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Paradoxical embolism: an underestimated entity. A plea for comprehensive work-up
A F AbuRahma1, F C Lucente, J P Boland
1Department of Surgery, West Virginia University Health Sciences Center, Charleston Area Medical Center.
Insights
A significant number of arterial embolism cases remain undiagnosed. In patients under 50, paradoxical embolism should be investigated using contrast echocardiography.
Area of Science:
- Cardiovascular Medicine
- Diagnostic Imaging
- Vascular Surgery
Background:
- Arterial embolism presents a diagnostic challenge, necessitating comprehensive work-up.
- Understanding the source of emboli is crucial for effective patient management and secondary prevention.
Observation:
- A review of 41 arterial embolism cases revealed varied diagnostic approaches, including echocardiography and arteriography.
- Cardiac and arterio-arterial sources were identified in a proportion of patients.
- A notable percentage of cases, particularly in younger patients (<50 years), had an unknown source or potential paradoxical embolism.
Findings:
- Cardiac sources (probable and possible) accounted for 49% of identified emboli.
- Paradoxical embolism was identified in 12% of cases, with a higher prevalence in patients under 50.
- In 22% of cases, the source of arterial embolism remained unknown after conventional work-up.
Implications:
- A significant proportion of patients with arterial embolism are discharged without a definitive source identified.
- Paradoxical embolism should be strongly considered in younger patients, with contrast echocardiography recommended for diagnosis.
- Improved diagnostic strategies are needed to elucidate the etiology of arterial embolism, especially in cases with initially unknown sources.
Unlabelled:
Forty-one cases of arterial embolism were reviewed. The work-up included M + 2D echocardiography in 29 patients (71%), arteriography in 22 (54%), both echocardiography and arteriography in 19 (46%), and abdominal aortic ultrasound in 18 (43%). The sources of emboli were probable cardiac (8 = 20%)--mural cardiac thrombus detected by echocardiogram; possible cardiac (12 = 29%)--arrhythmias or other cardiac pathology detected without mural thrombus; probable arterio-arterial (7 = 17%)--proximal arterial thrombus detected; probable paradoxical embolism (2 = 5%)--fulfills the Johnson criteria with cardiac defect and right-to-left shunt detected by contrast echo in one patient and cardiac catheterization in the other; possible paradoxical embolism (3 = 7%)--meets two of three Johnson criteria without evidence of other source; and unknown source (9 = 22%)--conventional work-up negative or incomplete. Five of nine patients (56%) less than 50 years old had probable or possible paradoxical embolism, while in two patients (22%), the origin was unknown.
Conclusion:
(1) A significant proportion of patients with an arterial embolus are discharged with the source of emboli unknown, (2) paradoxical embolism must be considered and contrast saline or transesophageal echocardiogram should be done in patients under 50 years old.