[Multiple paradoxical emboli in patent foramen ovale]

A 38-year-old man was admitted because of angina pectoris with concomitant dyspnoea. Three months previously he had suffered an ischaemic stroke of the right middle cerebral artery and was treated in a neurological department. At that time, no aetiologic diagnosis was possible. There was no history of other diseases. Pulse rate was 100 beats per minute with a blood pressure of 140/60 mm Hg. The left calf had a 4 cm greater circumference without any symptoms. The rest of the physical examination in the markedly overweight patient was normal.

The ECG showed sinus rhythm and negative T-waves in leads V1-V4 and a slightly elevated ST-segments in II, III and aVF. An acute coronary thrombosis was ruled out by left heart catheter-angio.

Within the following hours, embolic occlusion of the left popliteal artery developed and was treated with a Fogarty catheter. On the first postoperative day, the patient complained about mild dysaesthesia of his right arm. Duplex sonography showed a floating thrombus in the left carotid bifurcation. The thrombus was removed surgically. Later a pulmonary embolism due to deep vein thrombosis in the left thigh and calf was found. Transoesophageal echocardiography performed in another hospital previously was repeated and a patent foramen ovale (PFO) with a middle-sized shunt was found. The patent foramen ovale was closed percutaneously by implanting a Cardioseal-Starflex occluder. There was neither a complication nor a residual shunt. Neurological symptoms disappeared completely within the next few months. The patient has now been free from new neurological events for 11 months.

In patients with PFO, paradoxical embolism remains a challenging diagnosis that can be made highly probable by documentation of venous thromboses, pulmonary embolism, missing evidence of atherosclerosis in the vessels of the embolized organ and exclusion of other cardiovascular sources of emboli and prothrombotic coagulation disorders. Interventional closure of a patent foramen ovale appears to be the treatment of choice in proven paradoxical embolism.