Hypoxemia secondary to right-to-left interatrial shunt through a patent foramen ovale in a patient with an elevated right hemidiaphragm

Though uncommon, right-to-left shunt through a patent foramen ovale with normal right-side pressure and with a normal interatrial pressure gradient has been reported. The speculated pathophysiology is attributed to directional blood flow streaming from the vena cava to the left atrium. Hypoxemia secondary to right-to-left shunt with normal pulmonary artery pressure has been extensively documented after right pneumonectomy. Five prior cases have documented hypoxemia secondary to a right-to-left shunt through a patent foramen ovale in the presence of an elevated right hemidiaphragm. This is the sixth documented case of right-to-left shunt through a patent foramen ovale in the presence of an elevated right hemidiaphragm with a similar presentation in which closure of the patent foramen ovale resulted in resolution of hypoxemia.     

Cryptogenic stroke and patent foramen ovale

A stroke of unknown etiology is commonly referred to as cryptogenic and is diagnosed in a considerable patient population of especially young age. Numerous case-control studies revealed a strong and consistent association between cryptogenic stroke and the presence of a patent foramen ovale. This relationship corroborates paradoxical embolism as likely stroke mechanism in this patient population. In approximately twenty-five percent of patients with cryptogenic stroke, the patent foramen ovale is accompanied by an atrial septal aneurysm, which considerably heightens the risk for recurrent neurological events. Therapeutic measures for secondary prevention in this patient population encompass medical treatment with antiplatelet agents or anticoagulants and surgical or percutaneous closure of patent foramen ovale. Currently, randomised clinical studies compare medical treatment with closure of patent foramen ovale to determine the most effective treatment strategy in this patient population.     

右心声学造影检查对卵圆孔未闭导致偏头痛的诊断价值

目的 探讨右心声学造影检查对卵圆孔未闭导致偏头痛的诊断价值。方法 选取2018年5月至2020年8月我院收治的120例不明原因偏头痛患者作为研究对象,所有患者实施经颅多普勒超声检查、右心声学造影检查。以数字减影血管造影（DSA）检查结果为参照,比较经颅多普勒超声检查与右心声学造影检查对卵圆孔未闭的诊断效能及对卵圆孔未闭量化分级的诊断符合率。结果 参照DSA检查结果,右心声学造影检查诊断卵圆孔未闭的灵敏度、特异度、准确度、阳性预测值、阴性预测值均高于经颅多普勒超声检查（P<0.05）。经颅多普勒超声检查诊断卵圆孔未闭的结果与DSA检查结果之间具有中度一致性,而右心声学造影检查结果与DSA检查结果之间具有高度一致性。右心声学造影检查对卵圆孔未闭Ⅰ、Ⅱ、Ⅲ级的诊断符合率均高于经颅多普勒超声检查（P<0.05）。结论 右心声学造影检查可更为灵敏、准确地检出卵圆孔未闭,在卵圆孔未闭所致偏头痛患者中具有良好的诊断价值。     

Transient Sulcal Hyperintensities on Fluid‐Attenuated Inversion Recovery in Migraine With Aura

Migraine has been found to be associated with patent foramen ovale. However, in practice, it is difficult to show that microemboli via patent foramen ovale can induce a migraine attack. Our patient showed transient sulcal hyperintensities on fluid‐attenuated inversion recovery images during a migraine attack. This supports the hypothesis that microemboli via right‐to‐left shunt may induce migraine attacks through transient occlusion of microcirculation.     

Transcatheter closure for decompression sickness with a patent foramen ovale: A case report

A patent foramen ovale is one of the predisposing factors of neurotic decompression sickness. Transcatheter closure of a patent foramen ovale is effective in the secondary prevention of decompression sickness associated with intracardiac shunt. The size of the umbrella should not be limited to the diagnosis of a patent foramen ovale or an atrial septal defect but should be determined by the supporting force of the soft margin of the atrial septum. The surgical method of patent foramen ovale closure is the same as that of the closure of an atrial septal defect, but the closure umbrella of a patent foramen ovale is different from that of the closure umbrella of an atrial septal defect. The size of the umbrella of the right atrium is larger than that of the left atrium, and it is better to close the atrial septum.     

Valsalva maneuver as migraine inducer: a case report of a woman with patent foramen ovale and an ischemic stroke

The association between patent foramen ovale, ischemic stroke, and migraine with aura is well known. It is, however, complicated and generates a considerable debate about the features and clinical consequences of the phenomenon. We report a case of a woman for whom patent foramen ovale has possibly acted as an inducer of both migraine attacks and ischemic stroke.     

Editorial

Right-to-left shunt through a patent foramen ovale was searched for in 80 patients with acute ischemic stroke by simultaneously performing transthoracic two-dimensional echocardiography and transcranial Doppler during agitated saline injection. A patent foramen ovale was detected by echocardiography in 14 patients (17.5%). Transcranial Doppler correctly identified all 14 patients, and 7 more patients in whom echocardiographic findings were indeterminate. Prevalence of patent foramen ovale by transcranial Doppler was therefore 26.3% (21 of 80 patients). Concordance between the two tests was 91.3% (73 of 80 patients). The delivery of contrast material to cerebral vessels is therefore demonstrable by transcranial Doppler in all patients diagnosed by contrast echocardiography, suggesting that paradoxical embolization through a patent foramen ovale may be more frequent than previously thought. Transcranial Doppler with contrast injection is a valid alternative in case of poor echocardiographic image quality.     

生物可降解封堵器研究进展

介入封堵手术已成为房间隔缺损、室间隔缺损、卵圆孔未闭等先天性心脏病的首选治疗方法.既往介入封堵术中植入的封堵器多为镍钛合金封堵器,易诱发传导阻滞等多种术后并发症.生物可降解封堵器可有效避免镍钛合金封堵器的缺点,目前对其的研究多处于动物试验或临床试验阶段.本文就生物可降解封堵器在房间隔缺损、室间隔缺损、卵圆孔未闭中应用的...     

Successful aortic root replacement and shunt closure in a case with rare coexistence of congenital cardiac malformations: bicuspid aortic valve with annuloaortic ectasia,single coronary artery,and patent foramen ovale

This is the first report of rare simultaneous complication of three cardiac malformations: bicuspid aortic valve with annuloaortic ectasia, single coronary artery, and patent foramen ovale. We successfully operated to replace the aortic valve and ascending aorta, and to close the patent foramen ovale.     

Patent foramen ovale presenting as platypnea-orthodeoxia: diagnosis by transesophageal echocardiography.

Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale or atrial septal defect. We describe the case of a 65-year-old woman with progressive dyspnea and hypoxia when standing and walking, which was relieved by assuming the recumbent position. The diagnosis was confirmed by tilt-table transesophageal echocardiography demonstrating a large right-to-left shunt through a patent foramen ovale while the patient was in a semiupright position and no significant shunt while in a recumbent position. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be clearly demonstrated by the technique of contrast transesophageal echocardiography performed on a tilt table.     

Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVES: To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN: Case report. SETTING: Intensive care unit of a university hospital. PATIENT: A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION: Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS: Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.     

Vascular air embolism during percutaneous nephrolithotomy without pneumopyelogram: a case report of successful rescue

Vascular air embolism (VAE) is a rare complication of percutaneous nephrolithotomy. Paradoxical air embolization resulting from VAE may be more likely to occur in patients with an atrial-septal defect, such as patent foramen ovale. Here, the case of a female patient with VAE that occurred during percutaneous nephrolithotomy is presented. Although the patient was diagnosed with patent foramen ovale, she recovered well without any severe paradoxical air embolization symptoms. To our knowledge, this is the first report of VAE with paradoxical air embolization that occurred in a patient with patent foramen ovale during percutaneous nephrolithotomy that was conducted without pneumopyelography.     

Paradoxical embolism-report of a case involving four organ systems

Paradoxical embolism through a patent foramen ovale (PFO) can involve multiple organs simultaneously. The most commonly involved sites are the cerebrum and the extremities. Paradoxical embolism to coronary arteries or upper extremities is relatively uncommon. We report a case of acute pulmonary embolism and paradoxical embolism through a patent foramen ovale involving the left upper extremity, brain, and coronary artery. Early diagnosis in the emergency department was made by a trans-esophageal echocardiogram, and the patient was successfully treated with intravenous t-PA and heparin. Patients with acute pulmonary embolism or deep venous thrombosis who also develop signs of systemic embolism should be evaluated for a patent foramen ovale.     

Impending Paradoxical Embolism: A Case Report

Background

A thrombus straddling a patent foramen ovale (i.e., impending paradoxical embolism) is a very rare event. Most cases have been reported at autopsy only after finding a patent foramen ovale and arterial emboli. Patent foramen ovale in the population is common.

Objectives

The objective of this case report is to remind physicians that common presentations can have uncommon causes. Some of these uncommon causes are easy to find and may significantly change outcomes if treated early.

Case Report

We present the case of a dyspneic patient with concomitant pulmonary embolism, deep vein thrombosis, and impending paradoxical embolism. Emergency Physicians should be aware that dyspnea may be the only initial symptom. Although dyspnea may be linked to a pulmonary embolus, it may not represent the entire clinical picture. A thrombus formed within a patent foramen ovale portends the possibility of a larger pulmonary embolus and an arterial embolus.

Conclusion

Early detection of an impending paradoxical embolism may result in an improved outcome. Treatment choices consist of anticoagulation, thrombectomy, or thrombolysis. Choice of treatment is difficult but should be made quickly to reduce the possibility of adverse patient outcomes.     

P选择素联合右心声学造影诊断偏头痛合并卵圆孔未闭患者的价值

  目的  分析P选择素联合右心声学造影（cTTE）诊断偏头痛合并卵圆孔未闭患者的价值。  方法  选取2019年4月~2021年4月我院收治的64例偏头痛患者，根据是否并发卵圆孔未闭分为发生组47例，未发生组17例，比较所有患者血清中的P选择素水平，并进行右心声学造影检查，比较不同检查方法的诊断准确率。  结果  并发卵圆孔未闭患者P选择素水平明显高于未发卵圆孔未闭患者，差异有统计学意义（P < 0.05）；以术中封堵为金标准，P选择素诊断偏头痛合并卵圆孔未闭的敏感度为68.09%、特异性为82.35%、阳性预测值为91.43%、阴性预测值为48.28%、诊断符合率为71.88%，一致性为0.412；以术中封堵为金标准，P选择素联合cTTE诊断偏头痛合并卵圆孔未闭的敏感度为82.98%、特异性为88.24%、阳性预测值为95.12%、阴性预测值为65.22%、诊断符合率为84.38%，一致性为0.640。  结论  P选择素联合右心声学造影有利于提高偏头痛合并卵圆孔未闭患者的诊断准确率，在临床上有一定的应用价值。      

Patent foramen ovale as lifesaving purging valve.

Patent foramen ovale is considered as a potential risk factor for stroke owing to paradoxic embolism, leading to the question "to close or not to close the patent foramen ovale". We report a 26-year-old woman with chest pain, dyspnoea, sudden severe pain in both legs and paraplegia. Thoracic and abdominal computed tomography revealed massive pulmonary embolism and complete obstruction of the abdominal aorta. Interventional removal of the aortic thrombus was undertaken using the Fogarty catheter technique via the femoral arterial approach. As a result of worsening of cardiopulmonary function during the procedure, additional local thrombolysis, with a total of 50 mg recombinant tissue plasminogen activator, and fragmentation of the thrombus in the right pulmonary artery were performed via a femoral vein approach. Ultrasound studies revealed a patent foramen ovale of about 12 mm diameter with a significant right to left shunt. Under favourable conditions, a patent foramen ovale may allow the escape of a thrombus, sufficient to cause a potentially fatal pulmonary embolism, into the arterial system, where it can be removed by interventional manoeuvres.     

封堵卵圆孔未闭预防卒中的国外发展及中国现状

经过近20年的争议和大量研究,封堵卵圆孔未闭(patent foramen ovale,PFO)在卒中二级预防中的作用已经明确.本文从循证医学证据入手,回顾近年来国内外经导管封堵PFO预防卒中的研究成果,旨在明确能从封堵治疗中获益的PFO人群.     

Sildenafil to facilitate weaning from inhaled nitric oxide and mechanical ventilation in a patient with severe secondary pulmonary hypertension and a patent foramen ovale

We describe the case of a woman who presented to the intensive care unit with acute respiratory failure that required mechanical ventilation. She had severe pulmonary hypertension secondary to interstitial lung disease, and her history included sarcoidosis and tuberculosis. She was dependent on inhaled nitric oxide (INO) to maintain safe arterial oxygen saturation and could not be weaned from mechanical ventilation. Echocardiography revealed a patent foramen ovale with substantial right-to-left shunt, which probably contributed to her hypoxemia. Sildenafil enabled weaning from INO and substantially reduced the flow through the patent foramen ovale. She was successfully extubated and discharged home. To our knowledge, this is the first report of weaning from INO and mechanical ventilation in a patient with both severe secondary pulmonary hypertension and a right-to-left shunt through a patent foramen ovale.     

The role of environment and epigenetics in hypertension

Patent foramen ovale has been suggested to be a risk factor for cryptogenic stroke by means of paradoxical embolism. The data, however, are complex, conflicting and largely unavailable. In this review, we attempt to summarize the existing data separately for the questions of whether patent foramen ovale is associated with cryptogenic stroke and whether it is a risk factor for a first ischemic stroke and for recurrent strokes. Treatment options will be discussed, and the different viewpoints from the two specialists mainly involved in the care of those complex patients (neurologists and cardiologists) will be provided.     

Recurrent transient ischemic attacks in a patient with intrapulmonary arteriovenous shunting detected after closure of a patent foramen ovale.

Paradoxical embolism through right-to-left shunts is widely accepted as a potential cause of cerebral ischemia. Contrast echocardiography is an excellent tool for detection of these shunts. The timing of the appearance of bubbles in the left atrium (ie, early vs late) allows differentiation of foramen ovale patency from intrapulmonary shunting as a result of arteriovenous malformations. We report a patient with recurrent neurologic deficit after surgical closure of a patent foramen ovale. Transesophageal echocardiography demonstrated residual right-to-left shunting from previously unrecognized pulmonary arteriovenous malformations associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu). This case illustrates the fact that contrast echocardiography may fail to identify intrapulmonary shunts when a resting patent foramen ovale coexists.