心肌梗死、呼吸衰竭、死亡以及包括肺动脉高压和未来中风在内的长期后遗症至关重要。
