Paradoxical embolism, deep vein thrombosis, pulmonary embolism in a patient with patent foramen ovale: a case report

Login or register to view PDF.

Coexistence of pulmonary embolism and systemic arterial embolism suggest the diagnosis of paradoxical embolism which suggests the presence of intracardiac defects such as patent foramen ovale (PFO).

Case presentation
A 42 year old man was found to have a paradoxical embolism in the systemic arterial circulation, in the setting of pulmonary embolism and deep vein thrombosis (DVT) in the lower extremities.

Paradoxical embolism and intracardiac shunt should be immediately considered in a patient with pulmonary embolism and systemic arterial embolism. Diagnostic modalities included arteriogram and saline contrast echocardiography. Closure of intracardiac shunt is needed for patients who are at risk for recurrent embolic events./>/>


Coexistence of pulmonary embolism and systemic arterial embolism indicates the presence of paradoxical embolism, which suggests a diagnosis of an intracardiac defect. The most common intracardiac defect associated with paradoxical embolism is patent foramen ovale (PFO), which has been described in 25├óÔé¼ÔÇ£30 percent of individuals 1. Most patients with a patent foramen ovale (PFO) remain asymptomatic. Under normal physiological conditions, patent foramen ovale (PFO) allows a small amount of L-R shunt without causing significant hemodynamic change. However, in the setting of increased right atrial pressure, significant right to left shunt can occur and lead to paradoxical embolism. The most important potential clinical manifestation due to a paradoxical embolism is ischemic stroke. There have been few reports of paradoxical emboli in systemic circulation coexistent with PE, deep vein thrombosis (DVT) and hypercoagulable state.
The most frequently cited criteria for the diagnosis of paradoxical embolism are:1). Embolism in arterial system that is not originated from left heart or from the arterial system itself. 2). Abnormal communication between the arterial and venous systems as evidenced by imaging tests. 3). Presence of venous thrombosis or embolism in the form of deep vein thrombosis or pulmonary embolism. 4). Increased right sided pressure which contributes right to left shunting, be it transient or longstanding 2./>



  1. Hara H, Schwartz : Patent foramen ovale. [] webcite 2007 UpToDate version 15.1
  2. Chant H, McCollum C: Stroke in young adults: the role of paradoxical embolism. Thromb Haemost 2001, 85:22-29.
  3. Foster PP, Boriek AM, Butler BD, Gernhardt ML, Bove AA: Patent foramen ovale and paradoxical systemic embolism: a bibliographic review. Aviat Space Environ Med 2003, 74:B1-B64.
  4. Inoue T, Tadehara F, Hinoi T, Tsujiyama S, Matsuo S, Shichijo T, Ono T, Yamakido M: Paradoxical peripheral embolism coincident with acute pulmonary thromboembolism. Intern Med 2005, 44:243-245.
  5. AU Agostoni P, Gasparini G, Destro G: TI Acute myocardial infarction probably caused by paradoxical embolus in a pregnant woman. SO Heart 2004, 90:e12.
  6. Steuber C, Panzner B, Steuber T, Krause A, Teichmann W, Mende T: [Open foramen ovale in patients with arterial vascular occlusions of the retina and optic nerve]. Ophthalmologe 1997, 94:871-876.
  7. Mess─é┬® SR, Schwartz RS, Perloff JK: Treatment of atrial septal abnormalities (PFO, ASD, and ASA) for prevention of recurrent stroke in adults. [] webcite 2007 UpToDate version 15.1
  8. Carod-Artal FJ, Vilela Nunes S, Portugal D: [Thrombophilia and patent foramen ovale in young stroke patients]. Neurologia 2006, 21:710-716.