Clinical implications of a patent foramen ovale in patients with massive pulmonary embolism

  • A. Geibel
  • S. Konstantinides
  • W. Kasper


The aim of our investigations was to prospectively evaluate the clinical relevance of a patent foramen ovale in patients with acute massive pulmonary embolism with regard to mortality, the occurrence of cardiovascular complications and the extent of arterial hypoxemia.

In 85 patients and in a second study in 139 patients with acute massive pulmonary embolism a right-to-left shunt was diagnosed by contrast echocardiography. A patent foramen ovale was found in 39 % of the patients in the first and in 35 % in the second study.

With regard to the extent of arterial hypoexemia the oxygen tension was significantly lower in patients with a patent foramen ovale (55 ∓ 14 mm Hg vs 62 ∓ 16 mm Hg). Furthermore in the second study, clinical symptoms presumptive of paradoxical embolism occurred in 13 patients (27 %) with a patent foramen ovale and in 2 patients (2.2 %) without a patent foramen ovale. During the inhospital stay, patients with a patent foramen ovale had a death rate of 33 % as opposed to 14 % in patients without a patent foramen ovale. Logistic regression analysis demonstrated that after adjustment for the clinical characteristics the only independent predictors of inhospital mortality were arterial hypotension at presentation (p < 0.01) and a patent foramen ovale (p < 0.001). Patients with a patent foramen ovale also had a significantly higher incidence of cardiovascular complications. Overall, the risk of a complicated in-hospital course was 5.2 times higher in the patient group with a patent foramen ovale.

These investigations underlines the prognostic impact of a patent foramen ovale in high-risk patients with acute massive pulmonary embolism.

Key words

Pulmonary embolism patent foramen ovale paradoxical embolism contrast echocardiography prognosis 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE (1976) Mortality in patients treated for pulmonary embolism. JAMA 236:1477–80PubMedCrossRefGoogle Scholar
  2. 2.
    Carson JL, Kelly MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE (1992) The clinical course of pulmonary embolism. N Engl J Med 326:1240–45PubMedCrossRefGoogle Scholar
  3. 3.
    Cheng TO (1976) Paradoxical embolism. A diagnostic challenge and its detection during life. Circulation 53:565–68Google Scholar
  4. 4.
    Cohnheim J (1877) Thrombose und Embolie. Vorlesung über allgemeine Pathologie. Vol 1. Berlin: Hirschwald, p 134Google Scholar
  5. 5.
    D’Alonzo G, Bower JS, DeHart P, Dantzker DR (1983) The mechanisms of abnormal gas exchange in acute massive pulmonary embolism. Am Rev Respir Dis 128:170–72PubMedGoogle Scholar
  6. 6.
    Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S (1992) Patent foramen ovale as a risk factor for crytogenic stroke. Ann Intern Med 117:461–65PubMedGoogle Scholar
  7. 7.
    Dubourg O, Bourdarias JP, Farcot JC, Gueret P, Terdjam M, Ferrier A, Rigaud M, Bardet JC (1984) Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale. J Am Coll Cardiol 4: 587–94PubMedCrossRefGoogle Scholar
  8. 8.
    Hale GS, Clarebrough JK, Fox P, Blair N, McDonald IG, Chestermann C (1979) Severe pulmonary embolism complicated by right-to-left shunting: Diagnosis and implications in management. Aust NZ J Med 9:953Google Scholar
  9. 9.
    Hagen PT, Scholz DG, Edwards WD (1984) Incidence and size of patent foramen ovale during the first 10 decades of life; An autopsy study of 965 normal hearts. Mayo Clin Proc 59:17–20PubMedGoogle Scholar
  10. 10.
    Hausmann D, Mügge A, Becht I, Daniel WG (1992) Diagnosis of a patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events. Am J Cardiol 70:668–72PubMedCrossRefGoogle Scholar
  11. 11.
    Higgins JR, Strunk BL, Schiller NB (1984) Diagnosis of paradoxical embolism with contrast echocardiography. Am Heart J 107: 375–77PubMedCrossRefGoogle Scholar
  12. 12.
    Jardin F, Gurdjian F, Desfonds P, Fouilladieu JL, Margairaz A (1979) Hemodynamic factors influencing arterial hypoxemia in massive pulmonary embolism with circulatory failure. Circulation 59:909–12PubMedGoogle Scholar
  13. 13.
    Johnson BJ (1951) Paradoxical embolism. J Clin Pathol 4: 316–32PubMedCrossRefGoogle Scholar
  14. 14.
    Jones EF, Calafiore P, Donnan GA, Tonkin AM (1994) Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly. Am J Cardiol 74: 596–99PubMedCrossRefGoogle Scholar
  15. 15.
    Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J (1997) Management strategies and determinants of outcome in acute major pulmonary embolism: Results of a multicenter registry. J Am Coll Cardiol 30:1165–71PubMedCrossRefGoogle Scholar
  16. 16.
    Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77: 346–49PubMedGoogle Scholar
  17. 17.
    Kasper W, Geibel A, Tiede N, Bassenge D, Kauder E, Konstantinides S, Meinertz T, Just J (1993) Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography. Br Heart J 70: 352–56PubMedCrossRefGoogle Scholar
  18. 18.
    Kasper W, Geibel A, Tiede N, Just H (1992) Patent foramen ovale in patients with hemodynamically significant pulmonary embolism. Lancet 340: 561–64PubMedCrossRefGoogle Scholar
  19. 19.
    Kasper W, Geibel A, Tiede N, Hofmann T, Meinertz T, Just H (1989) Echocardiographic diagnosis of pulmonary embolism. Herz 14: 82–101PubMedGoogle Scholar
  20. 20.
    Keidar S, Grenadier E, Binenboim C, Palant A (1984) Transient right to left atrial shunt detected by contrast echocardiography in the acute stage of pulmonary embolism. J Clin Ultrasound 12:417–19PubMedCrossRefGoogle Scholar
  21. 21.
    Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K, Rauber K, Iversen S, Redecker M, Kienast J, Just H, Kasper W (1997) Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism. Circulation 96:882–888PubMedGoogle Scholar
  22. 22.
    Lang I, Steurer G, Weissel M, Burghuber OC (1988) Recurrent paradoxical embolism complicating severe thromboembolic pulmonary hypertension. Eur Heart J 9:678–81PubMedGoogle Scholar
  23. 23.
    Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczag M, Drobinski G, Thomas D, Grosgogeat Y (1988) Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 318:1148–52PubMedCrossRefGoogle Scholar
  24. 24.
    Leonard RCF, Neville E, Hall RJC (1982) Paradoxical embolism: A review of cases diagnosed during life. Eur Heart J 3:362–70PubMedGoogle Scholar
  25. 25.
    Loscalzo J (1986) Paradoxical embolism: Clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J 112:141–45PubMedCrossRefGoogle Scholar
  26. 26.
    Lynch JJ, Schuchard GH, Gross CM, Wann LS (1984) Prevalence of right-to-left shunting in the healthy population: Detection by Valsalva maneuver contrast echocardiography. Am J Cardiol 53:1478–80PubMedCrossRefGoogle Scholar
  27. 27.
    Meister SG, Grossmann W, Dexter L, Dalen JE (1972) Paradoxical embolism. Diagnosis during life. Am J Med 53:292–98PubMedCrossRefGoogle Scholar
  28. 28.
    Movsowitz C, Podolsky LA, Meyerowitz CB, Jacobs LE, Kotler MN (1992) Patent foramen ovale: A nonfunctional embryologic remnant or a potential cause of significant pathology. J Am Soc Echocardiogr 5: 259–70PubMedGoogle Scholar
  29. 29.
    Nagelhout DA, Pearson AC, Labovitz AJ. Diagnosis of paradoxic embolism by transesophageal echocardiography. Am Heart J 121:1552–54Google Scholar
  30. 30.
    Nellessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR (1985) Impending paradoxical embolism from atrial thrombus: Correct diagnosis by transesophageal echocardiography and prevention by surgery. J Am Coll Cardiol 5:1002–04PubMedCrossRefGoogle Scholar
  31. 31.
    Nelson CW, Snow FR, Barnett M, McRoy L, Wechsler AS, Nixon JV (1991) Impending paradoxical embolism: Echocardiographic diagnosis of an intra cardiac thrombus crossing a patent foramen ovale. Am Heart J 122: 859–62PubMedCrossRefGoogle Scholar
  32. 32.
    Rodgers DM, Singh S, Meister SG (1984) Contrast echocardiographic documentation of paradoxical embolism. Am Heart J 107:1270–71PubMedCrossRefGoogle Scholar
  33. 33.
    Teague SM, Sharma MK (1991) Detection of paradoxical cerebral echo contrast embolization by transcranial Doppler ultrasound. Stroke 22: 740–45PubMedCrossRefGoogle Scholar
  34. 34.
    The Urokinase Pulmonary Embolism Trial. A national cooperative study (1973) Circulation 47(II): 1–108Google Scholar
  35. 35.
    Thompson T, Evans W(1930) Paradoxical embolism. Q J Med 23:135–50Google Scholar
  36. 36.
    Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM, Glasgow GL (1988) Patent foramen ovale in young stroke patients. Lancet ii: 11–12CrossRefGoogle Scholar
  37. 37.
    Wilson JE, Pierce AK, Johnson (1971) Hypoxemia in pulmonary embolism, a clinical study. J Clin Invest 50: 481–91PubMedCrossRefGoogle Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag GmbH & Co. KG, Darmstadt 2000

Authors and Affiliations

  • A. Geibel
    • 1
  • S. Konstantinides
    • 1
  • W. Kasper
    • 2
  1. 1.Innere Medizin III - Kardiologie und AngiologieUniversitätsklinik FreiburgFreiburgGermany
  2. 2.Medizinische Klinik ISt. Josefs-Hospital WiesbadenWiesbadenGermany

Personalised recommendations