Iatrogenic paradoxical air embolism in pulmonary hypertension

Paradoxical systemic air embolism (PAE) occurring as a complication of right-to-left intracardiac shunting during evaluation and treatment of pulmonary hypertension (PH) has not been previously reported. We report four cases of PH-associated PAE recently encountered at our center. Two patients with PH experienced transient neurologic deficits during agitated-saline contrast echocardiography (ASCE), and a patent foramen ovale was subsequently diagnosed in both patients. Two patients with Eisenmenger's syndrome (ES), while receiving epoprostenol via multilumen catheters, experienced transient neurologic deficits while flushing the unused port of the catheter. No patient experienced permanent neurologic deficits. We conclude that ASCE poses a risk for PAE in patients with PH and clinically silent, previously undetected, right-to-left intracardiac shunts, and that multilumen catheters used for long-term epoprostenol therapy in ES carry a risk of PAE.