High prevalence of patent foramen ovale in recreational to elite breath hold divers

ObjectivesDuring apnea diving, a patent foramen ovale may function as a pressure relief valve under conditions of high pulmonary pressure, preserving left-ventricular output. Patent foramen ovale prevalence in apneic divers has not been previously reported. We aimed to determine the prevalence of patent foramen ovale in apneic divers compared to non-divers.DesignCross sectional.MethodsApnea divers were recruited from a training camp in Cavtat, Croatia and the diving community of Split, Croatia. Controls were recruited from the population of Split, Croatia and Eugene, Oregon, USA. Participants were instrumented with an intravenous catheter and underwent patent foramen ovale screening utilizing transthoracic saline contrast echocardiography. Appearance of microbubbles in the left heart within 3 cardiac cycles indicated the presence of patent foramen ovale. Lung function was measured with spirometry. Comparison of patent foramen ovale prevalence was conducted using chi-square analysis, p < .05.ResultsApnea divers had a significantly higher prevalence of patent foramen ovale (19 of 36, 53%) compared to controls (9 of 36, 25%) (X² (1, N = 72) = 5.844, p = .0156).ConclusionsWhy patent foramen ovale prevalence is greater in apnea divers remains unknown, though hyperbaria during an apnea dive results in a translocation of blood volume centrally with a concomitant reduction in lung volume and alveolar hypoxia during ascent results in hypoxic pulmonary vasoconstriction. These conditions increase pulmonary arterial pressure, increasing right-atrial pressure allowing for right-to-left blood flow through a patent foramen ovale which may be beneficial for preserving cardiac output and reducing capillary hydrostatic forces.     

Underutilization of echocardiography for patent foramen ovale in divers with serious decompression sickness

The presence of a patent foramen ovale (PFO) in compressed gas diving has been considered a risk factor for serious decompression illness (DCS) for more than 20 years. We conducted a ten year retrospective chart review aimed at determining if physicians treating DCS in a university medical center setting used echocardiography to assess PFO in patients with severe DCS, and if so whether PFO is over-represented in that population. Over the ten-year period, 113 divers underwent recompression therapy for decompression sickness. Of these patients, 48 had serious DCS defined by at least one objective neurological finding. We reviewed medical records for the presence of agitated saline contrast echocardiogram testing and whether or not PFO was present. Only 12 of 48 patients with serious DCS underwent transthoracic agitated saline contrast echocardiogram testing. Of these 12 patients, 6 (50%) had a resting PFO. Binomial proportion testing yielded 95% confidence limits of 21% and 79%. Given 27% PFO prevalence in the general population, PFO may be over-represented in our group of most seriously injured DCS patients yet 75% of patients with objective neurological signs did not undergo echocardiography.     

Diagnosis of patent foramen ovale using contrast-enhanced dynamic MRI: a pilot study

OBJECTIVE: The aim of this study was to evaluate the feasibility of dynamic contrast-enhanced MRI for detection of patent foramen ovale. SUBJECTS AND METHODS: Fifteen patients with and five patients without patent foramen ovale underwent transesophageal echocardiography and MRI, which were performed during the Valsalva maneuver. Grading results (grade 0, no patent foramen ovale and grades 1-3, minor to major enhancement due to intracardiac shunt) were assessed visually. Signal-intensity curves in the left atrium and in a pulmonary vein served to underline the diagnosis. RESULTS: The diagnoses of all patients with (15/15) and without patent foramen ovale (5/5) were correct compared with the findings of the reference transesophageal echocardiography. In 12 (60%) of 20 patients, the grading scores were identical, and in four (20%) of 20 patients, the scores differed by more than one grade. Overall, there was a good correlation of grading scores (r = 0.7, p < 0.05). Using signal-intensity curves, we found that the patients with patent foramen ovale showed an additional signal peak in the left atrium before the enhancement of the pulmonary vein because of an intracardiac shunt. In three of 15 patients with patent foramen ovale, an atrial septal aneurysm was correctly diagnosed. CONCLUSION: This pilot study shows that MRI is a new noninvasive method to detect patent foramen ovale and atrial septal aneurysm. A grading is possible but warrants further investigation regarding its predictive value and impact on treatment strategies.     

卵圆孔未闭导致儿童隐源性脑梗死1例

患儿 男,13岁.因右侧肢体偏瘫2天入院.2天前突发右侧肢体偏瘫,伴言语含糊,余无其它临床症状.查体:心率:62次/min,血压:105/63 mmHg,语言含糊,右侧眼球外展受限,左侧肢体肌力4+级,右侧肢体肌力0级、肌张力低,右侧腱反射低,右下肢病理征(+),共济感觉检查不能配合.     

The role of eustachian valve and patent foramen ovale in sudden death

Sudden unexpected cardiac death is the leading cause of death in industrialized countries. Patent foramen ovale and eustachian valve are two of cardiac diseases and they may be associated with clinical disorders as embolism, stroke, plathypnea-orthodeoxia syndrome, carcinoid heart disease, atrial flutter and endocarditis. The literature for the roles of patent foramen ovale and eustachian valve in the causes of sudden deaths are reviewed.     

卵圆孔未闭动物模型的建立

目的 探讨采用正常中华小型猪制作卵圆孔未闭动物模型的可行性。方法 中华小型猪11只，选取1只行预实验，10只用于正式实验。全身麻醉下，经股静脉送入Rups-100穿刺针系统，在透视引导下穿刺房间隔卵圆窝，然后对穿刺点行球囊扩张术。预实验动物术后1d处死，正式实验组动物术后21d处死。心脏取材，行病理检查。结果 11只猪均成功行房间隔穿刺和球囊扩张术，并经心房造影证实建立卵圆孔未闭模型。正式实验组动物除1只术中出现心包积液外，其余术中及术后均无并发症。预实验动物于处死后肉眼观房间隔卵圆窝有-0．7cm×0．8cm缺损，光学显微镜下见红细胞聚集。正式实验组动物于处死后观察，7只可见房间隔卵圆窝愈合，3只分别残留0．1cm×0．2cm、0．2cm×0．2cm、0．1cm×0．3cm缺损。正式实验组动物无论卵圆窝是否愈合，光学显微镜下在穿刺点周围均可见不同程度的局灶性心内膜增生和缺失、淋巴细胞聚集、心肌细胞肿胀、坏死和间质纤维化。结论 采用房间隔穿刺和球囊扩张的方法，用中华小型猪建立卵圆孔未闭模型是可行的。     

Transcranial duplex sonography in the detection of patent foramen ovale

PURPOSE: To determine the sensitivity of contrast material-enhanced transcranial color-coded sonography (c-TCCS) compared with that of contrast-enhanced transesophageal echocardiography (c-TEE) for detection of cardiac right-to-left shunt. MATERIALS AND METHODS: Forty consecutive patients with stroke or transient ischemic attack were admitted to the hospital and were examined by using c-TCCS and c-TEE. High-intensity transient signals (HITS) were counted for 25 seconds after the end of the Valsalva maneuver, and the numbers of HITS were classified in one of four categories (zero HITS, one to 10 HITS, >10 HITS without curtain, and curtain). A statistically significant difference was calculated with the Fisher exact test. RESULTS: HITS were counted in 21 (52%) patients by using c-TCCS and c-TEE. With both tests, no HITS were counted in 15 (38%) patients. In two (5%) patients, no HITS were counted with c-TEE but three HITS in one patient and five HITS in the other were counted with c-TCCS. In two (5%) patients, no HITS were counted with c-TCCS, but a small patent foramen ovale (PFO) was seen at c-TEE. With c-TCCS, the sensitivity was 91% (21 of 23) and the specificity was 88% (15 of 17). In 23 patients examined with c-TCCS, 14 (61%) patients had category 1 PFO; seven (30%) patients, category 2 PFO; and two (9%) patients, category 3 PFO. Mean HITS count in patients with category 1 PFO was 4.4 and that for those with category 2 PFO was 27.6. CONCLUSION: c-TCCS is a sensitive noninvasive method for detecting cardiac right-to-left shunt and is as sensitive as c-TEE.     

卵圆孔未闭动物模型的制备

目的 探讨采用经皮房间隔穿刺和球囊扩张法制备犬卵圆孔未闭(patent foramen ovale,PFO)动物模型的可行性.方法 采用22只健康成年犬,经皮房间隔卵圆窝穿刺、球囊扩张术制备犬PFO模型,对其中2只犬的卵圆窝穿刺点进行病理学等检查.结果 22只犬均成功进行房间隔卵圆窝穿刺和球囊扩张术,右房造影可见对比剂由右房进入左房,成功建立了犬PFO模型.完成房间隔卵圆窝穿刺及球囊扩张平均用时(25.1±5.1)min,X线曝光时间平均(5.8±1.6)min.穿刺前右心房平均压为(1.9±0.8)mmHg,穿刺后测得左心房平均压为(2.5±0.7)mmHg.对2只犬的心脏大体观察见心包膜完整;房间隔卵圆窝缺损分别为5 mm×6 mm和6 mm×6 mm,缺损周边均见少量淤血,未见血栓附着,余心内膜均完整.结论 经皮穿刺犬的房间隔卵圆窝、球囊扩张方法制备PFO模型可行.     

Brain magnetic resonance imaging findings in cryptogenic stroke patients under 60 years with patent foramen ovale

Purpose

To compare magnetic resonance imaging (MRI) brain feature in cryptogenic stroke patients with patent foramen ovale (PFO), cryptogenic stroke patients without PFO and patients with cardioembolic stroke.

Materials and methods

The ethics committee required neither institutional review board approval nor informed patient consent for retrospective analyses of the patients’ medical records and imaging data. The patients’ medical files were retrospectively reviewed in accordance with human subject research protocols. Ninety-two patients under 60 years of age were included: 15 with cardioembolic stroke, 32 with cryptogenic stroke with PFO and 45 with cryptogenic stroke without PFO. Diffusion-weighted imaging of brain MRI was performed by a radiologist blinded to clinical data. Univariate, Fischer's exact test for qualitative data and non-parametric Wilcoxon test for quantitative data were used.

Results

There was no statistically significant difference found between MRI features of patients with PFO and those with cardioembolic stroke (p < .05). Patients without PFO present more corticosubcortical single lesions (p < .05) than patients with PFO. Patients with PFO have more often subcortical single lesions larger than 15 mm, involvement of posterior cerebral arterial territory and intracranial occlusion (p < .05) than patients with cryptogenic stroke without PFO.

Conclusion

Our study suggests a cardioembolic mechanism in ischemic stroke with PFO.     

卵圆孔未闭的影像学检查及其临床特征的研究进展

卵圆孔未闭是一种特殊类型的房间隔交通,一般不引起相关的症状和体征,但近年来研究发现它与多种临床疾病有关。目前其影像学诊断方法主要依赖经食管超声检查（TEE）,多层螺旋CT（MSCT）心血管造影作为一种全新的无创性检查手段也日趋成熟。本文综述了卵圆孔未闭的影像学检查方法及其临床特征。     

四种超声检查方法对卵圆孔未闭诊断价值的比较

目的 比较经胸超声心动图、经胸超声心动图联合右心声学造影、经食管超声心动图、经食管超声心动图联合右心声学造影四种检查方法对卵圆孔未闭(PFO)诊断的应用价值。方法 收集联勤保障部队第940医院2020-12至2021-11临床疑似PFO和经颅多普勒超声声学造影阳性患者87例为研究对象,所有患者同时行经胸超声心动图(TTE)、经胸超声心动图联合右心声学造影(c-TTE)、经食管超声心动图(TEE)和经食管超声心动图联合右心声学造影(c-TEE)检查,比较不同方法的PFO检出率,分析各自优缺点。结果 87例中,c-TEE检出PFO 71例(检出率81.61%),TEE检出PFO 56例(检出率64.37%),c-TTE检出PFO 47例(检出率54.02%),TTE检出PFO 23例(检出率为26.44%),四组之间差异有统计学意义(P<0.05)。c-TEE组阳性检出率高于c-TTE组(P<0.05),而c-TTE与TEE两组间阳性检出率差异无统计学意义(P=0.165)。Valsalva动作后,c-TEE组阳性检出率高于c-TTE组(P<0.05)。结论 四种方法比较...     

Isolated brain metastases of osteosarcoma in a patient presenting with a patent foramen ovale

We report the case of a patient in whom brain MR imaging was requested for initial symptoms of intracranial hypertension. The presence of multiple intracranial hemorrhagic lesions suggested brain metastases. Body screening showed periosteal osteosarcoma of the left fibula with no lung metastases, but with a patent foramen ovale which probably allowed neoplastic cells to reach the brain without being filtered through the lungs. The conclusion of this study was that a left–right cardiac communication is to be considered in cases of isolated brain metastases from osteosarcoma. Received 21 February 1996; Revision received 29 May 1996; Accepted 19 July 1996     

Controversies in the medical clearance of recreational scuba divers: updates on asthma,diabetes mellitus,coronary artery disease,and patent foramen ovale

Primary care and sports medicine physicians are frequently consulted on medical clearance for prospective recreational divers. We discuss four common and controversial medical conditions—asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale—as they relate to fitness to dive. For each condition we review the relevant anatomy and physiology, current recommendations, and the pertinent medical literature. Finally, we offer evidence-based recommendations regarding fitness to dive for potential divers with these conditions.     

Temporary IVC filtration before patent foramen ovale closure in a patient with paradoxic embolism

Pulmonary embolism (PE) and associated acute peripheral ischemia suggest the diagnosis of paradoxic embolism. The most common intracardiac defect associated with paradoxic emboli is a patent foramen ovale (PFO). Therapeutic options include anticoagulation, thrombolysis, inferior vena cava (IVC) filtration, and closure of the intracardiac defect. The authors discuss the diagnosis and treatment of a young female athlete who presented with massive PE complicated by a paradoxic embolus to the right subclavian artery. Systemic and catheter-directed thrombolysis, IVC filtration, and percutaneous closure of a PFO were performed in an effort to return the patient to the level of competitiveness she desired.     

A review of the relationship between patent foramen ovale and type II decompression sickness.

The significance of patent foramen ovale (PFO) in the pathophysiology of Type II decompression sickness (DCS) remains controversial. PFOs are common, occurring in approximately one quarter of the normal population, thus making right-to-left shunting of venous gas emboli (VGE) a theoretical concern in both hyper- and hypobaric situations. Despite this high prevalence of PFO in the general population, and the relatively common occurrence of venous gas bubbles in diving and altitude exposures, the incidence of Type II DCS in diving or with altitude is remarkably low. Although the literature supports a relationship between the presence and size of PFO and cryptogenic stroke, and an increased relative risk of Type II DCS with a PFO in divers, the absolute increase in risk accrued is small. Hence, the value of screening is also controversial. This paper presents a summary of the literature on PFOs and DCS in animals, and in human altitude and diving, focusing on the latter; as well the analogous literature on cryptogenic stroke. The results of an examination of the literature on detection of, screening for, and treatment of PFOs is also presented.     

Risks of tumor embolization in the presence of an unrecognized patent foramen ovale: case report

A patent foramen ovale (PFO) is a fairly common septal defect in the general population. Paradoxical embolization through a PFO is a known cause of stroke. Preprocedural recognition of a PFO in a patient undergoing particulate arterial embolization can help reduce the risk of cerebral infarction.