矛盾栓塞是指体循环静脉系统或右心的栓子通过开放的卵圆孔等不同水平的动静脉交通到达左心或体循环动脉系统造成的栓塞，此概念于1877年由德国病理学家Julius Cohnheim首次提出。在动脉栓塞性疾病中，矛盾栓塞约占到2-16%。矛盾栓塞患者可表现为肺循环栓塞或体循环栓塞，由于临床表现多样，漏诊率较高。

本研究总结了过去10余年间在北京医院发生的4例矛盾栓塞患者临床特点。4例患者均为男性。病例1在治疗脑梗塞期间出现上消化道出血，抗凝治疗存在禁忌。入院后，发现深静脉血栓形成，后发生急性肺动脉栓塞，继而多脏器发生动脉栓塞梗死。超声心动提示心房水平存在异常血流通道，因溶栓、介入、手术取栓均存在禁忌，止血与抗凝治疗相矛盾。经改善通气、严密观察下的肝素抗凝治疗，稳定了生命体征。病例2因脑梗塞、一侧肢体偏瘫入院，在行康复锻炼中突发急性肺动脉栓塞，超声心动提示卵圆孔两侧骑跨血栓形成，经开胸行肺动脉血栓及心房血栓清除和抗凝治疗，患者恢复。病例3因骨折入院，预行手术时，突发急性肺动脉栓塞，超声心动提示心房内血栓形成、卵圆孔开放，行溶栓、抗凝、机械通气治疗，恢复良好。病例4因气短来诊，急诊行超声心动提示卵圆孔未闭，卵圆孔两侧骑跨血栓，肺通气灌注显象证实为肺动脉栓塞，临床给予抗凝治疗，但患者拒绝取栓手术，自行离院。

4例患者均有明确肺动脉栓塞征象，超声心动证实存在卵圆孔未闭。其中2例虽无明确体循环栓塞证据，但是超声心动可见卵圆孔开放，存在右向左分流，卵圆孔周围有血栓形成。患者均经历了抗凝治疗，2例患者还经历了机械通气治疗。急性肺动脉栓塞死亡风险高，再合并体循环栓塞和脏器梗死，治疗难度很大。本研究对4例矛盾栓塞患者临床特点进行分析，有助于加强对矛盾栓塞的认识，提高诊治水平。

Paradoxical embolism (PDE) refers to the embolism caused by the embolus of the systemic venous system or the right heart reaching the left cardiac or systemic arterial system through various levels of arterial and venous traffic. This concept was first proposed by the German pathologist Julius Cohnheim in 1877. In arterial embolism, PDE accounts for about 2-16%. Patent foramen ovale (PFO) is the most common cause in patients with PDE. PDE Patients may present as pulmonary circulatory embolism or systemic circulatory embolism because the presentation could be diversity. Strengthen of awareness of PDE is helpful to make the clinical strategy for stoke patients caused by PDE.

The present study summarized the clinical characteristics of 4 PDE patients in Beijing Hospital in the past 15 years. All 4 patients were male. Case 1 presented upper gastrointestinal bleeding during the treatment of cerebral infarction. Anticoagulation therapy was contraindicated. After admission, deep vein thrombosis was found, which lead to acute pulmonary embolism (PE). After then, several visceral arterial embolisms occurred. Echocardiography indicated PFO. Consideration of contraindication of intervention and thrombolysis and contradiction of bleeding and anticoagulation, non-invasive ventilation and half dose of heparin was prescribed to stabilize the vital sign. Case 2 was admitted to hospital because of cerebral infarction. During admission, acute PE occurred in the course of rehabilitation exercise. Echocardiography indicated traversing thrombus on both sides of the oval hole. The patient underwent pulmonary arterial thromboectomy and anticoagulation and symptom relieved. Case 3 was admitted to hospital because of bone fracture. During preoperative preparation, acute PE happened. PFO was found by echocardiography. Mechanical ventilation, thrombolysis and anticoagulation therapy were performed, and the patient finally recovered well. Case 4 presented to Emergency Department (ED) because of shortness of breath. In ED, echocardiography indicated thrombus rode across the disclosure foramen ovale. Pulmonary ventilation perfusion imaging confirmed PE. The patient refused thrombolysis and other invasive treatment and was discharged.

In the present study, 4 patients confirmed PE and PFO. However, there was no evidence of systemic circulatory embolism in last 2 cases. But, echocardiography showed the opening PFO with right-to-left shunt and thrombus around the foramen ovale. All patients underwent anticoagulation, while 2 patients underwent non-invasive ventilation. If acute PE occurred, the mortality will increase. Complication with systemic circulatory embolism and visceral infarction, treatment would be more difficult. In this study, the clinical data of 4 PDE patients were analyzed. It is aimed to strengthen the understanding of PDE and improve the diagnostic and therapeutic level for PDE patients.