Abstract | April 6, 2022

A Case of Systemic Paradoxical Embolization through Patent Foramen Ovale causing Acute Right Renal Infarction

Presenting Author: Masi Javeed, MD, BS, Internal Medicine Resident PGY2, Department of Medicine, Regional Medical Center of Bayonet Point, Hudson, FL

Coauthors: Taylor Kirkman, DO, Cardiology, PGY 6, HCA Healthcare, Hudson, FL; Michael Tedla, MD, Interventional Cardiology, PGY 7, HCA Healthcare, Hudson, FL; Keshav Ramireddy, MD, Interventional Cardiologist, HCA Healthcare, Hudson, FL

Learning Objectives

  1. Identify indications for PFO closure;
  2. Discuss management of systemic embolization;
  3. Describe risk of DVT/PE formation after procedures.

Introduction: Patent foramen ovale is present in only 25% of the population. A paradoxical embolism through a PFO is infrequent but is becoming increasingly recognized. Systemic paradoxical embolization or embolization to organs except for the brain, only accounts for 5-10% of paradoxical embolization. Furthermore, out of this already limited subset, involvement of the kidneys is rarely described. We present a unique case of a post-surgical patient on oral contraceptives who presented with dyspnea and was initially diagnosed with pulmonary embolism (PE). Incidentally during an interventional procedure, namely mechanical aspiration thrombectomy of her pulmonary embolism, she was noted to have a PFO. Due to systemic embolization across the PFO to her right kidney vasculature, a decision was made to close the PFO. This was successfully done.

Case Presentation: 20-year-old female, with a past medical history significant for breast reduction surgery 1-month prior to admission, PCOS, and chronic oral contraceptive use, presented with sudden shortness of breath and bilateral pleuritic chest pain. Significant vitals included heart rate 141 and respiratory rate 33 beats per minute. Patient also required 6 liters of supplemental oxygen via nasal cannula. However, blood pressure was stable. On physical exam, patient is clear to auscultation bilaterally; also patient with tachycardia but regular rhythm.

Computed tomography (CT) with angiography of the chest was ordered which revealed extensive pulmonary emboli involving bilateral main, lobar, segmental, and subsegmental arteries. Initial troponin was 2.57 and subsequently downtrended. Transthoracic echo revealed right ventricle dilation as well as moderate reduction in the ejection fraction of the right ventricle. CT imaging also showed findings suggestive of right-sided heart strain. Therefore on day 2 of admission, right common femoral vein access was obtained and the patient underwent a right heart catheterization followed by aspiration thrombectomy of bilateral main pulmonary arteries. Notably, during this right heart catheterization, the catheter was going into the left atrium although only the right-side of the heart was meant to be engaged. This led to concern for patent foramen ovale (PFO). Transesophageal echo confirmed PFO with a significant right-to-left shunt during provocative maneuvers to increase right atrial pressure. On day 4 of admission the patient developed right-sided abdominal pain. Computed tomography of the abdomen and pelvis with intravenous contrast was ordered. This revealed a perfusion defect in the posterior upper pole of the right kidney consistent with renal infarction.

Final/Working Diagnosis: Acute right renal infarct involving the posterior upper pole, secondary to paradoxical embolization through patent foramen ovale

Management/Outcome/Follow-up: Prior to finding the right renal infarction, the tentative plan was to monitor the patient’s PFO in the outpatient setting with yearly echocardiograms. However, after the aforementioned finding, discussion was had with the patient and her family regarding risks and benefits of various treatment options; patient and her family elected PFO closure. Procedure was conducted successfully without any complications. She was ordered therapeutic lovenox of 1 mg/kg BID IV as well as plavix 75 mg QD PO for at least 6 months for the patient’s PFO closure device. Patient was discharged and ordered to follow-up outpatient with cardiology and hematology.