Negative-pressure pulmonary edema presented with concomitant spontaneous pneumomediastinum: Moore meets Macklin

Negative-pressure pulmonary edema is an unusual complication mainly associated with general anesthesia. It is caused by excessive negative intrathoracic pressure following a deep inspiration against an acute airway obstruction. The resultant decreased intrathoracic pressure amplifies venous return to the right heart and increases pulmonary capillary wedge pressure that can be further amplified by massive sympathetic discharge due to hypoxia. The combination of increased venous return and pulmonary capillary wedge pressure favours the shift of fluid into the pulmonary interstitium with resultant pulmonary edema. Conversely, spontaneous pneumomediastinum (SP) results from alveolar rupture following an excessive positive intrathoracic pressure. The air leaks out of the alveoli and along the perivascular space toward the mediastinum. We experienced a case of negative pulmonary edema which presented in association with SP. Pneumomediastinum is probably caused by an excessive positive intrathoracic pressure for a subsequent expiration against a closed airway. In the present case, both complications resolved with conservative management.     

Prevention and rehabilitation in cardiology

Preventive cardiology occupies a central place in medicine today. The subject monopolizes a large proportion of epidemiological studies and clinical trials involving a range of drugs. Moreover, preventive cardiology provided the initial impetus for regarding genetic epidemiology as a basis for disease prevention. The aim of this article was to summarize just some of the publications that have appeared during the last few months, with special emphases on obesity and diabetes mellitus as the pre-eminent risk factors for disease, and on their combination as part of the so-called metabolic syndrome.     

Transcatheter closure of patent foramen ovale in patients with platypnea-orthodeoxia

Platypnea-orthodeoxia is a rare syndrome characterized by the occurrence of dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia) and by the absence of symptoms and hypoxemia in decubitus. This syndrome is frequently related to patent foramen ovale and right-to-left shunting. We describe two patients in whom patent foramen ovale with right-to-left shunting was observed on transthoracic and transesophageal echocardiography and who had platypnea-orthodeoxia in the absence of pulmonary disease. They underwent transcatheter closure using an Amplatz device. The echocardiographic diagnosis and closure procedure are discussed. These case reports demonstrate that closure of patent foramen ovale is an effective treatment for platypnea-orthodeoxia.     

Intravascular ultrasound in patients with challenging in-stent restenosis: importance of precise stent visualization

Intravascular ultrasound (IVUS) is widely used to optimize stent (ST) implantation. However, its value to guide therapy in challenging cases of in-stent restenosis (ISR) is not well established. We present 3 patients with complex ISR where IVUS interrogation was useful: (a) to readily identify the ST "entry door," (b) to accurately detect ST malapposition, (c) to measure the extent of ST protrusion out from its deployed position, and (d) to guide and optimize therapy. Thus, due to its unique ability to visualize the complete structure of the underlying ST, IVUS constitutes a superb diagnostic tool in patients with ISR, especially in challenging anatomic settings.