Cine angiographic diagnosis of patent foramen ovale in paradoxical embolism

A case of paradoxical embolism is presented in which the antemortem diagnosis was facilitated by a new simple angiographic technique that demonstrated a patent foramen ovale. An additional 14 patients were studied by this technique, and one had a patent foramen ovale. The mechanism of reversal of the normal intraatrial pressure gradient and subsequent right to left shunt through a patent foramen ovale is discussed. This angiographic technique may be readily applied in any diagnostic catheterization laboratory and complements existing methods for detecting patency of the foramen ovale in patients with suspected paradoxical embolism.     

Characteristics of the interatrial communication in patients undergoing transcatheter device closure of atrial septal defects for cryptogenic stroke

Background: Prior studies suggest that patent foramen ovale (PFO) diameter >4 mm is associated with a high probability of cryptogenic ischemic stroke (CIS). Methods: We evaluated all patients diagnosed with CIS who underwent closure of intra-atrial communication (IAC) using the Amplatzer atrial septal defect (ASD) occluder in our institution between August 1997 and March 2004. For each IAC, echocardiographic diameters and balloon-stretched diameters were recorded. Stretchability index was calculated as the ratio of stretched diameter to unstretched diameter. Results: Fifty-six patients met the inclusion criteria for this study. There was an inverse logarithmic relationship between unstretched IAC diameter and stretchability index. For the 28 smaller defects, the median IAC diameter was 2 mm, and median stretchability index was 5.58 (range 2.6–15). For the 28 larger defects, median diameter was 6 mm, and median stretchability index was 2.38 (range 1.05–5). The difference in stretchability index between the two groups was significant ( P < 0.0001). Conclusion: Our data bring into question the concept that the diameter of the defect would singularly predict the probability of stroke.     

Percutaneous PFO closure for the prevention of recurrent brain abscess.

A patent foramen ovale (PFO) can act as a conduit between the venous and arterial circulations, allowing right-to-left shunting and bypass of the pulmonary circulation. Brain abscess may develop as a result of paradoxical embolism of organisms through a PFO. In this small series, we report on the closure of PFO for the prevention of recurrent brain abscess. Only prospective, randomized trials comparing PFO closure to conservative therapy could provide a definitive answer as to the optimal strategy for preventing recurrent cerebral abscess.     

Calcified Plaques in Patients With Acute Coronary Syndromes

Objectives

This study conducted detailed analysis of calcified culprit plaques in patients with acute coronary syndromes (ACS).

Figulla PFO occluder versus Amplatzer PFO occluder for percutaneous closure of patent foramen ovale

Background : Percutaneous closure of patent foramen ovale (PFO) has been shown safe and feasible using several devices. The Occlutech Figulla single layer PFO Occluder (FPO) constitutes an alternative to the Amplatzer PFO Occluder (APFO). Objectives : We report our experience with both devices in a single‐center case–control study. Methods : Twenty patients undergoing percutaneous PFO closure using an FPO for secondary prevention of paradoxical embolism or diving were blindly matched with 20 patients receiving an APFO during the same time period. Contrast transesophageal echocardiography (TEE) was performed 6 months after device implantation to assess for residual shunting and device‐associated thrombus. Results : Patient baseline characteristics were well matched by study design. Procedural success was 95% with FPO vs. 100% for APFO (P = 1.0), with 3 (15%) peri‐procedural complications with FPO vs. none with APFO (P = 0.24). These comprised one asymptomatic device embolization in the descending aorta with percutaneous retrieval, one transient ischemic attacks, and one suspected device endocarditis. Contrast TEE at 6 months showed significantly more residual shunts in the FPO‐group (39% vs. 0%; P = 0.01). Two FPO patients with a moderate residual shunt underwent implantation of a second device (APFO 25 mm) vs. none in the APFO group (P = 0.48). No thrombi were observed in either group. During 1.7 ± 0.7 years of follow‐up, no death or recurrent embolic event occurred. Conclusions : According to this single‐center case–control study, PFO closure with the FPO appears less efficacious than with the APFO. © 2010 Wiley‐Liss, Inc.     

The Simultaneous Occurrence of Deep Vein Thrombosis and Pulmonary and Arterial Embolization

INTRODUCTION A 45-year-old female presented with 8 hours of right lower extremity pain and dyspnea. She was tachycardic and her right lower extremity was dusky, cold, and pulseless. DISCUSSION Computerized tomography of the venous and arterial systems revealed massive pulmonary embolism and right lower extremity arterial and left lower extremity venous thromboses. Management included intra-arterial thrombolytics, right lower extremity arterial embolectomy, and anticoagulation. Echocardiogram revealed a patent foramen ovale (PFO) with a right-to-left shunt. CONCLUSION We hypothesize that our patient developed deep venous thrombosis that led to major pulmonary embolization and increased right-sided pressures. In the setting of a patent foramen ovale, a later venous embolus transversed the PFO and lodged in the femoral artery. Our case illustrates the importance of a high index of suspicion for a paradoxical embolus in patients with arterial thrombosis. This abstract was presented at the meeting of the Southern Society of General Internal Medicine in February 2005     

Second harmonic transthoracic echocardiography: the new reference screening method for the detection of patent foramen ovale.

AIM: Transesophageal echocardiography (TEE) is still considered as the reference method for the non-invasive detection of right-to-left shunts. Echocardiographic laboratories are spending most of their time performing TEE studies to exclude a thromboembolic cardiac disease. In a considerable proportion of these patients the question can be simplified to exclude a PFO. Replacing these TEE studies by TTE would result in a considerable gain in time and money. We evaluated the value of transthoracic echocardiography with second harmonic imaging (TTE) (SH) and peripheral intravenous agitated saline solutions in the detection of patent foramen ovale (PFO) in a large cohort of patients. METHODS: In 256 consecutive patients, TEE and TTE (SH) with the consecutive administration of three intravenous contrast injections of agitated saline injections before the release phase of the Valsalva manoeuvre were performed. Semi-quantification and timing of contrast passage were assessed during both imaging modalities. A shunt was present if at least one imaging modality showed microbubbles appearing in the left atrium. PFO was defined when these bubbles appeared early and arteriovenous pulmonary malformations were suspected if bubbles appeared late after the opacification of the right atrium. Shunts were considered important when >20 bubbles were present in one frame in the left atrium or left ventricle. RESULTS: From the 256 patients, 60 presented a passage of contrast from the right to the left atrium in at least one imaging modality. PFO was detected by TEE in 53 patients and by TTE in 55 patients (sensitivity: 90.5% and specificity: 96.5% if TEE is accepted as the golden standard) (p>0.05). Considering only the important shunts TEE detected 39 important shunts and TTE 46 important shunts (sensitivity: 89.7% and specificity: 94.6%) (p>0.05). AV pulmonary malformations were detected by TEE in 7 patients and by TTE in 10 patients (sensitivity: 85.7% and specificity: 98.3%) (p>0.05). CONCLUSIONS: In this large cohort of patients TTE (SH) is as accurate as TEE for the detection of PFO and late right-to-left shunts. If the only purpose of TEE is the detection of PFO such as in young cryptogenic stroke patients and in divers, TEE can be replaced by TTE (SH).     

炎症因子与急性冠状动脉综合征的关系研究进展

急性冠状动脉综合征通常是由于动脉粥样硬化处于不稳定斑块破裂或者表面糜烂,继发血栓形成,引起心肌缺血导致严重不良事件的发生。目前临床上医生开始利用炎症因子来确定不稳定患者急性冠状动脉综合征的风险。炎症因子的升高不仅表现在血管壁上而且表现在外周血液中。目前认为联合这些炎症因子可以帮助诊断和判断以后。现对急性冠状动脉综合征的发生、发展以及预后与炎症因子的关系的研究现状做一综述。     

Overcoming a stubborn patent foramen ovale

Transesophageal echocardiography (TEE) with agitated saline contrast (“bubble study”) is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.     

Rare case of pulmonary arteriovenous fistula simulating residual defect after transcatheter closure of patent foramen ovale for recurrent paradoxical embolism.

We report on a patient suffering from recurrent cerebrovascular events despite previous transcatheter closure of persistent foramen ovale (PFO) with a Helex occluder. There was evidence of persistent left-to-right atrial shunt shown by transesophageal contrast echocardiography and the patient was admitted to our institution for interventional closure of the supposed residual defect. However, the PFO was completely closed by the device and left pulmonary artery injections showed a pulmonary arteriovenous fistula in the left lower lobe. This rare malformation may well explain the recurrent paradoxical embolism. Transcatheter fistula closure with coils was performed successfully. This case underlines that the existence of an isolated pulmonary arteriovenous fistula as a right-to-left shunt in patients with cryptogenic stroke should not be overlooked, even if a PFO is present and pulmonary arteriovenous fistula is not suggested by the initial physical findings or chest X-ray.     

Carbon dioxide: the cause of devastating stroke without hemodynamic compromise during laparoscopic nephrectomy with injury of the inferior vena cava: A case report

Rationale:Carbon dioxide pneumoperitoneum in laparoscopic surgery can bring about occult perioperative cerebral infarction, advancing our understanding of the causes of severe postoperative delayed recovery.Patient concerns:Here, we report the case of a 35-year-old woman who underwent a right renal tumor resection in our institution, during which a raised pneumoperitoneum pressure (from 15 to 20 mm Hg) was adopted by the surgeon to prevent errhysis and to help stop the bleeding. Despite an accidental minor tearing of the inferior vena cava, vital signs remained stable throughout the procedure, and no obvious abnormality was observed in either end tidal carbon dioxide values or blood gas analysis. However, the patient unexpectedly suffered delayed recovery after the operation, presenting incomplete left hemiplegia and a positive Babinski sign.Diagnoses:Perioperative stroke was diagnosed by anesthesiologists, after excluding the effects of anesthesia. Cerebral hemorrhage was excluded, as no obvious abnormality was found in the density of brain parenchyma in the emergency computed tomography examination, and a digital subtraction angiography showed no abnormal thrombosis. Further magnetic resonance diagnosis led us to consider diffuse gas embolisms to be the cause of this acute stroke; a right echocardiography revealed that a patent foramen ovale (PFO) may account for the global cerebral gas embolisms.Interventions:The patient received neuroprotective drugs (Vinpocetine, Edaravone, and Xingnaojing, which are commonly used as a standard of care in China), antiplatelets and other symptomatic treatments, plus dexamethasone to relieve edema. A contrast-enhanced echocardiography of the right heart was performed, the results of which were consistent with the sonography of a PFO.Outcomes:The patient was hospitalized for 14 days and eventually discharged after recovery. At the latest follow-up in August 2019, the patient recovered without residual neurological sequelae.Lessons:Our results emphasize the need for vigilance regarding adverse cardiovascular and neurological events caused by carbon dioxide gas embolisms when encountering the inadvertent situation of vessels rupturing. Timely monitoring of paradoxical gas embolism by transoesophageal echocardiography is necessary and can avert the risk of severe complications. Urgent consideration should be given to stopping pneumoperitoneum and switching to laparotomy for hemostasis so that the patient can obtain the best benefit–risk ratio.     

儿童卵圆孔未闭介入治疗21例临床分析

［摘要］　目的　分析儿童卵圆孔未闭的临床表现及介入治疗的适应证和治疗效果。方法　选择该院2017年1月至2019年12月因卵圆孔未闭接受介入治疗的21例患儿,分析其临床表现和介入治疗效果。结果　21例术后1周、1个月、3个月、6个月、12个月随访,经胸超声心动图检查显示右心室内径、右心房左右径及右心房前后径较介入前降低,差异有统计学意义（P<0.05）。经治疗,9例偏头痛患儿有7例症状消失,6例胸闷心悸患儿症状完全消失。结论　介入治疗儿童卵圆孔未闭的疗效及安全性良好,操作技术易于推广,值得临床推荐。     

Impact of Sex on Comparative Outcomes of Radial Versus Femoral Access in Patients With Acute Coronary Syndromes Undergoing Invasive Management: Data From the Randomized MATRIX-Access Trial

Objectives

This study sought to assess whether transradial access (TRA) compared with transfemoral access (TFA) is associated with consistent outcomes in male and female patients with acute coronary syndrome undergoing invasive management.