Impending paradoxical embolism through a patent foramen ovale in an octogenarian with pulmonary embolism: detection by transesophageal echocardiography and successful treatment by anticoagulation

Paradoxical embolism through a patent foramen ovale (PFO), an increasingly recognized cause of cryptogenic stroke and peripheral embolism, is believed to play little role in the elderly, mainly based on retrospective studies on selected populations. Paradoxical embolism is mostly a presumptive diagnosis, while definite demonstration of a thrombus crossing a PFO is rare. We describe the case of an 84-year-old patient with pulmonary embolism in whom a thrombus in transit through a PFO was found by transesophageal echocardiography (TEE). Treatment with anticoagulants allowed thrombus resolution without evidence of further embolic events. This finding demonstrates that (impending) paradoxical embolism may be present in the `oldest oldʹ. Its prompt diagnosis may allow effective treatment even with medical therapy alone. We suggest that paradoxical embolism may be not so rare in the elderly. The apparent decline in prevalence with age may be the result of less extensive diagnostic assessment in the elderly, as compared to younger patients.