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Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Sera et al.)

The foramen ovale serves as an opening between the right and left atria at the site of the fossa ovalis in the fetus during uterine life. During fetal life, it makes it possible for venous blood from the maternal placenta with oxygen and nutrients to bypass the immature fetal lung and get transported to the left side of the heart and onto the systemic circulation. This hole from the right to the left atrium is usually occluded at the time of birth or shortly after birth, due to increased pressures in the left-sided cardiac cavities associated with normal breathing during delivery or shortly afterwards. If the foramen ovale remains open and fails to fuse beyond the first year of life, it is known as a patent foramen ovale (PFO). PFO occurs when, during fetal life, the septum primum and secundum, which develop and overlap normally, fail to fuse at birth. This results in the persistence of communication between the right and left atria. Paradoxical embolism from the right to the left side of the heart can occur through a PFO, causing a cryptogenic stroke or embolic stroke of an undetermined source in an otherwise healthy adult. There was a debate on the long-term benefits of closure. However, data from the randomized evaluation of the recurrent stroke comparing PFO closure to established current standard of care treatment (RESPECT) trial and two randomized trials (patent foramen ovale closure or anticoagulants versus antiplatelet therapy to prevent stroke recurrence (CLOSE) and reduction by dutasteride of prostate cancer events (REDUCE)) have clarified that there is a benefit to closure. In this case report, we describe a patient who presented with cryptogenic stroke, the investigations, imaging modalities for diagnosis of PFO, and procedure for closure. We also describe long-term outcomes and management following closure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Ukponmwan et al.)

Eales disease is an idiopathic retinal vasculitis that mainly affects the periphery of the retina. The disease commonly manifests as peripheral retinal perivasculitis, peripheral retinal capillary nonperfusion, neovascularization, and recurrent vitreous hemorrhage. Here, we present the case of a 36-year-old male who was diagnosed with Eales disease after presenting with sudden onset flashes of light, reduced visual acuity, and a black spot in his left eye. Upon examination, his left eye exhibited a superior non-foveal branch retinal artery occlusion (BRAO) with a sludged blood column, an old extramacular branch retinal vein occlusion (BRVO) with hemorrhage, and vascular sheathing. Initial laboratory investigations, including antibody testing for causes of retinal ischemia and stroke workup, were negative. Later, the patient presented with a BRAO in the right eye and a cerebral infarction shortly thereafter, further complicating his clinical picture. A diagnosis of Eales disease was made based on the evolution of retinal findings showing peripheral non-perfusion, vascular sheathing, collateral formation, neovascularization with leakage, absence of additional BRAOs following repair of his patent foramen ovale, and lack of other explanatory conditions. The initiation of systemic corticosteroids resulted in the improvement and stabilization of his vision. This case highlights the challenges in diagnosing Eales disease, underscoring the importance of timely identification for the appropriate management and prevention of vision loss., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Horvath et al.)

Patent foramen ovale (PFO) is a congenital heart anomaly with persistent non-closure of the atrial septum that generally closes six to 12 months after birth in the majority of adults. While remaining asymptomatic in the majority of cases, PFO could lead to paradoxical embolism and cryptogenic strokes in most symptomatic cases. The incidence of small arterial occlusion due to paradoxical emboli is quite uncommon. In this report, we present a case of a 51-year-old man who presented with acute left-sided painless visual loss due to central retinal artery occlusion (CRAO). Stroke work-up and hypercoagulability evaluations were negative. The patient was found to have PFO with the initial presentation as CRAO, a rather rare presentation in the setting of PFO. In this report also, we discuss the clinical presentation, pathogenesis, and the current evidence-based therapeutic options in the management of PFO in adults, highlighting the importance of considering this diagnostic entity in the setting of acute visual loss, as with our case presentation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kaliounji et al.)

A 48-year-old man visited our emergency room after experiencing sudden left back pain, diaphoresis, and nausea. The patient underwent physical and laboratory examinations. Physical examination revealed tenderness in the left costovertebral angle. Laboratory examination revealed a slight elevation in D-dimer levels. Contrast-enhanced computed tomography revealed a bilateral pulmonary embolism and left renal infarction. Back pain was resolved following anticoagulation therapy with heparin. Transesophageal echocardiography revealed a patent foramen ovale (PFO). The patient was discharged on an anticoagulant, apixaban. Identifying the cause of paradoxical embolisms, such as an atrial septal defect or PFO, in cases with an arterial embolism in a young patient with no underlying disease is important., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Iizuka et al.)

In this report, we present an incidental finding of a rare combination of an Aberrant Right Subclavian Artery (ARSA), or arteria lusoria, with right-sided aortic arch and atrial septal defect associated with extensive thrombosis and paradoxical embolism causing acute stroke in an octogenarian woman with COPD presenting with acute hypercapnic respiratory failure. We also discuss the various surgical approaches for management and conservative treatment alternatives in non-surgical candidates (as in this case). We believe that this is the first reported case of these combined rare anomalies in an asymptomatic patient to the best of our knowledge., Competing Interests: I own the Publication and Licensing Rights for Figure 2 (Illustration) included in this Case Report., (Copyright © 2022, Gupta et al.)

The presence of myocardial injury in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection is common. The cardiac complications of SARS-CoV2 infection are varied and distinguishing between them can be complicated.  A 55-year-old man with recent diagnosis of SARS-CoV2 infection presented with chest pain, syncope, and was found to have saddle pulmonary embolism (PE). Marked elevation in cardiac enzymes prompted a coronary angiogram which was normal. Cardiac MRI revealed late gadolinium enhancement (LGE) in the anterolateral wall consistent with myocardial infarction (MI). He was diagnosed with paradoxical embolism causing MI. The differential for elevated cardiac enzymes is wide in patients with SARS-CoV2 infection. This case illustrates that sometimes multiple diagnoses exist, and that a high index of suspicion is required to continue work-up., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Yu et al.)

Controversies exist regarding the treatment of acute massive pulmonary embolism (PE) with anticoagulation alone or with thrombolytic therapy. Paradoxical embolism in the presence of a patent foramen ovale (PFO) is a rare but well-known entity and should always be looked for in case of a PE associated with systemic thromboembolism. We report a case of acute sub-massive PE treated with thrombolytic therapy in an elderly gentleman who had a paradoxical embolism and ischemic stroke as a result of a clot traversing through a PFO. We discussed diagnostic modalities, treatment of choice, and associated controversies in management., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Konala et al.)

We report a case of a 43-year-old African American female patient with otherwise stable sickle cell disease (SCD) in which use of megestrol acetate for appetite stimulation quickly potentiated her prothrombotic state within just a few days. This resulted in infarcts involving the bilateral cerebral hemispheres suggestive of embolic infarcts and the patient was subsequently confirmed to have a patent foramen ovale (PFO). A widespread literature search in PubMed revealed that this is a rare case in the literature and that the effects of megestrol acetate use in patients with SCD have not been well studied. Future research should focus on the risks of initiating megestrol acetate therapy to develop an advanced risk assessment algorithm in patients with SCD as the risk of thromboembolism may far outweigh the potential benefits., Competing Interests: The authors have declared that no competing interests exist.

This report describes a case of aortic valve endocarditis with systemic and paradoxical pulmonary embolism in a patient with congenital interventricular communication. The patient underwent cardiac surgery and did not have a favorable outcome, presenting refractory cardiogenic shock and subsequently dying while in the hospital. This is an extremely rare case of paradoxical embolism in a patient with infective endocarditis; only four similar cases have been reported in the literature., Competing Interests: The authors have declared that no competing interests exist.