A Successful Fibrinolytic Therapy of Trombus Entrapped in a Patent Foramen Ovale with Acute Pulmonary Embolism

A 75-year old male patient without prior history of chronic disease was admitted to hospital with worsening dyspnea for three days. On admission he was hypotensive (90/60 mmHg) and tachycardic (121 beat/pm). Electrocardiogram showed right bundle branch block, deep S waves in DI, Q waves and negative T waves in DIII. Transthoracic echocardiography (TTE) which was performed in emergency service revealed dilated right heart chambers (right ventricle area/left ventricle area: 1.27), depressed right ventricle (RV) systolic functions (RV ejection fraction: 22%, RV lateral wall basal segment tissue doppler Sm: 11.2 cm/s), elevated pulmonary artery pressure (45mmHg). In 2-D images, there was a mobile thrombus entrapped in a patent foramen ovale (PFO) which was also entering RV via tricuspid valve. The condition was considered as having high surgical risk since the patient was hemodynamically unstable with decreased O2 saturation (SaO2: 83%), high creatinine levels (2.6 mg/dl) and advanced age. Slow intravenous. infusion of alteplase (100 mg/2 hours) was administered after carefully ruling out contraindications. Thereafter, blood pressure and SaO2 rapidly improved. Control TTE after infusion showed that the thrombus had been dramatically resolved and disappeared. Pulmonary artery pressure decreased (36 mmHg), RV ejection fraction (36%) and RV systolic wall motion improved (Sm:15.1 cm/s), RV dilatation regressed (RV area/left ventricle area: 0.87) shortly after initial therapy. After full recovery, the patient was discharged with oral anticoagulant therapy.