Pulmonary Embolism In-Transit Crossing the Mitral and Aortic Valve

Summary

Pulmonary embolisms crossing a patent foramen ovale constitute a life-threatening emergency. This protocol details the steps for the surgical management of a patient with a pulmonary embolism crossing a patent foramen ovale.

Abstract

Hemodynamically significant pulmonary embolisms (PE) in the pulmonary artery or those crossing a patent foramen ovale (PFO) can become life-threatening emergencies requiring immediate removal. While cases of surgical management for a PE crossing a PFO have been reported, there are no documented cases of a PE extending across both the mitral and aortic valves. A 38-year-old female with a medical history of obesity, depression, and thalassemia minor was transferred from an outside hospital with hemodynamic compromise due to a large PE. Transesophageal echocardiography (TEE) revealed a PE crossing the PFO, extending across the mitral valve, and traversing the aortic valve into the ascending aorta. Cardiopulmonary bypass (CPB) was initiated using standard aortic cannulation distal to the known clot, along with bicaval venous cannulation. The heart was arrested, and the right and left atria were opened in a transeptal fashion. The clot, which extended from the PFO through the mitral and aortic valves, was identified and removed en bloc. A small aortotomy was performed, confirming a clear aorta. An additional clot was found in the right atrium crossing the tricuspid valve and was subsequently removed. Finally, the pulmonary artery was opened, and the bulk of the clot burden was extracted, completing the embolectomy. The patient was successfully weaned from CPB without complications and was extubated within 24 h post-surgery. She underwent inferior vena cava filter placement and was discharged on post-operative day seven. Extensive pulmonary emboli are life-threatening emergencies that require immediate intervention. This study presents an extensive clot burden crossing the PFO, mitral valve, and aortic valve. Prompt surgical intervention is crucial to preventing severe complications such as stroke, myocardial infarction, respiratory failure, death, and long-term sequelae, including pulmonary hypertension and future strokes.

Introduction

A pulmonary embolism (PE) is often a life-threatening medical emergency that requires immediate medical intervention. In clinical practice, a PE is defined as a blood clot that has obstructed a patient's pulmonary circulation¹. A PE falls under the umbrella term of venous thromboembolism (VTE) and is a result of a deep vein thrombosis (DVT) released from the systemic circulation, traveling to the right side of the heart, and entering the pulmonary arteries². As of 2020, PE is the third most common cardiovascular cause of death in the United States, behind myocardial infarction and stroke^3....

Protocol

This protocol complies with the human care guidelines of the University of Florida. Written informed consent was obtained from the patient who participated in this study. The inclusion criterion was hemodynamic instability due to clot burden or a patent foramen ovale. The exclusion criterion was patients with strict contraindications to surgery. The details of the reagents and equipment used are listed in the Table of Materials.

1. Pre-operative preparation

1. Initial evaluation
   1. Evaluate the patient's hemodynamic status by obtaining vitals, an EKG, and a chest X-ray.
   2. If a pulmonary emboli....

Results

Following the intervention, the patient was successfully weaned off cardiopulmonary bypass without incident. Figure 2A,B demonstrate clot removal using the en bloc technique. Post-operatively, the patient remained intubated and was placed on intravenous (IV) heparin but remained hemodynamically stable. The patient was extubated within 24 h of surgery. Post-operative CT angiography confirmed restored pulmonary artery blood flow, with the pulmo.......

Discussion

Extensive pulmonary emboli in transit are life-threatening emergencies that require immediate intervention. We present a case of extensive clot burden crossing the PFO, mitral valve, and aortic valve. Removal of the clot burden and closure of the PFO is a vital part of therapy when a clot is this vast. Immediate surgery not only prevents urgent life-threatening problems of stroke, heart attack, respiratory failure, and death but also prevents long-term consequences of pulmonary hypertension from clotting or future strok.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Aortic clamps	Wexler Surgical	AL2238.1
Aortic punch	Scanlan international	1001-600
arterial line filter (40 micron)	Lifeline Systems Pvt. Ltd.	ALF-01
Arterial tubing circuits	Medtronic	4949
Ascending aorta arterial cannula	Terumo Cardiovascular Systems	203879S
Bone wax	Ethicon	W810
Bubble detector	Quest Medical	Integrated into MPS 3 ND System
Bulldog clamps	Wexler Surgical	AL2102.1
Cardioplegia delivery system	Terumo Cardiovascular Systems	165720
Cardioplegia filter	Terumo Cardiovascular Systems	CPS-02
Cooley forceps	JJ International Instruments	356002
DeBakey forceps	Wexler Surgical	AL2412.1
Fine suction tips	Wexler Surgical	AL1171.1F.
Fogarty embolectomy catheters	Edward Lifesciences	120404F
Gerald forceps	Amber Surgical	190660053741
Heart lung machine	LivaNova	S5 Heart Lung Machine
Heat exchanger	LivaNova	D921
Heavy needle drivers	Ambler surgical	50-100
IVC filter	Boston Scientific	M001503010	Filter placed to prevent future PE/strokes
Left ventricular vent catheter	Medtronic	E060
Mayo scissors	KLS Martin Group	11-171-17-07
Membrane oxygenator	Terumo Cardiovascular Systems	Capiox FX Series
Metzenbaum scissors	Securos surgical	45070
Plegeted sutures for PA closure	Ethicon	D7143
Potts scissors	Novo Surgical	G1567-88
Pulmonary artery venting catheter	Edwards Lifesciences	774F75
Single stage venous cannula	Medtronic	69328
Sternal retractors	Integra LifeSciences	300-165
Sternal saw	Stryker Corportation	REF 8207-000-. 000
Sternal wire	Zimmer Biomet	ASTM F138
TEE probe	Philips Healthcare	X11-4t FUS9364 xMatrix
Tissue retractors	Integra LifeSciences	200-155
Vascular forceps	Ambler surgical	34-135.
Vascular needle holders	Ambler surgical	50-850
Vascular scissors	Ambler Surgical	78-742
Vascular sutures: Prolene 4-0, 5-0, 6-0	Ethicon	D7143
Venous clamps	JJ International Instruments	CV6011 -10T
Venous tubing circuits	Terumo Cardiovascular Systems	66112