Paradoxical Embolism Follow-up

  • Author: Igor A Laskowski, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Sep 17, 2009
 

Further Inpatient Care

  • Inpatient care for people with paradoxical embolism (PDE) depends on their hemodynamic stability and associated presenting clinical manifestations, such as PE, TIA, acute arterial embolism, or debilitating neurological deficits, that may warrant intensive care or regular monitoring.
    • Safety precautions and fall prevention when the risk for falls and safety concerns are present, especially in elderly patients.
    • Aspiration prophylaxis is paramount in patients who are bedridden with minimal or no cough reflex.
    • Neurologic watch is needed to monitor any further neurologic deficit to intervene before further deterioration.
    • Intensive care monitoring is needed in the presence of hypotension and when the patient needs vasopressors, intubation, and mechanical ventilation.
    • Pain management is needed in patients with acute arterial limb occlusion that commonly presents with severe pain and pain associated with DVT.
    • Gastrointestinal prophylaxis is needed to prevent stress ulcers in the presence of cerebral insult.
    • Skin care may involve frequent turning and protective skin devices to prevent skin breakdown and eventual decubitus ulcer.
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Further Outpatient Care

  • Outpatient care for paradoxical embolism (PDE) is based on evidence of idiopathic venous thrombosis, hypercoagulable states, PE, the risk-determined DVT, and the sequelae of the clinical manifestation.
    • Chronic anticoagulation therapy with warfarin may be used for 6 months in DVT/PE or as lifelong therapy with monitoring of the INR in the presence of hypercoagulable states.
    • Chronic antithrombotic therapy with antiplatelet drugs is needed for patients with history of TIA.
    • Physical therapy is needed for patients who will benefit from physical rehabilitation.
    • Visiting nurse may be highly beneficial for monitoring INR at home and helping patients in the administration of subcutaneous injection of LMWH when used for long-term anticoagulation for eventual self-administration.
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Inpatient & Outpatient Medications

  • Anticoagulation
    • Warfarin
    • Enoxaparin
    • Tinzaparin
  • Antiplatelet therapy
    • Dipyridamole/aspirin (Aggrenox)
    • Clopidogrel (Plavix)
    • Ticlopidine (Ticlid)
  • Thrombolytics, eg, alteplase (tPA)
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Transfer

  • Intensive care unit: Patients with paradoxical embolism (PDE) can be transferred to medical or surgical intensive care units in the presence of hemodynamic compromise.
  • Subacute rehabilitation facility: This may be beneficial in patients with significant neurological deficits and with no further risk of emboli.
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Deterrence/Prevention

Prevention remains controversial. Whether or not prophylaxis of persons with a recognized predisposition for paradoxical embolism (PDE) is beneficial and whether patients with hypercoagulable states should be screened routinely using contrast echocardiography for PFO or ASD are not established.

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Complications

  • Neurologic deficit as a manifestation of stroke
  • Hemiplegia
  • Amaurosis fugax with eventual blindness
  • Motor aphasia
  • Seizure disorder complicating a cerebral insult
  • Arrhythmia such as ventricular tachycardia/fibrillation in cases of impending paradoxical embolism (PDE)
  • Acute myocardial infarction
  • Loss of limb function with amputation
  • Organ damage, eg, renal infarction
  • Death
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Prognosis

  • Prognosis of paradoxical embolism (PDE) is good when it is not complicated.
  • Prognosis of paradoxical embolism (PDE) is poor when it is complicated by PE. When impending paradoxical embolism (PDE) occurs, the choice of treatment involves open-heart surgery.
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Patient Education

  • Patients on long-term anticoagulant therapy should be compliant with their medications to prevent recurrent thrombolic events; emphasize compliance.
  • Avoid vitamin K–containing foods such as green leafy vegetables, including spinach, broccoli, and cauliflower.
  • Varicose veins coexist commonly with cyanotic congenital heart disease, and these may predispose to thromboembolic phenomena. These patients should avoid passive standing, should avoid crossing their legs when sitting, and should not allow their legs to be dependent.
  • Avoid Valsalva maneuvers to prevent elevation of the right atrial pressure above the left atrial pressure, which can lead to transient right-to-left shunting in patients with risk factors for paradoxical embolism (PDE).
  • For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Blood Clot in the Legs.
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Contributor Information and Disclosures
Author

Igor A Laskowski, MD  Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center

Igor A Laskowski, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Peripheral Vascular Surgery Society, Society for Vascular Surgery, and Transplantation Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sateesh C Babu, MD  Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY

Sateesh C Babu, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Institute of Ultrasound in Medicine, American Medical Association, Eastern Vascular Society, International Society of Endovascular Specialists, New York Academy of Sciences, Royal Society of Medicine, Society for Vascular Surgery, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Oladayo Adisa Osinuga Sr, MBBS  Attending Physician, Department of Internal Medicine, Atlanta Medical Center

Oladayo Adisa Osinuga Sr, MBBS is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association

Disclosure: Nothing to disclose.

Maurice Rachko, MD, FACC, FACP  Director of Coronary Care Unit, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, Weill Medical College of Cornell University

Maurice Rachko, MD, FACC, FACP is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP  Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Sepracor None None

Nelson S Menezes, MD, FRCS(Edin), FACS  Assistant Professor of Surgery, Weill Cornell Medical College; Chief of Vascular Surgery, Department of Surgery, Brooklyn Hospital Center

Nelson S Menezes, MD, FRCS(Edin), FACS is a member of the following medical societies: American College of Surgeons, International Society of Endovascular Specialists, Medical Society of the State of New York, and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Forker, MD  Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke's Hospital

Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa

Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steven J Compton, MD, FACC, FACP  Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

References

  1. Cohnheim J. Thrombose und Embolie. Vorlesung ueber allgemeine Pathologie. Berlin, Hirschwald. 1877;1:134.

  2. Eichhorn V, Bender A, Reuter DA. Paradoxical air embolism from a central venous catheter. Br J Anaesth. May 2009;102(5):717-8. [Medline].

  3. Vellayappan U, Attias MD, Shulman MS. Paradoxical embolization by amniotic fluid seen on the transesophageal echocardiography. Anesth Analg. Apr 2009;108(4):1110-2. [Medline].

  4. Mascarenhas V, Kalyanasundaram A, Nassef LA, Lico S, Qureshi A. Simultaneous massive pulmonary embolism and impending paradoxical embolism through a patent foramen ovale. J Am Coll Cardiol. Apr 14 2009;53(15):1338. [Medline].

  5. Kuppuswamy M, Kourliouros A, Sutherland G, Sarsam M. Complete surgical correction for impending paradoxical embolism with pulmonary embolism, tricuspid regurgitation, and atrial flutter. Heart Surg Forum. Dec 2008;11(6):E378-9. [Medline].

  6. Cifarelli A, Musto C, Parma A, Pandolfi C, Pucci E, Fiorilli R, et al. Long-term outcome of transcatheter patent foramen ovale closure in patients with paradoxical embolism. Int J Cardiol. Jan 28 2009;[Medline].

  7. Allie DE, Lirtzman MD, Wyatt CH, et al. Septic paradoxical embolus through a patent foramen ovale after pacemaker implantation. Ann Thorac Surg. Mar 2000;69(3):946-8. [Medline].

  8. Bridges ND, Hellenbrand W, Latson L, et al. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation. Dec 1992;86(6):1902-8. [Medline].

  9. Cheng TO. Paradoxical embolism. Circulation. Jun 29 1999;99(25):3323. [Medline].

  10. Corrin C. Paradoxical embolism. Br Heart J. 1991;26:549.

  11. Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation. Nov 9 1999;100(19 Suppl):II171-5. [Medline].

  12. Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology. Nov 1996;47(5):1162-6. [Medline].

  13. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. Jan 1984;59(1):17-20. [Medline].

  14. Hung J, Landzberg MJ, Jenkins KJ, et al. Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol. Apr 2000;35(5):1311-6. [Medline].

  15. Ikonomidis JS, Nisco SJ, Liang DH, et al. Paradoxical embolism of a shotgun pellet. Ann Thorac Surg. Aug 1998;66(2):562-4. [Medline].

  16. Johnson BI. Paradoxical embolism. J Clin Pathol. 1951;4:316-32.

  17. Kuhl HP, Hoffmann R, Merx MW, et al. Transthoracic echocardiography using second harmonic imaging: diagnostic alternative to transesophageal echocardiography for the detection of atrial right to left shunt in patients with cerebral embolic events. J Am Coll Cardiol. Nov 15 1999;34(6):1823-30. [Medline].

  18. Loscalzo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J. Jul 1986;112(1):141-5. [Medline].

  19. Lynch JJ, Schuchard GH, Gross CM, et al. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol. May 15 1984;53(10):1478-80. [Medline].

  20. Mas JL. Diagnosis and management of paradoxical embolism and patent formen ovale. Curr Opin Cardiol. Sep 1996;11(5):519-24. [Medline].

  21. Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J. Nov 1995;130(5):1083-8. [Medline].

  22. Meacham RR 3rd, Headley AS, Bronze MS, et al. Impending paradoxical embolism. Arch Intern Med. Mar 9 1998;158(5):438-48. [Medline].

  23. Nemec JJ, Marwick TH, Lorig RJ, et al. Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts. Am J Cardiol. Dec 1 1991;68(15):1498-502. [Medline].

  24. Sadanandan S, Sherrid MV. Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm. J Am Coll Cardiol. Jun 2000;35(7):1932-1938. [Medline].

 
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