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A 46 year old man was admitted to hospital because of a two month history of hip pain. Radiography of the leg was consistent with an aseptic necrosis of the femur. Ten days later the patient became acutely dyspnoeic and had signs of severe pulmonary hypertension. Echocardiography demonstrated hypomobility of the inferior vena cava and right atrium. The patient was treated with heparin and streptokinase but died towards the end of the procedure.
Post mortem examination revealed a massive, bilateral pulmonary thromboembolism. The heart was enlarged and weighed 415 g. An atrial septal defect involving the region of the fossa ovalis was found. A long embolus reached the right atrium, passed through the foramen ovalis of the atrial septum (left) and thence through the left ventricle to lodge in the circumflex left coronary artery (right). Multiple small infarctions were detected in the brain, spleen, and left kidney.
Histology showed an extensive subendocardial necrosis in the lateral wall of the left ventricle. The massive pulmonary arteries obstruction, causing a significant rise of right atrial pressure, allowed the right to left shunt of thromboembolic material through the atrial septal defect.