An unexpected case of cor pulmonale

Introduction: A significant proportion of patients who experience „idiopathic“ thrombotic events have a detectable abnormality, such as thrombophilia, but most of these only develop thrombosis in the presence of additional risk factors. The most common clinical scenario is venous pulmonary thromboembolism (VTE), but also in situ thrombosis. When deep venous thrombosis is associated with arterial embolism a foramen ovale patent (FOP) should be always confirmed due to the unfavorable prognosis.
Case presentation: ECG, chest X-ray and TTE con-firmed the diagnosis of cord pulmonale. TEE revelead an interatrial septum aneurysm, patent foramen ovale with right-to-left shunt. The decisive finding in TTE is a thrombus on lateral wall of right ventricle and parietal thrombosis of arterial pulmonary trunk. The fin-ding is suggestive for hypercoagulable state, imposes thrombophilia diagnosis, further confirmed by specific laboratory tests (lupic anticoagulant, heterozygous factor V Leiden). The presence of patent foramen ovale is suggestive for the venous origin of arterial emboli, confirmed by Doppler ultrasound – deep femoral and popliteal vein thrombosis (in absence of clinical signs). Thoracic CTA was diagnostic for bilateral VTE. A neoplasia as cause of thrombophilia was ruled out by imagistic and tumoral markers. Digital substraction angiography confirmed left iliac artery embolism, urgently resolved by surgical embolectomy. By strictly and long-term monitoring of chronic oral anticoagulation, the evolution was uncomplicated. Patent foramen ovale closure is contraindicated in the presence of severe pulmonary hypertension.
Conclusions: T his report highlights the central role of echocardiography for confirming the paradoxical embolism. This case is also particular by revealing the right ventricle thrombosis as a rare condition. Similar to literature data, inherited thrombophilia produces venous VTE in the presence of additional risk factors, i.e. aging and smoking.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)