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Abstract Case Report A 67 years old Angolan woman was referred to our hospital for worsen dyspnea, palpitation and left flank pain while walking. She had no relevant medical history and her only cardiovascular (CV) risk factor was hypertension. For high suspicion of pulmonary embolism (PE), an abdominal–thoracic CT was performed, demonstrating the presence of bilateral PE with greater thrombotic burden of the right branch, right ventricle (RV) enlargement and left renal infarction. She was stratified in an intermediate–high risk class. The patient was hemodynamically stable (BP: 120/65 mmHg, HR: 115 bpm) with a calculated PESI class of III and elevated Hs–cTnI. Transthoracic echocardiography (TTE) showed RV dilation, McConnell sign, flattened intra–ventricle septum, mild pulmonary and severe tricuspid valve regurgitations. Therefore, we decided to start anticoagulation and to perform ultrasound–assisted thrombolysis (USAT) without procedural complications. A venous echo–doppler demonstrated the presence of thrombosis of the left popliteus veins. Moreover, screening for thrombophilia syndromes and neoplastic markers were negative. The day after, a partially–restored flow was noticed on renal artery US. The bubble test during transesophageal echocardiography revealed a patent foramen ovale (PFO) with a moderate right–to–left shunt. From these findings, a paradoxical embolism (PDE) through amoderate PFO was confirmed as the cause of her renal infarction. After 7 days of hospitalization, the patient was discharged on anticoagulant (apixaban) in good health status and with reduced serum creatinine levels. Discussion PE is the 3rd leading cause of CV mortality. A rare scenario in PE is PDE, manifesting in this case with acute kidney injury, with no other organ involvement. PDE occurs when a thrombus crosses an intracardiac defect into systemic circulation and it usually follows PE because elevated right–side pressure enhances right–to–left shunting. For patients with intermediate–risk PE, there is no clear consensus on 1st–line therapy. In our case, USAT has been effective in reversing RV dysfunction with early decrease of right–side pressures by TTE assessments. Compared with anticoagulation alone, USAT may quicker protect from PDE recurrence and potentially reduce the incidence of chronic thromboembolic pulmonary hypertension, a rare but serious long–term complication. Moreover, as we observed, thrombolytic local release can dissolve systemic clots when PDE occurs.
Falagario et al. (Mon,) studied this question.