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Editor's Correspondence
August 10/24, 1998

Impending Paradoxical Embolism

Arch Intern Med. 1998;158(15):1720. doi:

In reply

I appreciate Cheng's kind letter regarding our article.1 The primary purpose of our case report and review article was to describe cases of impending paradoxical embolus in which the diagnosis was made prior to death, and to describe a rational diagnostic and treatment approach. Using MEDLINE, we also reported cases of impending paradoxical embolus in which the diagnosis was made at autopsy; however, as Cheng points out, we missed some cases of impending paradoxical embolus in which the diagnosis was made at autopsy.2 I feel that it is important for investigators to be aware of these additional autopsy-proven cases of impending paradoxical embolus. Moreover, Cheng correctly points out that transcatheter closure of the patent foramen ovale or atrial septal defect in patients with a paradoxical embolism is a treatment option. Although this point is mentioned in our review article, it remains a topic of controversy, and we feel that transcatheter closure of the patent foramen ovale or atrial septal defect should only be attempted in institutions with considerable experience with this technique. Currently, surgical closure of the patent foramen ovale or atrial septal defect is the most widely used technique. Surgical embolectomy with closure of a patent foramen ovale or atrial septal defect appears to be the best treatment option for patients with an impending paradoxical embolism.

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