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Simultaneous Pulmonary and Coronary Embolism in a patient with Patent Foramen Ovale and Deep Venous Thromboses: A Case Report

Pejman Farhang, Anbar Ahmad, Hussein Bhikhapurwala, Jesus Gustavo Vazquez-Figueroa and Paul Douglass

Introduction: Simultaneous pulmonary and coronary embolism is an unlikely and rare complication of a deep venous thrombosis.
Case Presentation: A 43-year-old African-American, obese, male truck driver, current smoker, and hypertensive, presented with a four day history of shortness of breath and atypical chest pain. He was normotensive, tachypneic, and tachycardic on exam. D dimer was elevated and ABG demonstrated hypoxemia with respiratory alkalosis. Electrocardiogram was significant for sinus tachycardia, right axis deviation and an incomplete RBBB. Troponins were 43.0 ng/ml (reference range: < 0.03 ng/ml). Chest CT angiogram confirmed a massive bilateral pulmonary embolism, and ultrasound demonstrated bilateral lower extremity deep venous thromboses. Coronary angiography demonstrated a large thrombus located at the left main artery and a complete occlusion in the proximal LAD artery.  Thrombectomy was successful.
A PFO was demonstrated by transthoracic and transesophageal bubbles echocardiogram, and a large, mobile and complex thrombus was attached to the PFO and mobilized through the left ventricle. A sequential echocardiogram then demonstrated the migratory event of the thrombus from the right to the left cardiac chambers through a large PFO. Therefore, tPA was immediately administered. Follow-up echo and CT demonstrated only residual clot after thrombolytics. The patient was continued on anticoagulation throughout his stay, but later arrested and died.
Conclusion: Deep venous thrombosis could present with fatal and unexpected complications.  Physicians treating patients with deep vein thrombosis should consider serial advanced cardiac imaging. Debate still exists as to the management of intra-cardiac thrombi.