Paradoxical embolism is one of the predominant causes of cryptogenic stroke and interventional secondary prevention, i.e., closure of the patent foramen ovale (PFO), is a much discussed issue. This review aims to provide a complex perspective on this topic, aggregates and comments on the available data and current guidelines. Several large trials were performed, some of which proved the superiority of PFO closure over pharmacotherapy while others have not. Studies detecting significant superiority of intervention worked with disproportionately high representation of large shunts compared to the general population. Other controversies also remain, such as the lack of comparison of the effect of modern anticoagulant/antiplatelet treatment to PFO closure or the risk of developing unwanted side effects after intervention, and these are discussed in detail. PFO closure is a suitable method for secondary prevention of paradoxical embolism and, therefore, cryptogenic stroke. However, this is only true for carefully selected patient populations and such selection is of the utmost importance in deciding on interventional or conservative treatment.

• Klíčová slova
• catheterization PFO closure, interatrial septal aneurysm, paradoxical embolism, patent foramen ovale,
• MeSH
• cévní mozková příhoda * etiologie   prevence a kontrola   MeSH
• foramen ovale apertum * komplikace   chirurgie   MeSH
• ischemická cévní mozková příhoda * MeSH
• lidé MeSH
• paradoxní embolie * etiologie   prevence a kontrola   MeSH
• srdeční katetrizace MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

Patent foramen ovale is a persisting communication between the left and right atrium, present in approximately 25% of population, usually asymptomatic. Under normal conditions there is either no blood flow or a hemodynamically nonsignificant left-to-right shunt between the atria. However, increased right atrium pressure, as it is in pulmonary embolism, can make PFO a right-to-left shunt and poses a risk of paradoxical systemic embolism, including the risk of ischemic stroke. Here we report a case of a patient presenting with venous thromboembolism provoked by a recent polytrauma. We identified a large thrombus stuck in patent foramen ovale - an impending paradoxical embolism. Both surgical intervention and systemic thrombolysis were contraindicated so the patient was administered an anticoagulation treatment with unfractionated heparin and warfarin. By frequent echocardiography we were able to monitor complete resolution of the thrombus by 6 months from the diagnosis, with no systemic embolism.

• Klíčová slova
• Pulmonary embolism, anticoagulation, impending paradoxical embolism, patent foramen ovale, pulmonary embolism,
• MeSH
• foramen ovale apertum * komplikace   diagnostické zobrazování   MeSH
• heparin MeSH
• lidé MeSH
• paradoxní embolie * komplikace   diagnostické zobrazování   MeSH
• plicní embolie * diagnostické zobrazování   etiologie   MeSH
• trombóza * MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• Názvy látek
• heparin MeSH

An impending paradoxical embolism is a rare finding, with fewer than 200 cases being documented so far. A 68-year-old woman, who presented with 3 weeks of increasing exertional dyspnea and exercise intolerance, underwent transesophageal echocardiography with a finding of an embolus in both right and left atria. At an emergent cardiac surgery, a worm-shaped, 5-cm-long thrombus was found in the right atrium, it was protruding to left atrium through the foramen ovale. The thrombus was removed intact, and the foramen ovale was closed. By our experience, an emergent cardiac surgery should always be considered as a treatment option for impending paradoxical embolism.

• MeSH
• diferenciální diagnóza MeSH
• echokardiografie transezofageální MeSH
• echokardiografie trojrozměrná MeSH
• foramen ovale apertum komplikace   diagnóza   chirurgie   MeSH
• kardiochirurgické výkony metody   MeSH
• lidé MeSH
• paradoxní embolie komplikace   diagnóza   chirurgie   MeSH
• počítačová rentgenová tomografie MeSH
• senioři MeSH
• trombektomie metody   MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• práce podpořená grantem MeSH

We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.

• Klíčová slova
• acute limb ischemia, orthopedic surgery, paradoxical embolism, patent foramen ovale, systemic thrombolysis, venous thromboembolism,
• MeSH
• embolektomie MeSH
• foramen ovale apertum * komplikace   diagnostické zobrazování   farmakoterapie   MeSH
• ischemie farmakoterapie   MeSH
• lidé MeSH
• paradoxní embolie * farmakoterapie   chirurgie   MeSH
• plicní embolie * chirurgie   MeSH
• senioři MeSH
• trombolytická terapie MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

INTRODUCTION: Pulmonary embolism is a life-threatening condition that causes obstruction of the pulmonary arteries by an embolus, most often originating from the venous system of the lower limbs or pelvic veins. Depending on the extent of the embolism, an acute right-sided heart failure may result, with subsequent death. Paradoxical embolism is a condition in which a venous thrombus is embolized into the systemic circulation arteries by a right-to-left heart shunt. This condition most commonly occurs in the interatrial septum. The aim of treatment for pulmonary embolism is to remove the obstruction of the lung. Depending on the extent of the embolism and the patients hemodynamic status, thrombolytic or surgical treatment can be chosen. Thrombolytic therapy has become the basis of treatment for all types of acute pulmonary embolism. Currently, open surgery is indicated in hemodynamically unstable patients with massive pulmonary embolism, and increasingly frequently in submassive embolism where thrombolytic therapy is not effective or contraindicated. CASE REPORT: The case report describes a less common condition of pulmonary and concurrently systemic embolization in the subclavian artery. Thrombolytic therapy was contraindicated in this case due to the high risk of secondary embolism to the brain. Surgical embolectomy was performed from the pulmonary arteries simultaneously with direct embolectomy from the subclavian and brachiocephalic artery. The surgical management of acute pulmonary embolism is a suitable method of treatment for both massive pulmonary embolism where the procedure is performed as a life-saving indication, and submassive embolism where less invasive treatment would not be effective. CONCLUSION: Direct embolectomy of subclavian and brachiocephalic artery is associated with minimal risk of iatrogenic embolism into the arteries supplying the brain compared to indirect embolectomy performed from the cubital or brachial artery. Key words: embolism paradoxical embolization - embolectomy foramen ovale stroke.

• Klíčová slova
• embolism paradoxical embolization - embolectomy foramen ovale stroke,
• MeSH
• arteria pulmonalis MeSH
• dolní končetina MeSH
• embolektomie * MeSH
• lidé MeSH
• plicní embolie * diagnóza   chirurgie   MeSH
• trombóza * diagnóza   chirurgie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

INTRODUCTION: The cause of decompression sickness (DCS) in scuba-divers is bubble formation in tissues and in venous blood during ascent. Divers with patent foramen ovale (PFO) have an increased risk of paradoxical embolization to the brain or other vital organs. The aim of our study was to assess the incidence of PFO in scuba-divers with DCS, to compare the group with asymptomatic controls, and to evaluate ultrasound contrast methods suitable for screening. METHODOLOGY: We examined 28 scuba-divers (more than 100 dives). The right-to-left shunt detection was performed by bubble contrast transthoracic echocardiographic examination (TTE) and transcranial Doppler sonography over arteria cerebri media (TCD) in all divers. In divers with shunting, transoesophageal echocardiography (TEE) was performed to prove PFO. RESULTS: 15 divers had DCS associated with the ascent. In this group, PFO was diagnosed in 53% (8/15). The symptoms of all of them retrospectively were of paradoxical embolization (neurological form of DCS). In the group of asymptomatic divers, PFO was proven on the basis of right-to-left shunt screening in 1 diver (8% 1/13). TCD proved right-to-left shunt in all divers with PFO. CONCLUSION: DCS can unmask a so far asymptomatic intracardiac right-to-left shunting. PFO is a risk factor for paradoxical embolization in divers. TCD is suitable for screening; TEE is a gold standard in PFO detection. Our results showed that PFO detection is a useful clinical tool after repeated DCS and in all frequent divers and instructors.

• MeSH
• defekty septa síní komplikace   diagnóza   MeSH
• dekompresní nemoc etiologie   prevence a kontrola   MeSH
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• paradoxní embolie etiologie   prevence a kontrola   MeSH
• potápění škodlivé účinky   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH

The authors present a relatively rare finding of pathological changes in the visual field, the emergence of homonymous hemianopia, in connection with trauma and paradoxical embolism in a subsequently diagnosed open foramen ovale in a 56-year-old otherwise healthy patient. Cardiac source of embolism is a significant etiology of vascular embolization. The important group is the so-called paradoxical embolism, which occurs when a blood clot (embolus) is carried from the venous side of circulation to the arterial side via foramen ovale patens, what can manifests as ischemic stroke. Foramen ovale patens becomes a risk factor for the stroke development only if there is a peripheral source of embolism and at the same time there is a hemodynamically significant right-left short circuit. Therefore, screening for the causes of cryptogenic stroke should include not only the detection of foramen ovale patens but also evaluation of the peripheral venous system, coagulation parameters and hemodynamic severity of a right-left shunt. Neuroophthalmological aspects related to the described issues are discussed.

• Klíčová slova
• homonymous hemianopia, open foramen ovale, paradoxical embolism, patent foramen ovale,
• MeSH
• cévní mozková příhoda * komplikace   MeSH
• foramen ovale apertum * komplikace   diagnóza   MeSH
• foramen ovale * MeSH
• lidé středního věku MeSH
• lidé MeSH
• paradoxní embolie * komplikace   MeSH
• rizikové faktory MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: Pulmonary embolism (PE) is associated with a risk of consecutive paradoxical embolism with brain infarction through a patent foramen ovale (PFO). The aims of this study were to assess the rate of new ischemic brain lesions (IBLs) using magnetic resonance imaging (MRI) during a 12-month follow-up period with anticoagulation and to evaluate the potential relationship with the presence of PFO on transesophageal echocardiography (TEE). SUBJECTS AND METHODS: Seventy-eight patients with acute PE underwent baseline contrast TEE with brain MRI. After the 12-month follow-up, 58 underwent brain MRI. The rates of MRI documenting new IBLs were measured based on the presence of PFO. RESULTS: PFO was detected in 31 patients (39.7%). At baseline MRI, IBL was present in 39 of 78 patients (50%). The presence of IBL was not significantly higher in patients with PFO than in patients without PFO (20 [64.5% patients with PFO] versus 19 [40.4% without PFO] of 39 patients with baseline IBL, P = .063). At the follow-up MRI, in the group with new IBL (9 of 58 patients, 15.5%), the number of patients with PFO was significantly higher than that without PFO (7 [33.3%] versus 2 [5.4%], P = .008). PFO was identified as an independent predictor of new IBL (odds ratio 4.6 [1.6-47.4], P = .008). CONCLUSIONS: The presence of PFO was associated with new IBL in patients with PE. These patients are at a higher risk of ischemic stroke despite effective anticoagulation therapy.

• Klíčová slova
• Pulmonary embolism, brain infarction, brain magnetic resonance imaging, echocardiography, patent foramen ovale,
• MeSH
• antikoagulancia aplikace a dávkování   MeSH
• aplikace orální MeSH
• barevná dopplerovská echokardiografie MeSH
• časové faktory MeSH
• cerebrální infarkt diagnostické zobrazování   etiologie   MeSH
• CT angiografie MeSH
• difuzní magnetická rezonance MeSH
• echokardiografie transezofageální MeSH
• foramen ovale apertum komplikace   diagnostické zobrazování   MeSH
• lidé MeSH
• logistické modely MeSH
• magnetická rezonanční angiografie MeSH
• odds ratio MeSH
• paradoxní embolie diagnostické zobrazování   etiologie   MeSH
• plicní embolie komplikace   diagnostické zobrazování   farmakoterapie   MeSH
• prospektivní studie MeSH
• rizikové faktory MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• pozorovací studie MeSH
• Názvy látek
• antikoagulancia MeSH

INTRODUCTION: Foam sclerotization of varicose veins may cause paradoxical embolization through patent foramen ovale (PFO). The aim of our study was to: 1) select an optimal screening method for the detection of PFO; 2) determine the prevalence of PFO in a non-selected population; and 3) test the risk of paradoxical embolization of venous bubbles in patients with PFO. MATERIALS AND METHODS: A diver after decompression is a suitable model for determining the risk of paradoxical embolization of venous gas bubbles. 329 Czech divers were screened for PFO. In a pilot study, we compared Transcranial Doppler Sonography (TCD) with Transesophageal Echocardiography (TEE) in 100 patients. TCD alone was used for further screening. In 31 divers with PFO, nitrogen bubbles were detected after simulated dives. Transthoracic Echocardiography (TTE) was used to detect venous bubbles in right-sided heart chambers; TTE and TCD were used to detect arterial bubbles. The right-to-left shunt was rated as non-significant (<20 arterial bubbles) or significant (20 arterial bubbles). Different decompression regimens were compared. RESULTS: In the pilot study, TCD was compared with the gold standard in PFO detection - TEE. The negative predictive value of TCD was 100%, positive predictive value was 92%. Screening was performed in a total of 329 divers, PFO was detected in 85 (25%), significant R-L shunt in 45 (14%). In simulated dive to 50 m maximum depth, venous nitrogen bubbles were detected in 7/8 (88%) divers. In 6/8 (75%) divers, paradoxical embolization was confirmed - nitrogen bubbles were detected in the systemic circulation. CONCLUSION: PFO prevalence with significant R-L shunt was 14% in the non-selected population of Czech divers. Simulated dives indicate that PFO represents a risk factor for paradoxical embolization of gas bubbles. TCD is a suitable screening method for the detection of PFO and the evaluation of R-L shunt significance. These results are indicative of a possible high risk of paradoxical embolization of gas bubbles and the trombogenic substance in patients with a larger PFO and significant R-L shunt undergoing foam sclerotization of varicose veins.

• MeSH
• dekompresní nemoc komplikace   MeSH
• echokardiografie MeSH
• foramen ovale apertum komplikace   diagnostické zobrazování   MeSH
• lidé MeSH
• paradoxní embolie etiologie   MeSH
• potápění škodlivé účinky   MeSH
• rizikové faktory MeSH
• skleroterapie škodlivé účinky   MeSH
• ultrasonografie dopplerovská transkraniální MeSH
• varixy komplikace   terapie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: Pulmonary embolism (PE) is a common and potentially life-threatening diagnosis when a certain amount of thrombotic mass obstructs blood flow through the pulmonary circulation. The finding of acute and subacute ischaemic foci on magnetic resonance imaging (MRI) of the brain in a group of patients with this diagnosis in whom we demonstrate the presence of patent foramen ovale (PFO) by transoesophageal echocardiography (TEE) is surprisingly high. METHODS: A total of 129 patients with a diagnosis of pulmonary embolism (confirmed by computed tomography with contrast agent, CTA) who consented to further examination were examined by transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) with contrast agent, underwent magnetic resonance imaging of the brain according to a specific protocol, and underwent a comprehensive baseline laboratory examination. RESULTS: In our group of 129 patients, we found the presence of PFO in 36.4% (n=47) of them. A total of 5.4% (n=7) patients had asymptomatic acute and subacute ischaemic changes on brain MRI; 6 of them had concomitant PFO. The statistically significant correlation between troponin levels and the presence of pathological findings on MRI and the trend of a similar correlation for NT-proBNP values is also very interesting finding. CONCLUSIONS: The association between the presence of PFO and the occurrence of symptomatic or asymptomatic findings on brain MRI is a well-known fact (the issue of paradoxical embolism) but the high frequency of acute and subacute lesions on brain MRI in the group of patients with a diagnosis of acute PE is surprising.

• Klíčová slova
• paradoxical embolism, patent foramen ovale, pulmonary embolism, stroke,
• MeSH
• akutní nemoc MeSH
• dospělí MeSH
• echokardiografie transezofageální MeSH
• echokardiografie MeSH
• foramen ovale apertum * komplikace   diagnostické zobrazování   MeSH
• incidence MeSH
• ischemie mozku diagnostické zobrazování   MeSH
• lidé středního věku MeSH
• lidé MeSH
• magnetická rezonanční tomografie * MeSH
• plicní embolie * diagnostické zobrazování   MeSH
• senioři MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH