Undiagnosed patent foramen ovale with bi-atrial thrombus in transit: A case of pulmonary embolism and refractory hypoxia
Notice bibliographique
Résumé
Abstract Background: Pulmonary embolism (PE) is a potentially life-threatening condition that can cause hypoxia, hemodynamic instability, and, rarely, paradoxical embolism through intracardiac shunts. While a patent foramen ovale (PFO) is present in approximately 20–30% of the adult population, the presence of a bi-atrial thrombus in transit across a PFO is extremely rare. Its presence often reflects elevated pulmonary pressures due to a large or chronic thrombotic burden. If not promptly recognized and treated, this condition carries a high risk of systemic embolization and mortality. Case Presentation: An otherwise healthy 37-year-old female was admitted to a tertiary care academic center in Canada with an acute proximal left leg deep vein thrombosis (DVT) and saddle PE. Her risk factors for venous thromboembolism (VTE) included obesity and a laparoscopic hernia repair performed two months prior to admission. She was started on weight-based low-molecular-weight heparin (dalteparin) without dose capping. Despite therapeutic anticoagulation, the patient remained persistently hypoxic throughout her hospitalization, requiring 4 L/min of supplemental oxygen via nasal cannula to maintain oxygen saturation above 92%. A transthoracic echocardiogram on admission revealed normal LV systolic function (LVEF 56%), moderate enlargement of the RV, moderate impairment of RV systolic function, moderate pulmonary hypertension (RVSP 66 mmHg), and moderate tricuspid regurgitation. A thrombophilia screen was negative for both inherited and acquired causes of VTE. On day seven post-admission, the patient acutely decompensated and developed rapid atrial flutter, chest pain, and hypotension. Repeat bedside echocardiography demonstrated persistent right ventricular systolic dysfunction and a large, highly mobile thrombus extending from the right to left atrium across a previously undiagnosed PFO. The patient was transferred to the Cardiovascular Surgery service, where she underwent sternotomy and cardiotomy. Intraoperatively, a thrombus measuring 11.5 cm was found lodged across the PFO. The fossa ovalis was incised, the thrombus was removed in its entirety, and the PFO was closed. The patient's postoperative course was complicated by infective endocarditis involving her pulmonic valve; however, she recovered and was transitioned to warfarin for ongoing anticoagulation. Discussion: This case illustrates the rare but life-threatening occurrence of a bi-atrial thrombus in transit through a patent foramen ovale, resulting from elevated right heart pressures that permit paradoxical right-to-left shunting. The presence of this intracardiac thrombus likely accounted for the patient's refractory hypoxia despite anticoagulation. Although echocardiography is key for diagnosis, intracardiac shunts may be undetected without early imaging, especially in patients with PE and unexplained hypoxemia. In these cases, surgical thrombectomy with PFO closure tends to lead to better outcomes compared to anticoagulation or thrombolysis alone by decreasing the risk of systemic embolization and death. In cases of PE accompanied by persistent hypoxia or clinical deterioration, a thrombus in transit should be considered early in the diagnostic process to guide timely, definitive treatment.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,004 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,003 | 0,002 |
| Études des sciences et des technologies | 0,003 | 0,002 |
| Communication savante | 0,002 | 0,002 |
| Science ouverte | 0,001 | 0,001 |
| Intégrité de la recherche | 0,004 | 0,003 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».