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.