Chest
Original ResearchVenous ThromboembolismImpending Paradoxical Embolism: Systematic Review of Prognostic Factors and Treatment
Section snippets
Literature Search
Two investigators (P.O.M. and A.P.) independently did systematic electronic and manual literature searches using a predetermined to identify reports of IPDE. Articles were identified in electronic database searches of Medline, Embase, and the Cochrane Library, from 1964 to 2008. To achieve the maximum sensitivity of the search strategy and identify all reports on the subject, we used appropriate free text and thesaurus terms including “paradoxical embolism,” “impending paradoxical embolism,”
Literature Search Results and Baseline Characteristics
Literature search results are shown in Figure 1. One hundred fifty-four studies (see online supplement) and one personal communication were included in the review, representing 174 patients clinically diagnosed with IPDE. The IPDE passed through a patent foramen ovale in all but one patient, in whom the thrombus passed through an atrial septal defect. Most patients were reported as isolated case reports, with a ratio of 1.13 patients per study. The clustering effect was thus assumed to be
Discussion
Despite the high prevalence of patent foramen ovale, estimated at 26%,14 paradoxical embolism is a rare event. It requires the following criteria for diagnosis: (1) presence of deep venous thrombosis or pulmonary embolism; (2) abnormal communication between the right and left circulation; (3) clinical, angiographic, or pathologic evidence of systemic embolism; and (4) presence of a favorable pressure gradient promoting right-to-left shunting.10, 15 IPDEs represent DVTs embolized to the heart
Conclusions
This review attempts to help guide what to do in IPDE, despite the limitations of the methods. Surgical thromboembolectomy showed a nonsignificant trend toward improved survival and significantly reduced systemic embolism and composite of mortality and systemic embolism, compared with anticoagulation alone. Thrombolysis, on the other hand, had the opposite effect, although not to a significant level.
Acknowledgments
Author contributions: Dr Myers: contributed to designing the study, performing literature searches, collecting and analyzing the data, and drafting the manuscript.
Dr Bounameaux: contributed to designing the study, critically reviewing the manuscript, and approving the final draft.
Dr Panos: contributed to designing the study, performing literature searches, critically reviewing the manuscript, and approving the final draft.
Dr Lerch: contributed to designing the study, critically reviewing the
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