VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

PULMONARY EMBOLISM IN TRANSIT THROUGH PATENT FORAMEN OVALE: A CASE REPORT Rayhan Karimi, OMS-II, Danielle Drew, RN, OMS-II, C. Jason Rousseau, DO VCOM Carolinas, Spartanburg, SC. Purpose: To increase medical knowledge, treatment, and patient presentation of a Pulmonary Embolism In-Transit

Abstract # CBR-20

Abstract

Case Report

Treatment

Introduction ͵ͲǦ›‡ƒ”Ǧ‘Ž† ˆ‡ƒŽ‡ ’”‡•‡–‡† –‘ –Š‡ ‡‡”‰‡…› ”‘‘ ™‹–Š ƒ…—–‡ ‘•‡– •Š‘”–‡•• ‘ˆ „”‡ƒ–Š ƒ† ƒ••‘…‹ƒ–‡† †‹ƒ’Š‘”‡•‹•Ǥ ƒ•– ‡†‹…ƒŽ Š‹•–‘”› ‹…Ž—†‡† ’‘Ž›…›•–‹… ‘˜ƒ”‹ƒ •›†”‘‡ǡ ‘”ƒŽ …‘–”ƒ…‡’–‹˜‡ —•‡ǡ ƒ† ‘„‡•‹–› ™‹–Š ƒ ‘ˆ ͷͲǤ ‡” ’”‡•‡–‹‰ ˜‹–ƒŽ •‹‰• ‹…Ž—†‡† ƒ „Ž‘‘† ’”‡••—”‡ ‘ˆ ͳͲͻȀ͹ͻǡ ƒ Š‡ƒ”– ”ƒ–‡ ‘ˆ ͳͲͻǡ ƒ ”‡•’‹”ƒ–‘”› ”ƒ–‡ ‘ˆ ʹʹǡ ƒ† ͻͷΨ ‘š›‰‡ •ƒ–—”ƒ–‹‘ ‘ ”‘‘ ƒ‹”Ǥ Ǧ ‹‡” –‡•– ™ƒ• ‡Ž‡˜ƒ–‡† ƒ– εʹͲ ρ‰Ȁ •—‰‰‡•–‹‰ ƒ ’—Ž‘ƒ”› ‡„‘Ž‹•ǡ ™Š‹…Š ™ƒ• …‘ˆ‹”‡† „› ƒ ‘ˆ –Š‡ …Š‡•–Ǥ  ‡…Š‘…ƒ”†‹‘‰”ƒ ™ƒ• ’‡”ˆ‘”‡† •Š‘™‹‰ ƒ ‡Œ‡…–‹‘ ˆ”ƒ…–‹‘ ‘ˆ ͸ͲΨǡ ‹Ž† ”‹‰Š– ˜‡–”‹…—Žƒ” †›•ˆ—…–‹‘ ƒ† †‹Žƒ–ƒ–‹‘ǡ ƒ† ‘„‹Ž‡ ‡…Š‘†‡•‹–› ‹ –Š‡ ”‹‰Š– ƒ–”‹— ‡š–‡†‹‰ ˆ”‘ –Š‡ ƒ–”‹ƒŽ •‡’–—ǡ ‰‡‡”ƒ–‹‰ …‘…‡” ˆ‘” ƒ ’ƒ–‡– ˆ‘”ƒ‡ ‘˜ƒŽ‡ ȋ ȌǤ ƒ”†‹‘Ž‘‰› ™ƒ• •—„•‡“—‡–Ž› …‘•—Ž–‡† ˆ‘” …ƒ–Š‡–‡” ‰—‹†‡† –Š”‘„‡…–‘›Ǥ ƒ–Š‡–‡” †‹”‡…–‡† –Š”‘„‡…–‘› ™ƒ• †‡‡‡† —•ƒˆ‡ ƒˆ–‡” ˆ‹†‹‰• …‘ˆ‹”‡† ˆ‹†‹‰•ǡ –Š‡”‡ˆ‘”‡ǡ –Š‡ ’ƒ–‹‡– ™ƒ• –”ƒ•ˆ‡””‡† ‡‡”‰‡–Ž› –‘ –Š‡ ‘’‡”ƒ–‹‰ ”‘‘Ǥ ’‘ ‹†—…–‹‘ ‘ˆ ‰‡‡”ƒŽ ƒ‡•–Š‡•‹ƒǡ –Š‡ ’ƒ–‹‡– „‡…ƒ‡ Š›’‘–‡•‹˜‡ ƒ† ’”‘ˆ‘—†Ž› Š›’‘š‹… †‡•’‹–‡ ‡†‘–”ƒ…Š‡ƒŽ ‹–—„ƒ–‹‘ ƒ† ‹ ʹ ‘ˆ ͳͲͲΨǤ  ‹–”ƒ‘’‡”ƒ–‹˜‡ –”ƒ•‡•‘’Šƒ‰‡ƒŽ ‡…Š‘…ƒ”†‹‘‰”ƒ ȋ Ȍ ”‡˜‡ƒŽ‡† –Š‡ ’—Ž‘ƒ”› ‡„‘Ž‹•Ǧ‹Ǧ–”ƒ•‹– ™ƒ• ‘ Ž‘‰‡” ’”‡•‡– ƒ– –Š‡ ‹–‡”ƒ–”‹ƒŽ •‡’–— ƒ† •‡˜‡”‡ ”‹‰Š– Š‡ƒ”– †›•ˆ—…–‹‘ ™ƒ• ‘™ ’”‡•‡–Ǥ ‡”‰‡…› „‹Žƒ–‡”ƒŽ ’—Ž‘ƒ”› ‡„‘Ž‡…–‘› ™ƒ• ’‡”ˆ‘”‡† –‘ ”‡‘˜‡ –Š‡ …Ž‘–Ǥ ††‹–‹‘ƒŽŽ›ǡ ’‡”‹…ƒ”†‹ƒŽ ’ƒ–…Š ƒ—‰‡–ƒ–‹‘ ‘ˆ –Š‡ ƒ‹ ’—Ž‘ƒ”› ƒ”–‡”› ƒ† …Ž‘•—”‡ ‘ˆ –Š‡ ™‡”‡ ’‡”ˆ‘”‡†Ǥ Š‡ ’ƒ–‹‡– ”‡•’‘†‡† ™‡ŽŽ ƒ† ™ƒ• †‹•…Šƒ”‰‡† ƒ ˆ‡™ †ƒ›• Žƒ–‡”Ǥ ▪ ͸ͲͲǡͲͲͲ ’ƒ–‹‡–• †‹ƒ‰‘•‡† ™‹–Š ’—Ž‘ƒ”› ‡„‘Ž‹ ƒ—ƒŽŽ› ‹ –Š‡ ‹–‡† –ƒ–‡•Ǥ ȋ͸Ȍ ▪ Š‡ ‘”–ƒŽ‹–› ”ƒ–‡ ‘ˆ ’—Ž‘ƒ”› ‡„‘Ž‹• ‹• ͳ͹ǤͶΨ ƒˆ–‡” †‹ƒ‰‘•‹•Ǥ ȋ͸Ȍ ▪ ƒ–Š‡–‡”Ǧ†‹”‡…–‡† ‡„‘Ž‡…–‘› ‹• —–‹Ž‹œ‡† ˆ‘” •—„ƒ••‹˜‡ ’—Ž‘ƒ”› ‡„‘Ž‹ǡ ™Š‹Ž‡ •—”‰‹…ƒŽ ‡„‘Ž‡…–‘› ‹• ”‡•‡”˜‡† ˆ‘” ƒ••‹˜‡ ’—Ž‘ƒ”› ‡„‘Ž‹Ǥ ’”‡•‡–• ‹ ƒ„‘—– ʹͶΨ ‘ˆ –Š‡ ’‘’—Žƒ–‹‘ ƒ– ƒ—–‘’•›Ǥ ȋͷȌ Diagnosis ‡…‘†ƒ”› –‘ ƒ ‡Ž‡˜ƒ–‡† Ǧ ‹‡”ǡ ƒ ǡ ‘–ƒ„Ž‡ ƒ† ‡…Š‘…ƒ”†‹‘‰”ƒ• ˆ‹†‹‰•ǡ ƒ† ƒ –”ƒ•‹–‹‘ ‘ˆ •—„ƒ••‹˜‡ –‘ ƒ••‹˜‡ ’—Ž‘ƒ”› ‡„‘Ž‹•ǡ –Š‡ ’ƒ–‹‡– ™ƒ• †‹ƒ‰‘•‡† ™‹–Šǣ Pulmonary Embolism In-Transit ▪ Š‡ ‘’‡‹‰ „‡–™‡‡ –Š‡ ”‹‰Š– ƒ† Ž‡ˆ– ƒ–”‹— –Šƒ– •Š—–• „Ž‘‘† ‹ –Š‡ ˆ‡–ƒŽ Š‡ƒ”– •Š‘—Ž† …Ž‘•‡ ƒ– „‹”–Š ™‹–Š –Š‡ ‹…”‡ƒ•‡ ‹ ’—Ž‘ƒ”› ’”‡••—”‡ —’‘ „‹”–ŠǢ –Š‡ ’‡”•‹•–‡…‡ ‘ˆ –Š‹• †—…–ƒŽ ‘’‡‹‰ …‘•–‹–—–‡• ƒ Ǥ ▪ Š‡ ‹…‹†‡…‡ ‘ˆ ’—Ž‘ƒ”› ‡„‘Ž‹• ƒŽ‘‰ ™‹–Š ƒ …‘…—””‡– ǡ ƒ• •‡‡ ‹ –Š‹• ’ƒ–‹‡– ’”‡•‡–ƒ–‹‘ǡ ”‡’”‡•‡–• ƒ •ƒŽŽ ’‘”–‹‘ ‘ˆ –Š‡ ’‘’—Žƒ–‹‘ǡ ™‹–Š ƒ Š‹‰Š ƒ••‘…‹ƒ–‡† ‘”–ƒŽ‹–› ”ƒ–‡ †—‡ –‘ •‡˜‡”‡ ”‹‰Š– Š‡ƒ”– †›•ˆ—…–‹‘ǡ ’‘–‡–‹ƒŽ ˆ‘” …ƒ”†‹‘’—Ž‘ƒ”› …‘ŽŽƒ’•‡ǡ ƒ† ’‘–‡–‹ƒŽ ˆ‘” ƒ”–‡”‹ƒŽ •›•–‡‹… ‡„‘Ž‹œƒ–‹‘Ǥ

• ƒ–‹‡– ’”‡•‡–‡† ™‹–Š –ƒ…Š›’‡ƒ ƒ† •Š‘”–‡•• ‘ˆ „”‡ƒ–ŠǤ • Ǧ ‹‡” ‡Ž‡˜ƒ–‹‘Ǥ • ‘ˆ –Š‡ …Š‡•– •Š‘™‡† •—„ƒ••‹˜‡ ’—Ž‘ƒ”› ‡„‘Ž‹•Ǥ • ‹–‹ƒŽ ‡…Š‘ •Š‘™‡† „‹ƒ–”‹ƒŽ –Š”‘„—• –Š”‘—‰Š –Š‡ Ǥ • ƒ–‹‡– ™ƒ• –ƒ‡ –‘ …ƒ–Š Žƒ„ ˆ‘” …ƒ–Š‡–‡”Ǧ‰—‹†‡† –Š”‘„‡…–‘›Ǥ • ƒ–Š‡–‡”Ǧ‰—‹†‡† –Š”‘„‡…–‘› ™ƒ• †‡‡‡† —•ƒˆ‡ †—‡ –‘ ”‡•—Ž–• ‘ˆ ’‡”ˆ‘”‡† ‹ …ƒ–Š Žƒ„Ǥ • Š‡”‡ˆ‘”‡ǡ ’ƒ–‹‡– ™ƒ• –”ƒ•ˆ‡””‡† –‘ –Š‡ ‘’‡”ƒ–‹‰ ”‘‘ ˆ‘” •—”‰‹…ƒŽ ‡„‘Ž‡…–‘›Ǥ • ’‘ ‹†—…–‹‘ ‘ˆ ƒ‡•–Š‡•‹ƒ ƒ† ‡†‘–”ƒ…Š‡ƒŽ ‹–—„ƒ–‹‘ ‹ ‘’‡”ƒ–‹‰ ”‘‘ǡ –Š‡ ’ƒ–‹‡– „‡…ƒ‡ Š›’‘–‡•‹˜‡ ƒ† Š›’‘š‹…Ǥ • ƒ–‹‡– †‹ƒ‰‘•‹• ’”‘‰”‡••‡† ˆ”‘ •—„ƒ••‹˜‡ –‘ ƒ••‹˜‡ ’—Ž‘ƒ”› ‡„‘Ž‹• ‹ ‘•‡“—‡…‡ –‘ Š‡‘†›ƒ‹…Ȁ…ƒ”†‹‘‰‡‹… ‹•–ƒ„‹Ž‹–›Ǥ • ‡’‡ƒ– ‹–”ƒ‘’‡”ƒ–‹˜‡ •Š‘™‡† ƒ„•‡…‡ ‘ˆ ‡„‘Ž‹• ƒ– ™‹–Š –”ƒ•‹– ‹–‘ –Š‡ ’—Ž‘ƒ”› ƒ”–‡”‹‡•Ǥ • —”‰‹…ƒŽ ‡„‘Ž‡…–‘› ™ƒ• ‹’Ž‡‡–‡† ˆ‘” ‡‡”‰‡– –”‡ƒ–‡–Ǥ

Emergent Consultation of Cardiothoracic Surgery

Emergent Sternotomy

ƒ–‹‡– ”‡•‡–• –‘

Table 1. CT of Thrombus in Pulmonary Artery.

Bilateral Pulmonary Embolectomy

Pericardial Patch Augmentation

ƒ–Š ƒ„

Oversewing of Patent Foramen Ovale

Table 2. Echo with Biatrial Thrombus through Patent Foramen Ovale

Conclusions

•  ”‡ˆŽ‡…–‹‘ ‘ˆ –Š‹• ’ƒ–‹‡– …ƒ•‡ ’”‡•‡–ƒ–‹‘ǡ ‹– ‹• •Š‘™ –Šƒ– ‹ Š‡‘†›ƒ‹…ƒŽŽ› —•–ƒ„Ž‡ ’ƒ–‹‡–•ǡ •—”‰‹…ƒŽ ‡„‘Ž‡…–‘› ƒ „‡ ‹†‹…ƒ–‡† ƒ• ˆ‹”•–ǦŽ‹‡ –Š‡”ƒ’› ‹ ƒ…—–‡ ’—Ž‘ƒ”› ‡„‘Ž‹• ˆ‘” †‡…”‡ƒ•‡† ’ƒ–‹‡– ‘”–ƒŽ‹–›Ǥ •  ”‡…‘‡†ƒ–‹‘ –‘ ’”ƒ…–‹…‹‰ …Ž‹‹…‹ƒ• †‡ƒŽ‹‰ ™‹–Š ƒ…—–‡ ’—Ž‘ƒ”› ‡„‘Ž‹ǡ •—”‰‹…ƒŽ ‡„‘Ž‡…–‘› •Š‘—Ž† „‡ ‘•‹†‡”‡† ‹ ‡ƒ”Ž‹‡” •–ƒ‰‡• ‹•–‡ƒ† ‘ˆ ƒ• ƒ •ƒŽ˜ƒ‰‡ ‡ƒ•—”‡ –‘ ’”‘’Š›Žƒ…–‹…ƒŽŽ› ƒ˜‘‹† Š‡‘†›ƒ‹… …‘ŽŽƒ’•‡Ǥ • †—…–‹‘ ‘ˆ ’‘•‹–‹˜‡ ’”‡••—”‡ ˜‡–‹Žƒ–‹‘ •Š‘—Ž† „‡ —•‡† ™‹–Š ƒ—–‹‘ ‹ ’ƒ–‹‡–• ™‹–Š ƒ ƒ† ’—Ž‘ƒ”› ‡„‘Ž‹• –‘ ‹–‹‰ƒ–‡ ”‹• ‘ˆ ƒ ‡„‘Ž‹• ‹Ǧ–”ƒ•‹–Ǥ

‡‘†›ƒ‹… ‘ŽŽƒ’•‡

Table 3. 3-D Echo with Thrombus Extending from Right Atrium into PFO

–”ƒ‘’‡”ƒ–‹˜‡

Acknowledgements and References

Table 4. Results of surgical pulmonary embolectomy

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