venous thromboembolism ( vte ) occurs to be one of the most serious complications after undergoing total joint arthroplasty.1 ) generally , pulmonary thromboembolism is generated as the secondary by - product from deep vein thrombosis ( dvt ) while its emergence may possibly trigger the chronic thromboembolic pulmonary hypertension as well as post - thrombotic syndrome.2 ) patent foramen ovale ( pfo ) , a residue of fetal circulation , is found approximately about 25 - 30% among adults ; and , it is also known that thrombus from the venous circulation rarely causes arterial thromboembolism through right - to - left shunt.3 ) in this case , the authors experienced a patient with pfo and several thrombotic disease such as pulmonary thromboembolism , dvt , and right atrial thrombus along with cryptogenic ischemic stroke after total knee arthroplasty ( tka ) .
a 64-year - old female presented to the emergency room for the shortness of breath .
she had been taking antiplatelet drugs ( aspirin 100 mg / day , clopidogrel 75 mg / day ) for the treatment of the right posterior temporal lobe infarction detected in brain magnetic resonance imaging for the disorientation on the third day after the operation ( fig .
1 ) . carotid and brain computed tomography ( ct ) angiography showed no evidence of atherosclerosis .
afterwards , she experienced dyspnea in the second week after the operation and was performed the transthoracic echocardiography ( tte ) , which showed right atrial thrombi and was treated with the low molecular weight heparin ( lmwh ) .
the symptoms , nonetheless , remained so that she had been transferred to our hospital . in the medical history
her blood pressure was 127/79 mm hg while her heart rate was 89 bpm . on physical , pitting edema in her left lower leg was noted and neurologic examination was unremarkable . the chest x - rays did not show any signs of cardiomegaly as well as pulmonary edema .
both d - dimer and n - terminal pro - brain natriuretic peptide were increased respectively at 2686 ng / ml , and 3310 pg / ml and on the other hand , cardiac enzymes , such as creatinine kinase - mb and troponin - i were within a normal range .
tte demonstrated normal left ventricular systolic function ( ejection fraction of 63% ) , but in the right atrium two highly mobile masses ( 1.67  2.18 cm , 0.69  0.80 cm ) suggesting possible thrombi were observed .
the echocardiogram also revealed right atrium and right ventricle enlargement , severe pulmonary hypertension ( pulmonary artery systolic pressure 102 mm hg ) , and d - shaped left ventricle ( fig .
her chest ct showed that pulmonary thromboembolism was found in both main pulmonary arteries while dvt was observed in left femoral vein ( fig .
holter ecg did not reveal arrhythmia except rare atrial premature complex and ventricle premature complex .
the patient was administered to warfarin ( target inr 2 - 3 ) after using lmwh . in follow - up
tte 3 weeks later , the two previous thrombi in right atrium ( ra ) disappeared .
along with the improvement in ra , there was also a positive change on the extent of pulmonary hypertension .
the follow up ct taken 4 weeks after the hospitalization did not reveal pulmonary thromboembolism and dvt ( fig .
3 ) . since the cause of the cerebral infarction was unclear , additional evaluation were needed . in order to examine the intracardiac shunt ,
the results confirmed the transference of microbubble from right atrium to left atrium without showing atrial septal defect ; and therefore , we diagnosed the patient with pfo ( fig .
currently , the patient is taking warfarin continuously without any signs of abnormalities in outpatient clinic .
we recommended further treatment for pfo including device closure but patient refused because of poor general condition .
as vte is one of the fatal complications after undergoing tka , dvt , and pulmonary embolism ( pe ) are known to occur approximately around 13% and 3% , respectively.4 ) the occurrence period of vte after tka is reported to be 3 to 9 days after the operatio5 ) and , there are mostly cases that accompany dvt and pe and occasionally thrombi observed on several organs .
particularly , it was reported that the patients with pfo even might develop arterial thromboembolism with cryptogenic stroke.3)6 ) in the present case , the authors suspected that cryptogenic stroke 3 days after the operation might possibly have been caused by the vte changed into arterial thromboembolism through pfo .
pfo , one of the congenital heart diseases that can be observed even in adulthood , typically have no symptom .
nonetheless , it can affect as the risk factor for several conditions including ischemic stroke , platypnea - orthodeoxia syndrome , and decompression sickness.7 ) pfo as the cause of cryptogenic stroke is not uncommon ; hence , the occurrence of ischemic stroke with either pe or dvt can be considered as the possible example of paradoxical embolism through right - to - left shunt.8 ) among the treatments on the prevention of frequent strokes within a patient who has pfo , there are medical options and invasive methods.9 ) the medical options include the use of antiplatelet agents as well as the prescription of warfarin in the patients with hypercoagulable state or venous thrombosis . in terms of invasive methods ,
it was used to have an operation in the past while the application of device closure is being used recently.10 ) in this case , cryptogenic stroke took place within 3 days after tka while right atrial thrombus , dvt , and pe were present in a way that the passage through right to left shunt was speculated and the result of subsequent echocardiography led to the diagnosis of a positive reaction from the agitated saline test for pfo .
the patient was treated with lmwh and then administered warfarin ; and the patient discharged with the recovered conditions . in conclusion , the occurrence of pulmonary thromboembolism or dvt in a patient with pfo can trigger the development of cryptogenic stroke through right to left shunt . therefore ,
further evaluation of cause are essential in patients with the occurrence of cryptogenic stroke who are associated with a high risk of vte after total joint arthroplasty .
also , anticoagulation treatment is necessary if a patient has a right to left shunt , such as pfo .
 patients undergoing total joint arthroplasty frequently develop post - operative complication , such as deep vein thrombosis and pulmonary thromboembolism . 
 however , it is not common coexisting deep vein thrombosis , pulmonary thromboembolisms , right atrial thrombus and acute cerebral infarction raised by thrombus through patent foramen ovale . 
 we reported the patient who had multiple thrombi which were accompanied with a cryptogenic ischemic stroke and associated with patent foramen ovale after operation . 
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