Case Report
Acute coronary syndrome of paradoxical origin
Síndrome coronária aguda de origem paradoxal
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array:24 [ "pii" => "S0870255113002102" "issn" => "08702551" "doi" => "10.1016/j.repc.2013.09.002" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "332" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2010" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:817-21" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6106 "formatos" => array:3 [ "EPUB" => 204 "HTML" => 5145 "PDF" => 757 ] ] "itemSiguiente" => array:19 [ "pii" => "S0870255113002199" "issn" => "08702551" "doi" => "10.1016/j.repc.2013.07.008" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "341" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:823-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4143 "formatos" => array:3 [ "EPUB" => 159 "HTML" => 3139 "PDF" => 845 ] ] "pt" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Falha de integridade dos elétrodos de desfibrilhação Riata e Riata ST: um problema atual" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "823" "paginaFinal" => "826" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1171 "Tamanyo" => 131986 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Radioscopia, incidência PA, com visualização de fio condutor para além da sombra do cateter (exteriorização) na porção situada aurícula direita (seta).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "João Madeira, Leonor Parreira, Pedro Amador, Luís Soares" "autores" => array:4 [ 0 => array:2 [ "nombre" => "João" "apellidos" => "Madeira" ] 1 => array:2 [ "nombre" => "Leonor" "apellidos" => "Parreira" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Amador" ] 3 => array:2 [ "nombre" => "Luís" "apellidos" => "Soares" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113002199?idApp=UINPBA00004E" "url" => "/08702551/0000003200000010/v1_201311090028/S0870255113002199/v1_201311090028/pt/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255113002187" "issn" => "08702551" "doi" => "10.1016/j.repc.2013.02.016" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "340" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:811-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 10601 "formatos" => array:3 [ "EPUB" => 194 "HTML" => 9256 "PDF" => 1151 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Coronary artery perforations: Four different cases and a review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "811" "paginaFinal" => "815" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Perfurações de artérias coronárias: quatro casos diferentes e uma revisão" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1500 "Ancho" => 4815 "Tamanyo" => 389016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Long, thin, angulated and eccentric critical sequential lesions with thrombus in the mid to distal portion of the left anterior descending coronary artery (A); type IV coronary rupture showing prominent contrast flow into the left ventricle (B); control angiogram showing no extravasation around the target area after covered stent implantation (C).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ismail Dogu Kilic, Yusuf Izzettin Alihanoglu, Serhat B. Yildiz, Ozgur Taskoylu, Mustafa Zungur, Ihsan S. Uyar, Harun Evrengul" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ismail Dogu" "apellidos" => "Kilic" ] 1 => array:2 [ "nombre" => "Yusuf Izzettin" "apellidos" => "Alihanoglu" ] 2 => array:2 [ "nombre" => "Serhat B." "apellidos" => "Yildiz" ] 3 => array:2 [ "nombre" => "Ozgur" "apellidos" => "Taskoylu" ] 4 => array:2 [ "nombre" => "Mustafa" "apellidos" => "Zungur" ] 5 => array:2 [ "nombre" => "Ihsan S." "apellidos" => "Uyar" ] 6 => array:2 [ "nombre" => "Harun" "apellidos" => "Evrengul" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113002187?idApp=UINPBA00004E" "url" => "/08702551/0000003200000010/v1_201311090028/S0870255113002187/v1_201311090028/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Acute coronary syndrome of paradoxical origin" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "817" "paginaFinal" => "821" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Rita Ferreira, António Freitas, Pedro Magno, Ana Oliveira Soares, Pedro Farto e Abreu, José Pedro Neves, Victor M. Gil" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Ana Rita" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "aritaf@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "António" "apellidos" => "Freitas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Pedro" "apellidos" => "Magno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Oliveira Soares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Pedro" "apellidos" => "Farto e Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "José Pedro" "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Victor M." "apellidos" => "Gil" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital Fernando da Fonseca, Amadora, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome coronária aguda de origem paradoxal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 430 "Ancho" => 999 "Tamanyo" => 63109 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Coronary angiography showing distal occlusion of the right coronary artery; (B) final result after thrombus aspiration and stent implantation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Paradoxical embolism is an uncommon situation, accounting for less than 2% of all arterial emboli.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 44-year-old woman, taking oral contraceptives, with a medical history of type 2 diabetes and mild obesity, presented with an acute episode of non-radiating substernal chest pain, which aroused her from sleep. She also suffered dyspnea, nausea, diaphoresis and transient loss of consciousness before reaching the emergency department two and a half hours later. Her vital signs were blood pressure 120/80 mmHg, heart rate 85 beats per minute, respiratory rate 23 cycles per minute and oxygen saturation 75% in room air. The remainder of the physical examination was unremarkable. The electrocardiogram (ECG) showed sinus rhythm and ST-segment elevation in leads II, III, aVF, V5 and V6 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). She was diagnosed with acute inferior ST-elevation myocardial infarction (MI) and was admitted to the coronary care unit (CCU).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In the CCU screening transthoracic echocardiography excluded mechanical complications of MI and showed a non-dilated left ventricle, with good global systolic function, akinesia of the inferior wall and dilatation of the right cardiac chambers. In view of a possible inferior MI with extension to the right ventricle, the patient underwent emergency coronary angiography that confirmed an occlusion (TIMI flow 0) of the distal right coronary artery (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A). The other coronary arteries were normal. An Export® aspiration catheter (Medtronic, Minneapolis, USA) was advanced into the right coronary artery and multiple thrombi were aspirated. After thrombectomy, TIMI flow 3 was documented, but residual stenosis was noted in the distal right coronary artery and a bare-metal stent was implanted (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On return to the CCU, the patient experienced complete relief of chest pain and ST-segment normalization on the ECG. Nonetheless, her oxygen saturation level was still 90% despite high-flow oxygen by mask. A full transthoracic echocardiogram examination was then performed. A mass consistent with a thrombus was noted in the left atrium, appearing to arise from a redundant interatrial septum, while the right ventricle was moderately dilated with positive McConnell sign and the interventricular septum was displaced into the left ventricle, which was D-shaped in short-axis view (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The pulmonary artery was dilated and the flow across the pulmonary valve suggested severe pulmonary hypertension with pulmonary artery systolic pressure estimated at 70 mmHg. In apical 4-chamber view, color flow imaging of the interatrial septum showed a right-to-left shunt. It was then decided to perform transesophageal echocardiography (TEE) to better characterize the relationship of the mass with the interatrial septum and its embolic potential, and also to look for masses in the right atrium. TTE showed a long thrombus that appeared to be attached to the atrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale (PFO) and the atrial septum was aneurysmatic. The thrombus had a snake-like movement inside the left atrium and its distal end was freely mobile, prolapsing through the mitral valve (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). No mass was observed in the right atrium or pulmonary arteries. Thoracic computed tomography angiography revealed bilateral thrombi in the main and lobar branches of the pulmonary artery (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">According to the criteria suggested by Johnson,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the patient had a definitive diagnosis of paradoxical embolism: a thrombus crossing an intracardiac defect was seen during echocardiography in the presence of an arterial embolus. The therapeutic options for paradoxical embolism are still a matter of debate. In our case, cardiothoracic surgeons were consulted and considered the operative risk to be too high, and the patient did not consent to surgical intervention. Due to her stable clinical condition and the absence of neurological signs, we decided to maintain her on full-dose anticoagulation with enoxaparin and double antiplatelet therapy. Venous Doppler echocardiography of the lower limbs was normal. Five days later the transthoracic echocardiogram was repeated; no reduction was noted in the size of the left atrial thrombus, whereupon the cardiothoracic surgeons were again consulted and it was decided to operate. The same day, she was transferred to a surgical center and surgery was performed: an atrial aspiration system was placed in the right superior pulmonary vein, the right atrium and the interatrial septum were opened and the left atrium was inspected. No thrombus was seen in any cardiac chamber or vessel and the PFO was sutured. The patient's postoperative course was remarkably stable and the transthoracic echocardiogram before hospital discharge showed no signs of right ventricular overload. She was discharged home anticoagulated with warfarin and advised to discontinue oral contraceptives. Further laboratory testing showed no thrombophilia status.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">As proposed by Johnson, the diagnosis of paradoxical embolism can be: 1) definitive – when made at autopsy or when a thrombus is seen crossing an intracardiac defect during echocardiography in the presence of an arterial embolus; 2) presumptive – when there is systemic arterial embolus in the absence of a left-sided cardiac or proximal arterial source plus a right-to-left shunt at some level plus venous thrombosis and/or pulmonary embolus; 3) possible – only arterial embolus and PFO detected.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our patient we had a definitive diagnosis of paradoxical embolism, as noted above. Although in situ thrombus formation over a ruptured plaque cannot be definitively excluded in our patient, the angiographic appearance of the thrombus was most consistent with coronary embolization. The patient's increased risk of venous thrombosis can be explained by oral contraceptive use. An interesting point is that when the left atrium was opened during surgery no thrombus was seen, even though the transthoracic echocardiogram on the same day had shown no reduction in the size of the mass. The most probable explanation is aspiration of the mass by the atrial aspiration system put in place before the left atrium was opened.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most cases of paradoxical embolism have been associated with PFO.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Although PFO is a frequent finding in the general population, paradoxical embolism is an uncommon event.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Paradoxical embolism in a coronary artery is a recognized clinical entity, but is rare and usually definitively established only at autopsy.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Impending paradoxical embolism, in which a thrombus is seen straddling an interatrial defect, is also a rare diagnosis. Finally, paradoxical embolism with coronary embolization and visualization of the thrombus crossing a PFO is even rarer, with very few cases described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6–9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The vast majority of patients with paradoxical embolism present with symptoms of pulmonary embolism (82%) or arterial embolism (25%). Only 16% of patients present with findings suggestive of both venous and arterial embolism.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Pulmonary embolism (or any condition that raises right atrial pressure) is frequently implicated in the increased right heart pressures that set the stage for right-to-left shunting via a PFO.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">TEE is crucial for accurate diagnosis and appropriate management when paradoxical embolism is suspected.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> TEE study with color Doppler and contrast echocardiography is the most sensitive diagnostic technique for diagnosing PFO.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The four cases described in the literature of antemortem diagnosis of paradoxical coronary embolism with visualization of a thrombus crossing a PFO used TEE to establish the diagnosis. TEE is the ideal diagnostic procedure in the setting of suspected myocardial infarction of thromboembolic origin because of its ability to visualize both paradoxical emboli and the proximal portions of the coronary arteries.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Mortality in paradoxical embolism with entrapped embolus is estimated at 21%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The treatment of paradoxical or impending paradoxical embolism is a clinical dilemma. Acute treatment options include anticoagulation, fibrinolysis or surgical embolectomy. In the presence of a thrombus with a high embolic potential, fibrinolysis carries a high risk of fragmentation and systemic embolization.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a> In the setting of a thrombus crossing a PFO, thrombolytic therapy has the potential to result in systemic embolization and devastating neurological complications. Surgery also enables simultaneous closure of the PFO.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,10</span></a> Overall survival appears to be equivalent among the three therapeutic options, although more complications relating to arterial and pulmonary embolization occur with anticoagulation and fibrinolysis. For this reason, anticoagulation followed by surgical embolectomy has been recommended as the optimal therapy, although recommendations for the management of paradoxical embolism are based on small series and isolated case reports. A medical strategy using thrombolytic therapy or heparin therapy alone may have a role in patients at increased surgical risk.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres290291" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec273988" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres290290" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec273989" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-09-08" "fechaAceptado" => "2013-07-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec273988" "palabras" => array:3 [ 0 => "Paradoxical embolism" 1 => "Patent foramen ovale" 2 => "Myocardial infarction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec273989" "palabras" => array:3 [ 0 => "Embolia paradoxal" 1 => "<span class="elsevierStyleItalic">Foramen ovale</span> patente" 2 => "Enfarte do miocárdio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descreve-se um caso raro de enfarte agudo do miocárdio por embolia paradoxal em contexto de tromboembolismo pulmonar agudo. Uma mulher de 44 anos recorreu à urgência por dor torácica. A observação foi normal com exceção de saturação periférica de 75%. O electrocardiograma mostrou supradesnivelamento do segmento ST nas derivações inferiores. Realizou-se cateterismo urgente que mostrou coronária direita ocluída distalmente, tendo sido aspirados múltiplos trombos. Verificou-se alívio da dor e desaparecimento do supradesnivelamento de ST. No entanto, a saturação periférica mantinha-se baixa apesar de aporte com oxigénio. O ecocardiograma transtorácico mostrou massa auricular esquerda e dilatação das cavidades direitas. O ecocardiograma transesofágico revelou um trombo no septo interauricular, na região do <span class="elsevierStyleItalic">foramen ovale</span>. O estudo por Doppler-cor foi compatível com <span class="elsevierStyleItalic">foramen ovale</span> patente. A angio-tomografia computorizada do tórax documentou trombos nos ramos principais da artéria pulmonar. Após cinco dias de anticoagulação a doente foi submetida a cirurgia cardíaca e o <span class="elsevierStyleItalic">foramen ovale</span> encerrado.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 869 "Ancho" => 1667 "Tamanyo" => 152516 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">12-lead electrocardiogram with ST-segment elevation in leads II, III, aVF, V5 and V6.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 430 "Ancho" => 999 "Tamanyo" => 63109 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Coronary angiography showing distal occlusion of the right coronary artery; (B) final result after thrombus aspiration and stent implantation.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2153 "Ancho" => 2500 "Tamanyo" => 333341 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) parasternal long-axis view; (B) parasternal short-axis view of the aortic valve; (C) zoom of short-axis view; (D) D-shaped left ventricle. Ao: aorta; IVS: interventricular septum; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; RVOT: right ventricular outflow tract; Tr: thrombus.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 865 "Ancho" => 2333 "Tamanyo" => 102744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing thrombus crossing the interatrial septum. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; Tr: thrombus.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 703 "Ancho" => 827 "Tamanyo" => 104485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography showing bilateral thrombi in the main branches of the pulmonary artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paradoxical embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.I. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 8 | 5 | 13 |
| 2024 Outubro | 51 | 31 | 82 |
| 2024 Setembro | 55 | 25 | 80 |
| 2024 Agosto | 54 | 26 | 80 |
| 2024 Julho | 48 | 27 | 75 |
| 2024 Junho | 35 | 23 | 58 |
| 2024 Maio | 59 | 15 | 74 |
| 2024 Abril | 38 | 29 | 67 |
| 2024 Maro | 40 | 28 | 68 |
| 2024 Fevereiro | 43 | 36 | 79 |
| 2024 Janeiro | 25 | 19 | 44 |
| 2023 Dezembro | 41 | 21 | 62 |
| 2023 Novembro | 34 | 21 | 55 |
| 2023 Outubro | 26 | 17 | 43 |
| 2023 Setembro | 34 | 16 | 50 |
| 2023 Agosto | 32 | 21 | 53 |
| 2023 Julho | 33 | 11 | 44 |
| 2023 Junho | 28 | 16 | 44 |
| 2023 Maio | 36 | 26 | 62 |
| 2023 Abril | 31 | 3 | 34 |
| 2023 Maro | 23 | 28 | 51 |
| 2023 Fevereiro | 25 | 20 | 45 |
| 2023 Janeiro | 25 | 15 | 40 |
| 2022 Dezembro | 22 | 24 | 46 |
| 2022 Novembro | 57 | 18 | 75 |
| 2022 Outubro | 69 | 20 | 89 |
| 2022 Setembro | 61 | 32 | 93 |
| 2022 Agosto | 54 | 32 | 86 |
| 2022 Julho | 63 | 34 | 97 |
| 2022 Junho | 70 | 20 | 90 |
| 2022 Maio | 44 | 33 | 77 |
| 2022 Abril | 44 | 32 | 76 |
| 2022 Maro | 40 | 30 | 70 |
| 2022 Fevereiro | 31 | 21 | 52 |
| 2022 Janeiro | 36 | 16 | 52 |
| 2021 Dezembro | 31 | 27 | 58 |
| 2021 Novembro | 46 | 39 | 85 |
| 2021 Outubro | 35 | 48 | 83 |
| 2021 Setembro | 36 | 30 | 66 |
| 2021 Agosto | 41 | 28 | 69 |
| 2021 Julho | 33 | 19 | 52 |
| 2021 Junho | 31 | 20 | 51 |
| 2021 Maio | 33 | 26 | 59 |
| 2021 Abril | 57 | 40 | 97 |
| 2021 Maro | 82 | 13 | 95 |
| 2021 Fevereiro | 79 | 10 | 89 |
| 2021 Janeiro | 44 | 20 | 64 |
| 2020 Dezembro | 35 | 5 | 40 |
| 2020 Novembro | 45 | 11 | 56 |
| 2020 Outubro | 22 | 4 | 26 |
| 2020 Setembro | 52 | 4 | 56 |
| 2020 Agosto | 24 | 9 | 33 |
| 2020 Julho | 42 | 8 | 50 |
| 2020 Junho | 42 | 4 | 46 |
| 2020 Maio | 57 | 3 | 60 |
| 2020 Abril | 33 | 7 | 40 |
| 2020 Maro | 56 | 7 | 63 |
| 2020 Fevereiro | 93 | 12 | 105 |
| 2020 Janeiro | 35 | 6 | 41 |
| 2019 Dezembro | 39 | 9 | 48 |
| 2019 Novembro | 47 | 9 | 56 |
| 2019 Outubro | 46 | 15 | 61 |
| 2019 Setembro | 48 | 9 | 57 |
| 2019 Agosto | 37 | 3 | 40 |
| 2019 Julho | 50 | 10 | 60 |
| 2019 Junho | 40 | 7 | 47 |
| 2019 Maio | 52 | 14 | 66 |
| 2019 Abril | 47 | 18 | 65 |
| 2019 Maro | 81 | 10 | 91 |
| 2019 Fevereiro | 83 | 15 | 98 |
| 2019 Janeiro | 95 | 3 | 98 |
| 2018 Dezembro | 82 | 7 | 89 |
| 2018 Novembro | 161 | 8 | 169 |
| 2018 Outubro | 398 | 12 | 410 |
| 2018 Setembro | 96 | 11 | 107 |
| 2018 Agosto | 108 | 12 | 120 |
| 2018 Julho | 67 | 7 | 74 |
| 2018 Junho | 83 | 5 | 88 |
| 2018 Maio | 88 | 13 | 101 |
| 2018 Abril | 89 | 13 | 102 |
| 2018 Maro | 126 | 8 | 134 |
| 2018 Fevereiro | 61 | 7 | 68 |
| 2018 Janeiro | 84 | 5 | 89 |
| 2017 Dezembro | 108 | 20 | 128 |
| 2017 Novembro | 59 | 7 | 66 |
| 2017 Outubro | 52 | 15 | 67 |
| 2017 Setembro | 45 | 9 | 54 |
| 2017 Agosto | 54 | 13 | 67 |
| 2017 Julho | 44 | 7 | 51 |
| 2017 Junho | 57 | 21 | 78 |
| 2017 Maio | 75 | 18 | 93 |
| 2017 Abril | 24 | 2 | 26 |
| 2017 Maro | 46 | 31 | 77 |
| 2017 Fevereiro | 45 | 7 | 52 |
| 2017 Janeiro | 30 | 6 | 36 |
| 2016 Dezembro | 38 | 10 | 48 |
| 2016 Novembro | 24 | 4 | 28 |
| 2016 Outubro | 68 | 10 | 78 |
| 2016 Setembro | 89 | 4 | 93 |
| 2016 Agosto | 15 | 0 | 15 |
| 2016 Julho | 7 | 2 | 9 |
| 2016 Junho | 7 | 3 | 10 |
| 2016 Maio | 0 | 7 | 7 |
| 2016 Abril | 33 | 2 | 35 |
| 2016 Maro | 63 | 8 | 71 |
| 2016 Fevereiro | 94 | 16 | 110 |
| 2016 Janeiro | 88 | 9 | 97 |
| 2015 Dezembro | 56 | 8 | 64 |
| 2015 Novembro | 78 | 4 | 82 |
| 2015 Outubro | 77 | 12 | 89 |
| 2015 Setembro | 70 | 10 | 80 |
| 2015 Agosto | 88 | 14 | 102 |
| 2015 Julho | 128 | 6 | 134 |
| 2015 Junho | 49 | 4 | 53 |
| 2015 Maio | 66 | 7 | 73 |
| 2015 Abril | 53 | 5 | 58 |
| 2015 Maro | 68 | 2 | 70 |
| 2015 Fevereiro | 55 | 3 | 58 |
| 2015 Janeiro | 64 | 7 | 71 |
| 2014 Dezembro | 52 | 9 | 61 |
| 2014 Novembro | 66 | 8 | 74 |
| 2014 Outubro | 63 | 11 | 74 |
| 2014 Setembro | 73 | 14 | 87 |
| 2014 Agosto | 33 | 7 | 40 |
| 2014 Julho | 79 | 7 | 86 |
| 2014 Junho | 44 | 10 | 54 |
| 2014 Maio | 69 | 19 | 88 |
| 2014 Abril | 60 | 13 | 73 |
| 2014 Maro | 67 | 19 | 86 |
| 2014 Fevereiro | 55 | 15 | 70 |
| 2014 Janeiro | 87 | 16 | 103 |
| 2013 Dezembro | 78 | 27 | 105 |
| 2013 Novembro | 75 | 23 | 98 |
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