Case Presentation:
A 51‐year‐old female with no significant past medical history presented with a 1‐week history of left‐sided abdominal pain. The patient was aferile and physical exam revealed mild diffuse abdominal tenderness. Laboratory data were significant only for mild leukocytosis. The patient was started on antibiotics for possible diverticulosis as outpatient. CT scan of the abdomen and pelvis showed a left renal wedge‐shape infarct. During her hospital workup for an embolic source, transthoracic echocardiogram revealed atrial septal aneurysm. A patent foramen ovale (PFO) with right‐to‐left shunt was discovered by transesophageal echocardiography (TEE) supporting a diagnosis of paradoxical embolism. The EKG and telemetry monitoring demonstrated noimal sinus rhythm. Venous Doppler failed to reveal deep venous thrombosis in lower extremities, there was no renal artery stenosis and the renal veins were patent. Hypercoagulable studies were negative for thrombophilia. Diagnosis of renal infarction due to paradoxical embolism via PFO was made. After the initial medical therapy with low‐dose aspirin and atorvastalin, the patient underwent percutaneous closure of PFO. Repeat TEE demonstrated a successfully placed intraseptal device without a shunt.
Discussion:
Foramen ovale is an interatrial opening that functions as a 1‐way valve during fetal development. In about a quarter of population it doesn't to close but remains open for life. PFO is an asymptomatic condition in the majority of people. Paradoxical embolism through patent foramen ovale is an uncommon but increasingly reported cause of arterial embolic events. This mechanism is often discussed in cryptogenic cerebrovascular stroke of young patients. In order for paradoxical embolism to occur, increased right atrial pressure, venous or in situ thrombosis, and an interatrial defect must be present. Atrial septal defects and pulmonary arteriovenous malformations have also been associated with paradoxical embolism. We describe renal infarction, without acute renal failure, as a rare and frequently undiagnosed complication of PFO. The recognition, evaluation and treatment of PFO has attractec increasing interest as the importance and frequency of paradoxical embolism has become better understood. The evaluation of suspected PFO should include TTE with “bubble study“ or transcranial Doppler ultrasonography. TEE should follow either of these studies to further evaluate the septum. Optimal therapy in symptomatic PFO remains controversial but there is growing evidence that percutaneous closure may be effective in preventing recurrent embolization.
Conclusions:
Due to relatively common occurrence of PFO in general population and its potentially significant morbidity and mortality, hospitalists need to be aware of its various clinical presentations. As this case illustrates, paradoxical embolism should be considered in embolic events of unknown etiology.
Author Disclosure:
A. Sykora, Winthrop‐University Hospital, employmenl/none; D. Chenouda, Winthrop‐University Hospital, employment/none.