• François Bagate, Alexandre Bedet, Armand Mekontso Dessap, and Guillaume Carteaux.
• AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, F-94010, France; Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, F-94010, France. Electronic address: francois.bagate@aphp.fr.
• Am J Emerg Med. 2018 Aug 1; 36 (8): 1527.e1-1527.e2.

AbstractPatent foramen ovale is frequently observed in the general population. In case of massive pulmonary embolism, the sudden increase in the right heart cavity's pressure may cause a right-to-left shunting across this foramen, which could be associated with conflicting outcomes. Herein, we report a case of reversible cardiac arrest preceded by seizures, and followed by hemodynamic stability without any vasopressor. A brain CT-scan showed a limited ischemic stroke. Initial echocardiographic assessment revealed an acute cor pulmonale and a right-to-left intracardiac shunt across a large patent foramen ovale, suggesting the diagnosis of massive pulmonary embolism that was lately confirmed by a multidetector CT-angiography. Anticoagulation therapy was rapidly complicated by a hemorrhagic transformation of the ischemic stroke leading to a fatal outcome. This case illustrates the double-edged circulatory effect of shunting across a patent foramen ovale in case of massive pulmonary embolism: it may have limited circulatory failure but caused in the meanwhile a fatal paradoxical brain embolism.Copyright © 2018 Elsevier Inc. All rights reserved.

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