Chest
Volume 110, Issue 3, September 1996, Pages 846-848
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Atrial Septal Aneurysm Plus a Patent Foramen Ovale: A Predisposing Factor for Paradoxical Embolism and Refractory Hypoxemia During Pulmonary Embolism

https://doi.org/10.1378/chest.110.3.846Get rights and content

We report three consecutive cases of patients who had refractory hypoxemia and paradoxical embolism during the course of pulmonary embolism. Transesophageal echocardiography showed an atrial septal aneurysm and a patent foramen ovale in all patients. The latter was detected by an early and massive passage of contrast from the right to the left atrium. We suggest that the presence of an atrial septal aneurysm plus a patent foramen ovale greatly enhances both magnitude of shunting and the risk of systemic embolism. The presence of an atrial septal aneurysm plus a patent foramen ovale should be considered and checked using transesophageal echocardiography in every patient with significant pulmonary embolism.

Section snippets

Case 1

A 74-year-old woman was admitted to the ICU in a deep coma and with severe hypoxemia requiring immediate mechanical ventilation. The chest x-ray film was normal. The ECG showed a sinus rhythm and a complete right bundle branch block. Measurements using a Swan-Ganz catheter confirmed right ventricular failure, inversion of the normal interatrial gradient (inferring the mean left atrial pressure from the mean pulmonary artery occlusive pressure), and important shunting (Table 1). Angiography

Discussion

We believe this to be the first transesophageal echocardiography study of pulmonary embolism complicated by the association of severe hypoxemia and paradoxical embolism. The fortuitous discovery of an atrial septal aneurysm plus a massive right-to-left shunt through a patent foramen ovale in patient 1 prompted the systematic check for these two anatomic abnormalities using transesophageal echocardiography with contrast10 in the next two patients who presented with similar symptoms (cases 2 and

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