Recommended Citation
Paolella G, Bentsen C, Kalapurakal G, et al. Closing the Hole Before Clearing the Clot: A Staged Approach to PE with Large PFO. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Introduction/Background:
Management of intermediate- to high-risk pulmonary embolism (PE) is complex when intracardiac shunting is present. A patent foramen ovale (PFO) increases the risk of paradoxical embolization and complicates decisions regarding thrombolysis, thrombectomy, and timing of definitive intervention. Limited guidance exists on optimal sequencing of therapies in patients with recurrent PE, right ventricular (RV) strain, and suspected malignancy. We present a case highlighting multidisciplinary management of submassive PE with large PFO requiring staged intervention.
Description:
A 65-year-old female with hypertension, chronic kidney disease, heart failure with preserved ejection fraction, and obesity presented with progressive dyspnea and presyncope. Imaging demonstrated a large saddle PE with RV strain and hypoxemic respiratory failure. Echocardiography revealed RV dilation, reduced systolic function, and atrial-level shunting consistent with PFO. She underwent catheter-directed thrombolysis with temporary clinical improvement and was discharged on anticoagulation. She re-presented within 24 hours with hypotension, persistent RV dysfunction, and residual bilateral PE despite a decreased clot burden. Given the large right-to-left shunt and concern for systemic embolization, a multidisciplinary team pursued staged intervention with percutaneous PFO closure followed by mechanical pulmonary thrombectomy, resulting in improved pulmonary pressures, oxygenation, and hemodynamic stability. Concurrent imaging revealed peritoneal carcinomatosis with markedly elevated CA-125, suspicious for advanced gynecologic malignancy. She was discharged stable on direct oral anticoagulation with plans for oncologic evaluation and neoadjuvant therapy.
Discussion:
This case illustrates the therapeutic challenge of managing submassive PE in the presence of a large PFO and suspected malignancy. Intracardiac shunting alters risk-benefit considerations for thrombolysis and thrombectomy due to potential paradoxical embolization. A staged strategy of PFO closure followed by thrombectomy enabled definitive clot removal while mitigating embolic risk and stabilizing RV function. Multidisciplinary coordination among cardiology, critical care, and oncology was essential. Further study is needed to clarify optimal sequencing of structural and pulmonary vascular interventions in similar high-risk patients.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Poster
Open Access
Available to all.
Closing the Hole Before Clearing the Clot: A Staged Approach to PE with Large PFO
Introduction/Background:
Management of intermediate- to high-risk pulmonary embolism (PE) is complex when intracardiac shunting is present. A patent foramen ovale (PFO) increases the risk of paradoxical embolization and complicates decisions regarding thrombolysis, thrombectomy, and timing of definitive intervention. Limited guidance exists on optimal sequencing of therapies in patients with recurrent PE, right ventricular (RV) strain, and suspected malignancy. We present a case highlighting multidisciplinary management of submassive PE with large PFO requiring staged intervention.
Description:
A 65-year-old female with hypertension, chronic kidney disease, heart failure with preserved ejection fraction, and obesity presented with progressive dyspnea and presyncope. Imaging demonstrated a large saddle PE with RV strain and hypoxemic respiratory failure. Echocardiography revealed RV dilation, reduced systolic function, and atrial-level shunting consistent with PFO. She underwent catheter-directed thrombolysis with temporary clinical improvement and was discharged on anticoagulation. She re-presented within 24 hours with hypotension, persistent RV dysfunction, and residual bilateral PE despite a decreased clot burden. Given the large right-to-left shunt and concern for systemic embolization, a multidisciplinary team pursued staged intervention with percutaneous PFO closure followed by mechanical pulmonary thrombectomy, resulting in improved pulmonary pressures, oxygenation, and hemodynamic stability. Concurrent imaging revealed peritoneal carcinomatosis with markedly elevated CA-125, suspicious for advanced gynecologic malignancy. She was discharged stable on direct oral anticoagulation with plans for oncologic evaluation and neoadjuvant therapy.
Discussion:
This case illustrates the therapeutic challenge of managing submassive PE in the presence of a large PFO and suspected malignancy. Intracardiac shunting alters risk-benefit considerations for thrombolysis and thrombectomy due to potential paradoxical embolization. A staged strategy of PFO closure followed by thrombectomy enabled definitive clot removal while mitigating embolic risk and stabilizing RV function. Multidisciplinary coordination among cardiology, critical care, and oncology was essential. Further study is needed to clarify optimal sequencing of structural and pulmonary vascular interventions in similar high-risk patients.
Affiliations
Advocate Lutheran General Hospital