Caught in Transit. a Case of Paradoxical Embolism in Patient with a Pfo: The Role of Obstructive Sleep Apnea

Case Presentation:

A 54‐year‐old male was hospitalized due to right femur fracture following a fall. Past medical history was significant for OSA, obesity and hypertension. Pelvic Computed Tomography (CT) scan demonstrated acute fractures of right femur associated with prominent soft tissue hematoma. Twelve hours post‐admission, he suddenly became hypotensive and hypoxic. ECG demonstrated tachycardia associated with non‐specific changes in ST and T waves in anterior leads. CT chest with contrast showed extensive bilateral pulmonary embolism and a three‐dimensional reconstruction of the heart revealed a tubular mass within the left atrium measuring 3.5 cm extending from the right atrium. Trans‐esophageal echocardiography confirmed a PFO with large traversing mobile thrombus into the atria. Subsequent CT scans showed a hypo‐dense infarct in the left occipital lobe, arterial emboli into the left kidney and a thrombus in right profunda femoral vein, confirming the PDE. The patient underwent emergent removal of atrial blood clots, foramen ovale closure and pulmonary arteries embolectomy. An inferior vena cava filter was placed and intravenous heparin infusion was started. Patient remained on mechanical ventilation and vasopressors support for few days and was subsequently discharged on warfarin treatment.

Discussion:

PDE is a critical medical condition, often described in association with a PFO. Despite the high prevalence in general population, a PFO is generally asymptomatic. The association between OSA and PFO is well described. Interestingly, the presence of a PFO is involved in transient episodes of hypoxemia and the development of pulmonary hypertension. However, a rapid increase of right‐side pressures of the heart could allow the passage of venous embolism into the arterial circulation.We strongly believe that the development of DVT following a traumatic injury induced the subsequent progression of serious events including massive pulmonary thrombo‐embolism and a right‐to‐left shunt with systemic embolism into the brain and kidney.

Conclusions:

Despite OSA and PFO are common in the general population, their association and clinical consequences are often underestimated.