Case Report:
A 44 year old female patient presented with worsening dyspnea. The patient was in sinus tachycardia (116 bpm), hyperventilating (respiratory rate 25/min), and normotensive. She had a history for smoking and immobility due to air travel two weeks before presentation. The ECG showed a SIQIII-pattern and a right bundle branch block. The transthoracic echocardiography showed an interatrial and intraventricular thrombus in transit through a PFO. The CT scan showed an embolism in the right pulmonary artery. The preoperative transesophageal echocardiography (Figure 1) showed a substantially impaired right ventricular function with pulmonary hypertension (systolic pulmonary artery pressure 50 mmHg), moderate tricuspid regurgitation and a thrombus in the right atrium crossing the PFO into the left atrium and left ventricle. Additionally a thrombus in the right pulmonary artery was found (Figure 1 B). After median sternotomy and establishment of cardiopulmonary bypass the right atrium was opened and a thrombus crossing the PFO (Figure 2 A) was revealed. After incision of the interatrial septum an 18 cm long and 1 cm thick vermiform thrombus was extracted. After an additional transverse incision of the right pulmonary artery between aorta and superior vena cava we performed an embolectomy by using a Fogarty catheter and removed additional thrombotic material (Fig 2 B upper part). The pulmonary artery was closed with a pericardial patch. The patient was weaned from cardiopulmonary bypass with mild inotropic support. Intraoperative transesophageal echocardiography revealed no remaining thrombotic material.
Intravenous heparinization was started 24 hours after ICU admission. The postoperative echocardiographic controls showed a normal right ventricular function with a mild tricuspid regurgitation and no signs of pulmonary hypertension. Doppler sonographic examination of the veins showed a DVT of the right leg. Due to a positive family history for thromboembolic events, additional genetic testings were performed, and a heterozygous prothrombin G2021 mutation could be diagnosed. A Factor V Leiden mutation was ruled out. The postoperative course was uneventful. On the fifth postoperative day the patient was started on phenprocoumon (INR 2-3) and was discharged eight days after surgery.