PULMONARY AND PARADOXICAL SYSTEMIC EMBOLI FROM RIGHT ATRIAL THROMBI

Ten days after surgical treatment of a gastric perforation a 70-year-old woman developed progressive dyspnoea and hypertension without any signs of deep vein thrombosis. Emergency echocardiography revealed acute cor pulmonale with a dilated right atrium and ventricle, as well as paradoxical ventricular septal motion. In addition it demonstrated an elongated, extremely mobile thrombus stuck in a patent foramen ovale with most of it floating in the right atrium, the remainder in the left atrium. Within 2 hours of the ultrasound examination she went into fulminant pulmonary embolism with circulatory arrest and paradoxical embolization from the atria to the brain, after which the intraatrial thrombus was no longer detectable. She was successfully resuscitated and thrombolysis was immediately started with tissue-plasminogen activator (100 mg over 90 min), with ensuing stabilization of the circulation. The patient was gradually weaned off the ventilator over the following few days, but she died 10 days after the resuscitation from the severe cerebral damage.