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Shah AH, Horlick EM, Kass M, Carroll JD, Krasuski RA. The pathophysiology of patent foramen ovale and its related complications. Am Heart J 2024; 277:76-92. [PMID: 39134216 DOI: 10.1016/j.ahj.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024]
Abstract
The foramen ovale plays a vital role in sustaining life in-utero; however, a patent foramen ovale (PFO) after birth has been associated with pathologic sequelae in the systemic circulation including stroke/transient ischemic attack (TIA), migraine, high altitude pulmonary edema, decompression illness, platypnea-orthodeoxia syndrome (POS) and worsened severity of obstructive sleep apnea. Importantly, each of these conditions is most commonly observed among specific age groups: migraine in the 20 to 40s, stroke/TIA in the 30-50s and POS in patients >50 years of age. The common and central pathophysiologic mechanism in each of these conditions is PFO-mediated shunting of blood and its contents from the right to the left atrium. PFO-associated pathologies can therefore be divided into (1) paradoxical systemic embolization and (2) right to left shunting (RLS) of blood through the PFO. Missing in the extensive literature on these clinical syndromes are mechanistic explanations for the occurrence of RLS, including timing and the volume of blood shunted, the impact of age on RLS, and the specific anatomical pathway that blood takes from the venous system to the left atrium. Visualization of the flow pattern graphically illustrates the underlying RLS and provides a greater understanding of the critical flow dynamics that determine the frequency, volume, and pathway of flow. In the present review, we describe the important role of foramen ovale in in-utero physiology, flow visualization in patients with PFO, as well as contributing factors that work in concert with PFO to result in the diverse pathophysiological sequelae.
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Affiliation(s)
- Ashish H Shah
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Eric M Horlick
- Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Malek Kass
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - John D Carroll
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO.
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Voudris KV, Poulin MF, Kavinsky CJ. Updates on Patent Foramen Ovale (PFO) Closure. Curr Cardiol Rep 2024; 26:735-746. [PMID: 38913234 DOI: 10.1007/s11886-024-02073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure. RECENT FINDINGS PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.
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Affiliation(s)
- Konstantinos V Voudris
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Marie-France Poulin
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA
| | - Clifford J Kavinsky
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA.
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Otsuka A, Yamano M, Yamano T, Kawajiri H, Nukui Y, Yaku H, Matoba S. Platypnea-orthodeoxia syndrome developed with the progression of pulmonary parenchymal involvement: A case report. J Cardiol Cases 2024; 29:234-237. [PMID: 39100511 PMCID: PMC11295019 DOI: 10.1016/j.jccase.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 08/06/2024] Open
Abstract
Platypnea-orthodeoxia syndrome (POS) attributed to patent foramen ovale (PFO) can be caused by a variety of clinical conditions. A 70-year-old woman was admitted to our hospital for further evaluation of POS. Her symptoms developed along with the spread of infiltrative shadows in both lower lung fields during the preceding 2 years. Contrast transthoracic echocardiography with agitated saline revealed grade III intracardiac right-to-left shunting, presumably across a PFO. Transesophageal echocardiography demonstrated severe tricuspid regurgitation (TR) caused by the prolapse of the anterior leaflet. Bidirectional shunt flow, mainly from right-to-left across a PFO, that increased in the sitting position was also observed. She was diagnosed as having PFO associated with severe primary TR. Therefore, tricuspid valve repair and direct PFO closure were performed. Her symptoms resolved completely soon after the operation and her oxygen saturation was maintained. This patient's disease seemed to have worsened with the spread of pulmonary parenchymal involvement, which caused ventilation-perfusion mismatch and elevation of alveolar pressures. Echocardiography is an essential imaging modality in addition to other diagnostic examinations and imaging studies when assessing the pathogenesis in patients with POS. Learning objective Platypnea-orthodeoxia syndrome (POS) associated with patent foramen ovale may be caused by a variety of clinical conditions, and POS in our patient may be caused by the worsening of pulmonary parenchymal involvement. Examinations to evaluate all causes of POS are essential for making the diagnosis. Contrast transthoracic echocardiography was useful in assessing the cause of POS.
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Affiliation(s)
- Akiko Otsuka
- Faculty of Clinical Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michiyo Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Infection Control and Molecular Laboratory Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoko Nukui
- Department of Infection Control and Molecular Laboratory Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Leaver BA, Cliff ERS, Jefford M, Fogarty S, Zentner D. The paradox of platypnoea-orthodeoxia syndrome. Intern Med J 2024; 54:675-677. [PMID: 38572793 DOI: 10.1111/imj.16365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/11/2023] [Indexed: 04/05/2024]
Abstract
Platypnoea-orthodeoxia is a rare clinical syndrome characterised by dyspnoea and oxygen desaturation in the upright position which improves when supine. It requires two components: a sufficiently sized anatomical vascular defect (typically intra-cardiac or intra-pulmonary) combined with a functional component that promotes positional right-to-left shunting. We describe the rare occurrence of a patient with platypnoea-orthodeoxia syndrome (POS) because of a paradoxical shunt through a patent foramen ovale caused by a large right atrial line-associated thrombus in a male with metastatic oesophageal cancer undergoing chemotherapy. This case is a timely reminder to consider POS amongst differentials for hypoxia as it is often treatable if recognised.
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Affiliation(s)
- Benjamin A Leaver
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Edward R S Cliff
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Jefford
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Samuel Fogarty
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Randhawa S, Mehta JL, Dhar G. Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond. Curr Cardiol Rev 2024; 20:77-86. [PMID: 38485682 DOI: 10.2174/011573403x276984240304044109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/13/2024] [Accepted: 01/20/2024] [Indexed: 07/20/2024] Open
Abstract
Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.
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Affiliation(s)
- Sandeep Randhawa
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jawahar L Mehta
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gaurav Dhar
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
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Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
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Honasoge AP, Suradi HS, Tobis JM, Kavinsky CJ. Patent Foramen Ovale Closure for Nonstroke Indications. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101135. [PMID: 39129903 PMCID: PMC11307832 DOI: 10.1016/j.jscai.2023.101135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 08/13/2024]
Abstract
The patent foramen ovale (PFO) is a flap or tunnel-like communication in the atrial septum present in 20% to 34% of the adult population. In most cases, it is a benign finding and poses no health risk. However, some PFOs may provide a conduit for bloodborne materials, such as thrombi, vasoactive substances, or air to pass into the systemic circulation causing a paradoxical embolus. PFOs have been linked with several clinical disease states including cryptogenic stroke, migraine headache, platypnea-orthodeoxia, and decompression illness. Percutaneous PFO closure provides a practical solution to the problem of PFO in carefully selected populations. Recent randomized control trials have demonstrated that PFO closure in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke compared with medical therapy. This translated into a dramatic increase in the number of PFO closure procedures worldwide, primarily for the indication of cryptogenic stroke, with high procedural success and low complication rates. However, there are no randomized clinical trials available to support PFO closure in other clinical conditions. This article reviews potential indications, existing data, and management approaches for PFO closure in disorders other than cryptogenic stroke.
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Affiliation(s)
- Akilesh P. Honasoge
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Hussam S. Suradi
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | | | - Clifford J. Kavinsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Huang W, Wang H. Predictive value of transesophageal echocardiography combined with contrast transthoracic echocardiography for embolic stroke of undetermined source. Perfusion 2023:2676591231198356. [PMID: 37657946 DOI: 10.1177/02676591231198356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
OBJECTIVE In this study, we aimed to assess the predictive value of transesophageal echocardiography (TEE) combined with contrast transthoracic echocardiography (cTTE) for embolic stroke of undetermined source (ESUS). METHODS A total of 52 patients with ESUS were examined by TEE and cTTE. The detection rate of patent foramen ovale (PFO) and right-to-left shunt (RLS) grade were compared in patients with ESUS between cTTE alone and cTTE combined with TEE. The Risk of Paradoxical Embolism (RoPE) score, PFO diameter, and PFO length of patients with PFO-associated ESUS and non-PFO-associated ESUS were compared by cTTE alone and cTTE combined with TEE. The receiver operating characteristic (ROC) curve was utilized to determine the effect of RoPE score and PFO diameter on patients with PFO-associated ESUS. RESULTS The positive rate of PFO detected by cTTE alone (46.15%) was lower than that detected by cTTE combined with TEE (69.23%). The proportion of patients with RLS grade I + II + III detected by cTTE combined with TEE (69.23%) was higher than that detected by cTTE alone (46.15%). Both the RoPE score and PFO diameter were significantly greater in the patients with PFO-associated ESUS than in the patients with non-PFO-associated ESUS (p < .05). The combination of RoPE score and PFO diameter had the largest area under the ROC curve (AUC = 0.875), which was larger than the AUC alone of RoPE score (AUC = 0.819) and PFO diameter (AUC = 0.783) (p < .05). CONCLUSION The combination of cTTE and TEE is helpful to the diagnosis of ESUS patients caused by PFO and to judge the degree of RLS.
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Affiliation(s)
- Wei Huang
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
- Department of Neurology, Baoding No.1 Central Hospital, Baoding, China
| | - Hebo Wang
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
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Verdoia M, Viola O, Marenna B, Marrara F, Bertola B, Brancati MF, Gioscia R, Soldà PL, Rognoni A. Managing Congenital Heart Defects in Elderly: The Platypnea-Orthodeoxia Syndrome in Underestimated Patent Foramen Ovale. Angiology 2023:33197231199229. [PMID: 37651548 DOI: 10.1177/00033197231199229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The platypnea-orthodeoxia syndrome (POS) is a rare and often suboptimally managed condition with a complex diagnostic workup, conversely displaying an easy treatment and a good recovery of symptoms, especially if consequent to an intracardiac shunt. However, its identification is challenging, due to the several clinical manifestations, the multiple etiologies, representing often the delayed presentation of a congenital heart disease. We present a case report and review of available literature on patients with the POS secondary to a patent foramen ovale successfully treated with its closure.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
- Università Del Piemonte Orientale, Novara, Italy
| | - Orazio Viola
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | - Biondino Marenna
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | - Federica Marrara
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | - Benedetta Bertola
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | | | - Rocco Gioscia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | - Pier Luigi Soldà
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
| | - Andrea Rognoni
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Biella, Italy
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Rao P, Undavalli C, Ghoweba M, Kanuparthy A, Vahdat K. Platypnea Orthodeoxia Syndrome Secondary to a Persistent Eustachian Valve. Cureus 2023; 15:e42900. [PMID: 37664400 PMCID: PMC10474851 DOI: 10.7759/cureus.42900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Platypnea-Orthodeoxia syndrome (POS) is a rare and poorly understood syndrome characterized by platypnea and oxygen desaturation in the upright position that is relieved by recumbency. Here, we report a case of an 84-year-old woman who had chronic hypoxia in an upright position despite using home oxygen. The patient presented for hypoxia evaluation and was noted to have a restrictive pattern on pulmonary function tests (PFT). An echocardiogram showed a prominent eustachian valve extending from inferior to superior vena cava with contrast approaching the interatrial septum. The patient had a complete resolution of her platypnea following the closure of the patent foramen ovale.
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Affiliation(s)
- Poonam Rao
- Internal Medicine, CHRISTUS Health/Texas A&M School of Medicine Internal Medicine Residency Program, Longview, USA
| | - Chaitanya Undavalli
- Internal Medicine, CHRISTUS Health/Texas A&M School of Medicine Internal Medicine Residency Program, Longview, USA
| | - Mohamed Ghoweba
- Internal Medicine, Texas A&M College of Medicine/CHRISTUS Good Shepherd Medical Center, Longview, USA
| | - Aparna Kanuparthy
- Internal Medicine, CHRISTUS Health/Texas A&M School of Medicine Internal Medicine Residency Program, Longview, USA
| | - Khashayar Vahdat
- Cardiology, CHRISTUS Health/Texas A&M School of Medicine Internal Medicine Residency Program, Longview, USA
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Salam A, Mandal S, Fathima S, Rasthapuram S, Radhakrishnan K. Platypnoea orthodeoxia syndrome and its association with cryptogenic ischaemic stroke. J R Coll Physicians Edinb 2023; 53:109-110. [PMID: 36869700 DOI: 10.1177/14782715231159470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Platypnoea orthodeoxia syndrome is a rare condition, which can be present in patients with patent foramen ovale (PFO). In this case, a 72-year-old lady presented to the emergency department with a cryptogenic stroke associated with right thalamic infarct. While in hospital, it was noticed that the patient had desaturations in the upright position, and these improved in the recumbent position, consistent with platypnoea orthodeoxia syndrome. The patient was found to have a PFO, which was then closed, and her saturations returned to normal. This case highlights the importance of patients who present with cryptogenic stroke and features of platypnoea orthodeoxia syndrome need to be considered for underlying PFO or other septal defect.
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Chino S, Mochizuki Y, Mizuma K, Ichikawa S, Miyazaki H, Hachiya R, Toyosaki E, Fukuoka H, Ono K, Shinke T. Reply to 'patent foramen ovale device closure for patients with stroke and high-risk PFO morphology'. Heart Vessels 2022; 38:871-872. [PMID: 35999318 DOI: 10.1007/s00380-022-02157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/17/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Saori Chino
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Yasuhide Mochizuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan.
| | - Keita Mizuma
- Division of Neurology, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Saaya Ichikawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Haruka Miyazaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Rumi Hachiya
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Eiji Toyosaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Hiroto Fukuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Kenjiro Ono
- Division of Neurology, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
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Gama E Castro A, Luz A, Oliveira F, Brochado B, Santos R, Alexandre A, Campinas A, Couto DS, Silveira J, Torres S. Platypnea Orthodeoxia Syndrome and Patent Foramen Ovale Closure: Single-Centre Experience and Long-Term Follow-Up. Heart Lung Circ 2022; 31:1547-1552. [PMID: 35987719 DOI: 10.1016/j.hlc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Platypnea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS. METHODS Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO2) improved to >94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO2 improved from baseline but still required oxygen to achieve >94%. Secondary outcomes were an absolute improvement in SpO2 and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up. RESULTS Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO2 ratio increased from 155.9±50.6 to 318.3±73.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO2 and complete resolution of dyspnoea, which was maintained at follow-up (37±20 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up. CONCLUSION The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.
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Affiliation(s)
- Ana Gama E Castro
- ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - André Luz
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal; Cardiovascular Research Group - Unit of Multidisciplinary Investigation in Biomedicine, ICBAS, Porto University, Porto, Portugal.
| | - Filomena Oliveira
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - Bruno Brochado
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - Raquel Santos
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - André Alexandre
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - Andreia Campinas
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - David Sá Couto
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - João Silveira
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
| | - Severo Torres
- Department of Cardiology, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; ICBAS School of Medicine and Biomedical Sciences, Porto University, Porto, Portugal
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14
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Othman F, Bailey B, Collins N, Lau E, Tanous D, Rao K, Celermajer D, Cordina R. Platypnea-Orthodeoxia Syndrome in the Setting of Patent Foramen Ovale Without Pulmonary Hypertension or Major Lung Disease. J Am Heart Assoc 2022; 11:e024609. [PMID: 35876406 PMCID: PMC9375500 DOI: 10.1161/jaha.121.024609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Patent foramen ovale (PFO)‐associated platypnea‐orthodeoxia syndrome is characterized by dyspnea and hypoxemia when upright. The pathogenesis is thought to involve an increase in right atrial pressure or change in degree of right to left shunting with upright posture. Methods and Results We sought to characterize patients with platypnea‐orthodeoxia syndrome related to PFO without pulmonary hypertension. We retrospectively reviewed databases at 3 tertiary referral hospitals in New South Wales, Australia from 2000 to 2019. Fourteen patients with a mean age of 69±14 years had a PFO with wide tunnel separation. Mean New York Heart Association Classification was II (±0.9) and 7 inpatients had been confined to bed (from postural symptoms). Baseline oxygen saturations supine were 93%±5% and 84%±6% upright. Two patients had a minor congenital heart defect and 4 had mild parenchymal lung disease with preserved lung function. The mean aortic root diameter was 37±6 mm and distance between aortic root and posterior atrial wall was 16±2 mm. Platypnea‐orthodeoxia syndrome was preceded by surgery in 5 patients and 1 patient had mild pneumonia. Successful closure of the PFO using an Amplatzer device was performed in 11 of 14 patients. Post‐closure, all patients had New York Heart Association Classification I (improvement 1.6±0.9, P<0.003) and semi‐recumbent oxygen saturations increased by 13%±8% (P<0.001, n=10). Conclusions Platypnea‐orthodeoxia syndrome is a debilitating condition, curable by PFO closure. Anatomical distortion of the atrial septum related to a dilated aortic root or shortening of the distance between the aortic root and posterior atrial wall may contribute to the syndrome.
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Affiliation(s)
| | - Brian Bailey
- Royal Prince Alfred Hospital Sydney NSW Australia
| | | | - Edmund Lau
- Royal Prince Alfred Hospital Sydney NSW Australia
| | - David Tanous
- Royal Prince Alfred Hospital Sydney NSW Australia.,Westmead Hospital Sydney NSW Australia
| | - Karan Rao
- Westmead Hospital Sydney NSW Australia
| | - David Celermajer
- Royal Prince Alfred Hospital Sydney NSW Australia.,Heart Research Institute Sydney NSW Australia.,Sydney Medical SchoolUniversity of Sydney NSW Australia
| | - Rachael Cordina
- Royal Prince Alfred Hospital Sydney NSW Australia.,Heart Research Institute Sydney NSW Australia.,Sydney Medical SchoolUniversity of Sydney NSW Australia
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15
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Wiertsema MH, Dickinson MG, Hoendermis ES, Geluk CA. Platypnea orthodeoxia syndrome after recent stroke: a case report of a sandwiched right atrium. Eur Heart J Case Rep 2022; 6:ytac275. [PMID: 35854888 PMCID: PMC9290560 DOI: 10.1093/ehjcr/ytac275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/21/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022]
Abstract
Background Platypnea orthodeoxia syndrome (POS) is a condition characterized by onset or worsening of dyspnoea and desaturation in upright position that is relieved by returning to a supine position. This case report illustrates a sudden onset of severe platypnea caused by compression of the right atrium (RA) due to aortic dilatation and unilateral diaphragmatic paralysis after a recent stroke. Case summary A 71-year-male patient with a medical history of recent stroke of the left hemisphere was referred to emergency department with acute dyspnoea. During observation in the emergency department, desaturation was noted in upright position. A contrast computed tomography excluded pulmonary embolism but revealed a dilated aortic root and an elevated right hemidiaphragm. The RA was compressed between these two structures (sandwiched). Given the clinical suspicion of a POS, a transoesophageal echocardiography was performed which confirmed the presence of a persistent foramen ovale (PFO) in supine position. In upright position, there was a torrential increase in right-to-left shunting. The PFO was closed using an Occlutech™ device. Directly after the procedure, the patient was symptom free. Discussion A rise in RA pressure or difference in flow pattern in the RA can make a PFO become symptomatic. Elevated RA pressure was ruled out. Most anatomical pathologies influencing the flow pattern develop slowly over time. This case shows a presentation of POS after a recent stroke possible due to change in anatomy because of right hemidiaphragm paralysis in combination with the aortic dilatation.
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Affiliation(s)
- Marijn H Wiertsema
- Department of Cardiology, University of Groningen, University Medical Center Groningen , Hanzeplein 1 , 9713 GZ Groningen, The Netherlands
| | - Michael G Dickinson
- Department of Cardiology, University of Groningen, University Medical Center Groningen , Hanzeplein 1 , 9713 GZ Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University of Groningen, University Medical Center Groningen , Hanzeplein 1 , 9713 GZ Groningen, The Netherlands
| | - Christiane A Geluk
- Department of Cardiology, Martini Ziekenhuis , Groningen , The Netherlands
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16
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Goldsweig AM, Batlivala SP, Al-Azizi K, Aggarwal V, Babatunde I, Falck-Ytter Y, Morgan RL. SCAI Technical Review on Management of Patent Foramen Ovale. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100040. [PMID: 39131927 PMCID: PMC11307539 DOI: 10.1016/j.jscai.2022.100040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Background Patent foramen ovale (PFO) is a common anatomic variant associated with intermittent right-to-left shunting. Transcatheter PFO closure has been proposed to address multiple clinical conditions including stroke, transient ischemic attack, migraine, and decompression illness. Methods A systematic review was conducted using the GRADE approach to address 5 questions formulated by the Society for Cardiovascular Angiography and Interventions (SCAI) Guideline Panel in patient, intervention, comparator, outcome (PICO) format. Medical literature from January 2015 through May 2021 was searched. Extracted data underwent review and risk-of-bias assessment by 2 independent researchers. Pooled effect estimates were calculated. Certainty of evidence was determined for each query. Results Our search identified 2701 titles and abstracts, of which 30 met eligibility criteria and informed the technical review. Data were abstracted to address outcomes of PFO closure for patients with and without prior stroke, in comparison to antiplatelet therapy, in comparison to anticoagulation, and with various post-procedure antithrombotic regimens. Conclusion In appropriately selected patients with prior stroke, transcatheter PFO closure reduces the risk of recurrent stroke more than antiplatelet therapy alone. Evidence to support PFO closure is weaker regarding older patients, anticoagulation, thrombophilia, transient ischemic attack, migraine, and decompression illness. Data from this technical review will inform the SCAI Guideline for Transcatheter Patent Foramen Ovale Closure.
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Affiliation(s)
- Andrew M. Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sarosh P. Batlivala
- Heart Institute, Cincinnati Children's Hospital Medical Center & Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karim Al-Azizi
- Baylor Scott & White Health, The Heart Hospital, Plano, Texas
| | - Vikas Aggarwal
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan (Frankel Cardiovascular Center), Ann Arbor, Michigan
- Section of Cardiology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Yngve Falck-Ytter
- Evidence Foundation, Cleveland Heights, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Case Western University, Cleveland, Ohio
| | - Rebecca L. Morgan
- Evidence Foundation, Cleveland Heights, Ohio
- Case Western University, Cleveland, Ohio
- Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada
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17
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Kavinsky CJ, Szerlip M, Goldsweig AM, Amin Z, Boudoulas KD, Carroll JD, Coylewright M, Elmariah S, MacDonald LA, Shah AP, Spies C, Tobis JM, Messé SR, Senerth E, Falck-Ytter Y, Babatunde I, Morgan RL. SCAI Guidelines for the Management of Patent Foramen Ovale. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100039. [PMID: 39131947 PMCID: PMC11307505 DOI: 10.1016/j.jscai.2022.100039] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Background Patent foramen ovale (PFO) is a vestigial congenital cardiovascular structure present in around 25% of adults. In most cases, PFO is entirely benign and requires no treatment. However, it may cause serious complications under certain circumstances. Objective These evidence-based guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI) aim to support patients, clinicians, and other stakeholders in decisions about management of PFO. Methods SCAI convened a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The Evidence Foundation, a registered 501(c)(3) nonprofit organization, provided methodological support for the guideline-development process. Following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the guideline panel formulated and prioritized clinical questions in population, intervention, comparison, outcome (PICO) format. A separate technical review team of clinical and methodological experts conducted systematic reviews of the evidence, synthesized data, and graded the certainty of the evidence across outcomes. The guideline panel then reconvened to formulate recommendations and supporting remarks informed by the results of the technical review and additional contextual factors described in the GRADE evidence-to-decision framework. Results The panel agreed on 13 recommendations to address variations on 5 clinical scenarios. Conclusions Key recommendations address patient selection for PFO closure in the prevention of recurrent PFO-associated stroke, including populations not commonly included in randomized studies, and scenarios where the PFO closure might serve a role in the prevention of other outcomes such as migraine headaches and decompression illness. The panel has also identified future research priorities to advance the field.
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Affiliation(s)
| | - Molly Szerlip
- Baylor Scott & White The Heart Hospital, Plano, Texas
| | | | - Zahid Amin
- AdventHealth Medical Group, Orlando, Florida
| | | | - John D. Carroll
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | | | - Christian Spies
- Sutter Health Palo Alto Medical Foundation, Burlingame, California
| | | | - Steven R. Messé
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Senerth
- Society for Cardiovascular Angiography & Interventions, Washington, DC
| | - Yngve Falck-Ytter
- Case Western Reserve University/VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Rebecca L. Morgan
- Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada
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18
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Oguntade AS, Oguntade MS. Patent foramen ovale closure review: decades of research and the evolution of the evidence. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A quarter of the population suffers from patent foramen ovale, a form of interatrial shunt. It has been linked to cryptogenic strokes and is a common cause of paradoxical embolism.
Main text
The benefit of closing the patent foramen ovale in cryptogenic stroke patients aged 18-60 years to prevent recurrent strokes, particularly in those with large shunts or associated atrial septal aneurysms, was recently demonstrated. It is a relatively safe procedure that necessitates post-operative anticoagulation, but it has been linked to new-onset atrial fibrillation of uncertain significance. The effectiveness of patent foramen closure depends on patient selection, and prediction scores such as the Risk of Paradoxical Embolism (RoPE) score should be used. Newer closure devices, such as bioabsorbable devices like the Biostar system and ‘device-less’ devices like the Noble Stitch, are becoming more common due to their lower operative risks. The use of such devices in future trials, as well as careful case selection, could improve the acceptability of patent foramen ovale closure in the general population, removing the need for perioperative anticoagulation.
Conclusion
Individuals aged 18-60 years with cryptogenic stroke who have adverse patent foramen ovale morphology on imaging should be offered patent foramen ovale closure, preferably using the newer closure devices. More studies are needed to determine the significance of periprocedural atrial fibrillation after device closure.
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19
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Hayek A, Rioufol G, Bochaton T, Rossi R, Mewton N, Paccalet A, Bonnefoy-Cudraz E, Thibault H, Derimay F. Prognosis After Percutaneous Foramen Ovale Closure Among Patients With Platypnea-Orthodeoxia Syndrome. J Am Coll Cardiol 2021; 78:1844-1846. [PMID: 34711343 DOI: 10.1016/j.jacc.2021.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
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20
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Rajendram R, Hussain A, Mahmood N, Via G. Dynamic right-to-left interatrial shunt may complicate severe COVID-19. BMJ Case Rep 2021; 14:14/10/e245301. [PMID: 34598966 PMCID: PMC8488708 DOI: 10.1136/bcr-2021-245301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.
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Affiliation(s)
- Rajkumar Rajendram
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Arif Hussain
- Department of Cardiovascular Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Naveed Mahmood
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Gabriele Via
- Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
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21
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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22
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Ribeiro R, Fialho I, Boavida L. Platypnea-Orthodeoxia Syndrome: A Case of Persistent Hypoxemia in an Elderly Patient. Circulation 2021; 144:395-398. [PMID: 34339308 DOI: 10.1161/circulationaha.121.054424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Renata Ribeiro
- Internal Medicine Department 4 (R.R., L.B.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Inês Fialho
- Cardiology Department (I.F.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Leonor Boavida
- Internal Medicine Department 4 (R.R., L.B.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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23
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Punzengruber G, Kolb R, Meier B, Binder RK. Percutaneous closure of a patent foramen ovale causing exercise hypoxemia: Case report and a review of the literature. Catheter Cardiovasc Interv 2021; 98:733-737. [PMID: 34145952 DOI: 10.1002/ccd.29825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 05/13/2021] [Accepted: 06/05/2021] [Indexed: 11/11/2022]
Abstract
Provoked exercise desaturation is a rare presentation of patent foramen ovale (PFO), when vigorous exercise leads to desaturation of arterial blood and subsequent dyspnea. We present a case of provoked exercise desaturation and curative percutaneous closure and review the literature. A 54-year-old male patient presented with shortness of breath during exercise in the pneumology outpatient department. During exercise spirometry, a relevant drop in arterial oxygen saturation and partial pressure of oxygen was observed and a right-left shunt suspected. In a transesophageal echocardiogram, a PFO was observed. Cardiac catheterization documented a right-left-shunt causing desaturation during exercise. Following percutaneous closure of the PFO, exercise induced desaturation was no longer detectable during exercise spirometry and there was considerable improvement in exercise capacity and subjective dyspnea. To sum up, provoked exercise desaturation is a rare but curable presentation of PFO. Percutaneous closure is a safe and effective way to treat this entity.
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Affiliation(s)
- Georg Punzengruber
- Department of Cardiology and Intensive Care, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Rainer Kolb
- Department of Pneumology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Bernhard Meier
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Ronald K Binder
- Department of Cardiology and Intensive Care, Klinikum Wels-Grieskirchen, Wels, Austria
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24
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Jung SM, Lee SH, Cho HM, Lee SY, Park YH. Platypnea-Orthodeoxia Syndrome after Thoracic Vertebral Compression Fracture Successfully Treated by Percutaneous Patent Foramen Ovale Closure. J Cardiovasc Imaging 2021; 29:281-283. [PMID: 33605095 PMCID: PMC8318820 DOI: 10.4250/jcvi.2020.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Soon Myung Jung
- Department of Internal Medicine, Pusan National University School of Medicine, Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Hyun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, Korea.
| | - Hyun Myung Cho
- Department of Internal Medicine, Pusan National University School of Medicine, Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo Yong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong Hyun Park
- Department of Internal Medicine, Pusan National University School of Medicine, Cardiovascular Center, Pusan National University Yangsan Hospital, Yangsan, Korea
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25
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Kheiwa A, Hari P, Madabhushi P, Varadarajan P. Patent foramen ovale and atrial septal defect. Echocardiography 2020; 37:2172-2184. [PMID: 33368546 DOI: 10.1111/echo.14646] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/07/2020] [Indexed: 11/30/2022] Open
Abstract
Atrial septal defects (ASD) are among the most common congenital heart diseases encountered in adulthood. Patent foramen ovale (PFO) is present in up to 25% of the population. ASD could present as isolated lesion or in association with more complex congenital heart disease form as tetralogy of Fallot, or Ebstein's anomaly of tricuspid valve. There is a wide range of clinical presentation ranging from asymptomatic subjects surviving to adulthood undiagnosed to subjects presenting with right heart failure and severe pulmonary vascular disease (Eisenmenger syndrome). This manuscript is an in depth review of the complex atrial septation, the variable clinical presentation of ASD and PFO, and its clinical and therapeutic implications.
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Affiliation(s)
- Ahmed Kheiwa
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pawan Hari
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pranav Madabhushi
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Padmini Varadarajan
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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26
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Structural heart intervention for prevention of embolic and hemorrhagic stroke: The new field of neurocardiology. J Cardiol 2020; 76:227-235. [PMID: 32482326 DOI: 10.1016/j.jjcc.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022]
Abstract
Cardiogenic stroke (CS), characteristic causes of which include atrial fibrillation (AF) and right-to-left shunting due to a patent foramen ovale (PFO), has a well-known tendency to be associated with a more extensive ischemic area. This may result in severe neurological damage, and require strict life-long antithrombotic therapy. However, the fact that some patients have problems complying with the requirement for extended oral antithrombotic treatment has motivated the development of alternative approaches for stroke prevention. Heart structures such as the left atrial appendage (LAA) and PFO are potential targets for stroke prevention by way of device implantation. Several large prospective randomized clinical trials have demonstrated efficacy and safety of devices dedicated to this purpose. Percutaneous LAA occlusion for patients with non-valvular AF resulted in similar embolic event rates but significantly reduced bleeding events than did therapy with warfarin. Furthermore, PFO closure significantly reduced the frequency of recurrent embolic stroke relative to oral antithrombotic treatment. Current unsolved problems remaining in the application of these two strategies can be identified as the lack of standardized regimens for post-procedural antithrombotic therapy, ambiguity of determining the indications therefore, and the problem of device-related thrombus, which need to be investigated in depth in future. Cost-benefit analysis in comparison with standard medication is also required for each instance. A heart-brain multidisciplinary team approach, mandated to start such structural heart interventions, will become the future standard unit of personnel for stroke management, which promises to usher in the new field of neurocardiology.
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27
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Tong J, Quek WY. Not so innocuous after all: a case report of platypnoea-orthodeoxia syndrome. Singapore Med J 2020; 61:338-339. [PMID: 32754767 PMCID: PMC7905129 DOI: 10.11622/smedj.2018102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jieli Tong
- Department of Cardiology, Tan Tock Seng Hospital, Singapore.
| | - Wei Yong Quek
- Department of Cardiology, Tan Tock Seng Hospital, Singapore.
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28
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Dvoretskiy LI, Rezvan VV. [Platypnea: оne more type position shortness of breath]. TERAPEVT ARKH 2020; 92:92-97. [PMID: 32598799 DOI: 10.26442/00403660.2020.03.000436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Indexed: 11/22/2022]
Abstract
The article presents modern data on the causes of platypnea, methods of its diagnosis and treatment. The data on the development of platypnea syndrome are given not only in cardiac pathology, but also in severe liver diseases with the development of hepatopulmonary syndrome and chronic obstructive pulmonary disease of a severe course.
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Affiliation(s)
- L I Dvoretskiy
- Sechenov First Moscow State Medical University (Sechenov University)
| | - V V Rezvan
- Sechenov First Moscow State Medical University (Sechenov University)
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De Cuyper C, Pauwels T, Derom E, De Pauw M, De Wolf D, Vermeersch P, Van Berendoncks A, Paelinck B, Vermeersch G. Percutaneous Closure of PFO in Patients with Reduced Oxygen Saturation at Rest and during Exercise: Short- and Long-Term Results. J Interv Cardiol 2020; 2020:9813038. [PMID: 32265599 PMCID: PMC7109556 DOI: 10.1155/2020/9813038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 02/13/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A patent foramen ovale (PFO) is a rare cause of hypoxemia and clinical symptoms of dyspnea. Due to a right-to-left shunt, desaturated blood enters the systemic circulation in a subset of patients resulting in dyspnea and a subsequent reduction in quality of life (QoL). Percutaneous closure of PFO is the treatment of choice. OBJECTIVES This retrospective multicentre study evaluates short- and long-term results of percutaneous closure of PFO in patients with dyspnea and/or reduced oxygen saturation. METHODS Patients with respiratory symptoms were selected from databases containing all patients percutaneously closed between January 2000 and September 2018. Improvement in dyspnea, oxygenation, and QoL was investigated using pre- and postprocedural lung function parameters and two postprocedural questionnaires (SF-36 and PFSDQ-M). RESULTS The average follow-up period was 36 [12-43] months, ranging from 0 months to 14 years. Percutaneous closure was successful in 15 of the 16 patients. All patients reported subjective improvement in dyspnea immediately after device deployment, consistent with their improvement in oxygen saturation (from 90 ± 6% to 94 [92-97%] on room air and in upright position) (p < 0.05). Both questionnaires also indicated an improvement of dyspnea and QoL after closure. The two early and two late deaths were unrelated to the procedure. CONCLUSION PFO-related dyspnea and/or hypoxemia can be treated successfully with a percutaneous intervention with long-lasting benefits on oxygen saturation, dyspnea, and QoL.
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Affiliation(s)
- Céline De Cuyper
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Tristan Pauwels
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Daniël De Wolf
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Paul Vermeersch
- Department of Cardiology, Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | | | - Bernard Paelinck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Gaëlle Vermeersch
- Department of Cardiology, Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
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Arfaras-Melainis A, Palaiodimos L, Mojadidi MK. Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update. Interv Cardiol Clin 2019; 8:341-356. [PMID: 31445719 DOI: 10.1016/j.iccl.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA
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Cao L. Characteristics and analysis of right-to-left shunt-related dizziness in patients without hypoxemia. J Int Med Res 2019; 47:2921-2928. [PMID: 31130028 PMCID: PMC6683883 DOI: 10.1177/0300060519850940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/25/2019] [Indexed: 11/16/2022] Open
Abstract
Objective This study aimed to analyze right-to-left shunt-related dizziness in three patients without hypoxemia. Methods Case 1 was a 47-year-old man with a history of cerebral infarction 8 years previously and recurrent dizziness for > 6 months. Patent foramen ovale (PFO) was found with a severe right-to-left shunt. Case 2 was a 50-year-old man with acute stroke. He had a history of repeated dizziness for > 4 years. He was diagnosed with PFO with a severe right-to-left shunt after admission. Case 3 was a 73-year-old woman with recurrent dizziness for > 10 months. Pulmonary arteriovenous fistula was diagnosed upon admission. No patients had hypoxemia. Results After percutaneous PFO occlusion in Cases 1 and 2, the patients were followed up for 6 months and 1 year, respectively. Two patients had relief of dizziness without recurrence. In Case 3, the pallor improved and the dizziness was relieved after pulmonary arteriovenous fistula embolization and did not recur over a 6-month follow-up. Conclusions There was a possible association between a severe right-to-left shunt and dizziness, although hypoxemia was absent in the cases. Intervention to eliminate a left-to-right shunt can improve dizziness in patients without hypoxemia with a severe right-to-left shunt.
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Affiliation(s)
- Liming Cao
- First Affiliated Hospital of Jinan University, Department of Neurology, Guangzhou Guangdong, China
- The Third Affiliated Hospital of Shenzhen University, Department of Neurology, Guangdong, China
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Modified Method of Contrast Transthoracic Echocardiography for the Diagnosis of Patent Foramen Ovale. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9828539. [PMID: 31211145 PMCID: PMC6532309 DOI: 10.1155/2019/9828539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
Purpose To compare the sensitivity and specificity of modified and traditional methods of contrast echocardiography of the right portion of the heart in patients with a suspicion of patent foramen ovale (PFO). Methods The study population consisted of 506 patients with high clinical suspicion of PFO. The traditional Valsalva maneuver consists of expiration against a closed glottis after a full inspiration. A modified Valsalva maneuver was performed with a handmade pressure monitoring device, which measured pressure during performance of the Valsalva maneuver. Modified and traditional methods of contrast echocardiography were performed among all patients. Contrast transesophageal echocardiography (TEE) was regarded as the gold standard. Results A total of 279 patients with PFO were confirmed by TEE. 259 cases (sensitivity: 92.83%) were detected by a modified method of contrast echocardiography of the right portion of the heart, while 234 cases were detected using the traditional method (sensitivity: 83.87%). The sensitivity of modified contrast echocardiography of the right portion of the heart was significantly higher than that of the traditional method (92.83% vs. 83.87%, P=0.001). However, there was no significant difference in the specificity of the two methods for the diagnosis of PFO (97.35% vs. 96.03%, P=0.431). Additionally, the results of semiquantitative evaluation of PFO using modified method failed to show a more positive rate than shown by the traditional method (Z=−1.782, P=0.075). Conclusions Modified contrast echocardiography of the right portion of the heart yielded a higher sensitivity than the traditional method, which contributed to the diagnosis of cardiac PFO. The research was a part of a register study (https://register.clinicaltrials.gov/ ClinicalTrials ID: NCT02777359).
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Abstract
Patent foramen ovale (PFO), an embryonic remnant of the fetal circulation, is present in 20-25% of adults. Although recent observational studies and clinical trials have established the link between PFO-mediated right-to-left shunting with cryptogenic stroke and migraine with aura, the role of a PFO in exacerbating hypoxemic medical conditions (ie, sleep apnea, chronic obstructive pulmonary disease, pulmonary hypertension, platypnea-orthodeoxia, pulmonary arteriovenous malformation, high-altitude pulmonary edema, and exercise desaturation) remains less understood. PFO-mediated hypoxemia occurs when deoxygenated venous blood from the right atrium enters and mixes with oxygenated arterial blood in the left atrium. Patients with an intracardiac right-to-left shunt may have profound hypoxemia out of proportion to underlying primary lung disease, even in the presence of normal right-sided pressures. The presence of right-to-left cardiac shunting can exacerbate the degree of hypoxemia in patients with underlying pulmonary disorders. In a subset of these patients, percutaneous PFO closure may result in marked improvement in dyspnea and hypoxemia. This review discusses the association between PFO-mediated right-to-left shunting with medical conditions associated with hypoxemia and explores the role of percutaneous PFO closure in alleviating the hypoxemia.
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Agdamag AC, Gomez JM, Collado FM, Kavinsky C. Patent foramen ovale and ascending aortic aneurysm causing the platypnea-orthodeoxia syndrome. Proc (Bayl Univ Med Cent) 2019; 32:242-244. [PMID: 31191140 DOI: 10.1080/08998280.2018.1559387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022] Open
Abstract
Patent foramen ovale (PFO) is present in about 25% of the population. Platypnea-orthodeoxia syndrome (POS), which is dyspnea and hypoxemia in the upright position that is relieved when supine, is a rare manifestation of PFO. We describe a case of a 74-year-old woman who presented with new-onset hypoxia. A PFO and a dilated aorta causing POS were found on workup. Symptoms were resolved after undergoing percutaneous PFO closure. This case highlights the mechanism by which an ascending aortic aneurysm can alter hemodynamics through an existing PFO, leading to symptoms of a previously clinically insignificant PFO, and emphasizes how early recognition of POS allows for appropriate intervention.
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Affiliation(s)
| | | | - Fareed Moses Collado
- Division of Cardiology, Department of Internal Medicine, Rush University Medical CenterChicagoIllinois
| | - Clifford Kavinsky
- Division of Cardiology, Department of Internal Medicine, Rush University Medical CenterChicagoIllinois
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Iwai T, Miyamoto T, Miyazaki R, Nozato T. Platypnoea-orthodeoxia syndrome exacerbated by kyphosis progression. BMJ Case Rep 2018; 2018:bcr-2017-223514. [PMID: 30061123 DOI: 10.1136/bcr-2017-223514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is a case of an 86-year-old woman with gradually progressive dyspnoea and hypoxaemia that occurred after a cardiac surgery. It was underdiagnosed for several years, but diagnosis was triggered by the finding of hypoxaemia even during supplemental oxygen administration when in the upright position, such as when taking a shower, that rapidly improved when the patient returned to the supine position. A thorough workup disclosed platypnoea-orthodeoxia syndrome (POS) associated with right-to-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was performed. After treatment, the patient's arterial oxygen saturation gradually recovered to 98% on room air while she was in the sitting position and her symptoms disappeared. Reviewing this case retrospectively, we determined that the deviation of the spine with kyphosis progression had apparently proceeded as POS worsened over time. We therefore hypothesised that kyphosis progression had played a major role in the POS progression.
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Affiliation(s)
- Takamasa Iwai
- Department of Cardiology, Japan Red Cross Musashino Hospital, Tokyo, Japan
| | - Takamichi Miyamoto
- Department of Cardiology, Japan Red Cross Musashino Hospital, Tokyo, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Japan Red Cross Musashino Hospital, Tokyo, Japan
| | - Toshihiro Nozato
- Department of Cardiology, Japan Red Cross Musashino Hospital, Tokyo, Japan
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Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders. J Am Heart Assoc 2018; 7:e007146. [PMID: 29910192 PMCID: PMC6220531 DOI: 10.1161/jaha.117.007146] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Fareed Moses S Collado
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Marie-France Poulin
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Joshua J Murphy
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Hani Jneid
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
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Acute Hypoxic and Refractory Respiratory Failure Induced by an Underlying PFO: An Unusual Case of Platypnea Orthodeoxia and Transient Complication after Transcatheter Closure. Case Rep Crit Care 2018; 2017:4397163. [PMID: 29318052 PMCID: PMC5727695 DOI: 10.1155/2017/4397163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/12/2017] [Indexed: 11/18/2022] Open
Abstract
Platypnea orthodeoxia (PO) is an infrequent condition of dyspnea with hypoxemia, increased by adopting an upright position and is relieved in decubitus. This condition may occur in patients with hidden intracardiac shunts, usually across a persistent foramen ovale (PFO). The incidence of PFO in general population is quite common, around 27%; however, the concurrent presentation with PO, especially in acute refractory respiratory failure, is extremely rare. PFO closure in this setting is still the treatment of choice with significant improvement or complete resolution of symptoms after closure with an overall periprocedural complication in the first 24 hours of approximately less than 5%. A transient ST-segment elevation in the inferior leads is present in extremely rare occasions and most likely is induced by either an air embolism or a mechanically provoked spasm of coronary arteries. We report a case of an 83-year-old woman in acute hypoxic and refractory respiratory failure in whom PO was identified, most likely induced by a hidden PFO. The patient underwent percutaneous transcatheter closure and developed immediate chest pain, transient hemodynamic instability, and ST-segment elevation in the inferior leads; nevertheless, our patient recovered completely with rapid resolution of respiratory failure with no adverse clinical sequelae.
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38
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Comparison of Different Contrast Agents in Detecting Cardiac Right-to-Left Shunt in Patients with a Patent Foramen Ovale during Contrast-Transthoracic Echocardiography. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6086094. [PMID: 29333447 PMCID: PMC5733159 DOI: 10.1155/2017/6086094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 11/08/2017] [Indexed: 12/17/2022]
Abstract
The aim of this study is to evaluate the ability of two different contrast agents to detect cardiac right-to-left shunting in patients with a patent foramen ovale during contrast transthoracic echocardiography and transesophageal echocardiography. Eighty-four patients who had migraines or experienced cryptogenic stroke were prospectively enrolled. Contrast echocardiography of the right portion of the heart was performed using an injection of either (i) 8 ml of agitated saline, 1 ml of blood, and 1 ml of air (ASB) or (ii) 4 ml of vitamin B6 and 6 ml of sodium bicarbonate solution (VSBS). All patients underwent contrast echocardiography with different contrast agents successively before undergoing transesophageal echocardiography. The diagnostic sensitivity of VSBS and ASB for cardiac shunting diagnosis was 94.23% and 78.85%, respectively. The diagnostic sensitivity in the VSBS group was significantly higher than that in the ASB group (χ2 = 5.283, P = 0.022). The observed semiquantitative shunt grading suggests that the positive rate in the VSBS group was higher than that in the ASB group (Z = −1.998, P = 0.046). The use of vitamin B6 and sodium bicarbonate solution as a TTE contrast agent yielded a high sensitivity compared with ASB. However, further trials with large sample size are required to confirm this finding.
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Shah AH, Osten M, Leventhal A, Bach Y, Yoo D, Mansour D, Benson L, Wilson WM, Horlick E. Percutaneous Intervention to Treat Platypnea-Orthodeoxia Syndrome: The Toronto Experience. JACC Cardiovasc Interv 2017; 9:1928-38. [PMID: 27659570 DOI: 10.1016/j.jcin.2016.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/06/2016] [Accepted: 06/30/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study reviewed a series of patients treated with transcatheter closure of septal defect to treat platypnea-orthodeoxia syndrome, with specific attention to septal characteristics and device choice. BACKGROUND Platypnea-orthodeoxia syndrome is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO), an atrial septal defect, or pulmonary arteriovenous malformations. Percutaneous closure of such defects is the treatment of choice. METHODS In this single-center series, 52 patients were treated with percutaneous closure of an interatrial communication after presentation between January 1997 and July 2015. Septal morphology, clinical, procedural, and outcomes data were analyzed. RESULTS All patients had a PFO; however, nearly one-quarter required a non-PFO device (11 Amplatzer Septal Occluder and 1 post-infarct muscular VSD), as opposed to a dedicated PFO device to achieve shunt occlusion. These patients were characterized by an aneurysmal septum, shorter primum septum overlap with the secundum septum, and greater septal angulation from the midline. After closure, all demonstrated acute improvements in oxygen saturation (pre-procedure: 81 ± 8%; post-procedure: 95.1 ± 0.5% on room air). Each patient was treated with a single device and no one required re-intervention. CONCLUSIONS Patients presenting with platypnea-orthodeoxia syndrome can be treated successfully with a percutaneous intervention often requiring a variety of devices. Those requiring a non-PFO-type device had a greater prevalence of an aneurysmal septum, shorter primum septal overlap with the secundum septum, and greater septal angulation with the midline.
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Affiliation(s)
- Ashish H Shah
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Mark Osten
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Andrew Leventhal
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Yvonne Bach
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Daniel Yoo
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Danny Mansour
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Lee Benson
- The Labatt family Heart Centre, The Hospital for Sick Children, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - William M Wilson
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network
| | - Eric Horlick
- Peter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network.
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Abstract
A patent foramen ovale (PFO) is a common anatomic finding in 20% of the normal population. Significant hypoxemia can occur in circumstances in which hemodynamic or anatomic changes predispose to increased right-to-left intra-atrial shunting. The subsequent hypoxemia produces substantial dyspnea that may affect the patient's quality of life, independent of underlying pulmonary disease. Profound hypoxemia caused by right-to-left shunt across the interatrial septum usually responds to percutaneous PFO closure. An important impediment to successful treatment is the lack of awareness of the potential role of a PFO in this condition.
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Affiliation(s)
- Jonathan M Tobis
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Factor Building CHS, Room B-976, Los Angeles, CA 90095, USA.
| | - Deepika Narasimha
- Division of Cardiology, Interventional Cardiology, Loma Linda University Health, 11234 Anderson Street, MC 2434, Loma Linda, CA 92354, USA
| | - Islam Abudayyeh
- Division of Cardiology, Interventional Cardiology, Loma Linda University Health, 11234 Anderson Street, MC 2434, Loma Linda, CA 92354, USA
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Liu C, Lu T, Zhai NN, Bu N, Wang HQ, Chen MY, Wu HQ. Different Valsalva Manoeuvre Procedures for the Diagnosis of Right-to-Left Shunt by Contrast-Transcranial Doppler. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1716-1721. [PMID: 28545857 DOI: 10.1016/j.ultrasmedbio.2017.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 03/08/2017] [Accepted: 04/05/2017] [Indexed: 06/07/2023]
Abstract
The main purpose of this study was to compare two contrast agent injection times during the Valsalva manoeuvre (VM) for the diagnosis of right-to-left shunt using contrast-transcranial Doppler (c-TCD). In total, 992 consecutive patients underwent testing. All patients underwent step 1, and then a coin toss was used to determine the order of steps 2 and 3. The following testing steps were repeated twice: (1) a contrast agent (CA) was infused at rest (CA at rest testing); (2) the VM was initiated immediately after CA injection and released 10 s after CA injection (CA pre-VM testing); and (3) a CA was injected 5 s after initiating the VM, which was released 5 s after CA injection (CA mid-VM testing). For the CA at rest, pre-VM and mid-VM groups, significant differences were observed in the positive right-to-left shunt diagnosis rates (11.49% vs. 23.08% vs. 26.11%, respectively, with an inter-group significance of p < 0.05) and grade classifications (p < 0.05). Although the times to first microbubble appearance were similar between the CA at rest and the CA pre-VM groups (8.96 ± 3.40 s vs. 8.42 ± 3.72 s, p > 0.05), it was shorter (6.4 ± 2.75 s, p < 0.05) for the CA mid-VM group than for the other two groups. For the c-TCD testing, the CA mid-VM group yielded different results for diagnosing right-to-left shunts relative to the CA pre-VM group.
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Affiliation(s)
- Chao Liu
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China; Department of Education, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Teng Lu
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ni-Na Zhai
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ning Bu
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hu-Qing Wang
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Meng-Yi Chen
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hai-Qin Wu
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Zhao E, Zhang Y, Kang C, Niu H, Zhao J, Sun L, Liu B. Influence of the Valsalva maneuver on cardiac hemodynamics and right to left shunt in patients with patent foramen ovale. Sci Rep 2017; 7:44280. [PMID: 28266661 PMCID: PMC5339784 DOI: 10.1038/srep44280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/06/2017] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to investigate the influence of the Valsalva maneuver (VM) on cardiac hemodynamics in patients with patent foramen ovale (PFO). Sixty-five patients who were highly suspected to have PFO were included. The changes in E, A, E/A ratio of mitral valve blood flow, E, A, E/A ratio of tricuspid valve blood flow, left ventricular end-diastolic volume, area and right atrial area during the resting state and the strain phase of the Valsalva maneuver were observed by transthoracic echocardiography (TTE). Statistical analyses were performed using SPSS Version18.0. Compared to the resting state, mitral valve diastolic velocity E and A peaks at the strain phase of the Valsalva maneuver significantly decreased (P < 0.05), left ventricular end diastolic volume(LVEDV) and area(LVEDA) decreased significantly (P < 0.05), while E/A ratio of mitral valve, tricuspid valve systolic velocity E and A peaks and E/A ratio remained unchanged (P > 0.05). PFO hemodynamic changes mainly occurred in the left ventricle when the Valsalva maneuver was performed. The Valsalva maneuver increased pressure in the chest, then pulmonary venous return was impeded, which resulted in left ventricular limited filling, and E and A peaks decreased. The pressure of the left ventricle and atrium was lower than that of the right side, which resulted in right-to-left shunt (RLS) through PFO.
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Affiliation(s)
- Enfa Zhao
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yafei Zhang
- Department of General Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chunmiao Kang
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hua Niu
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jing Zhao
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lei Sun
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Baomin Liu
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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González-Bartol E, Rojas-González A, Díez-Villanueva P, Acosta-Gutiérrez C, Pozo-Osinalde E, Alfonso F. [Platypnea-orthodeoxia syndrome secondary to intracardiac shunt: Orientation issue?]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:357-359. [PMID: 28126374 DOI: 10.1016/j.acmx.2016.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/13/2016] [Accepted: 12/13/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | | | | | | | - Fernando Alfonso
- Servicio de Cardiología, Hospital Universitario La Princesa, Madrid, España
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Zier LS, Sievert H, Mahadevan VS. To close or not to close: contemporary indications for patent foramen ovale closure. Expert Rev Cardiovasc Ther 2016; 14:1235-1244. [DOI: 10.1080/14779072.2016.1224178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tobis JM, Abudayyeh I. Platypnea-Orthodeoxia Syndrome. JACC Cardiovasc Interv 2016; 9:1939-40. [DOI: 10.1016/j.jcin.2016.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 10/21/2022]
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Hovnanians N, Mojadidi MK, Brandt JC, Eshtehardi P, Tobis JM. Platypnea-Orthodeoxia Syndrome: From Gastroesophageal Reflux to Hypoxemia. Am J Med 2016; 129:e15-6. [PMID: 26773976 DOI: 10.1016/j.amjmed.2015.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 12/02/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Ninel Hovnanians
- Albert Einstein College of Medicine (Jacobi Program), Bronx, NY.
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Sekihara T, Kimura M, Hazama D, Kimura Y, Hayashi H, Okano M, Funasako M, Sasaki K, Nakane E, Miyamoto S, Izumi T, Haruna T, Fukui M, Inoko M. Platypnea-orthodeoxia Syndrome Diagnosed Using Contrast Transesophageal Echocardiography with Simultaneous SpO2 Monitoring. Intern Med 2016; 55:2203-7. [PMID: 27522995 DOI: 10.2169/internalmedicine.55.6385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Platypnea-orthodeoxia syndrome (POS) is a rare condition characterized by interatrial right-to-left shunting that is exacerbated in the upright position. We herein report a 78-year-old woman with POS that remained undiagnosed for 2 years, despite repetitive transthoracic echocardiography (TTE). POS was ultimately diagnosed using contrast transesophageal echocardiography (TEE), which revealed a marked increase in right-to-left shunting in the sitting position, associated with simultaneous desaturation. Therefore, we propose that POS should be considered according to the clinical symptoms, regardless of the repetitive TTE results, and contrast TEE should be performed in both the supine and sitting positions to exclude a diagnosis of POS.
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Affiliation(s)
- Takayuki Sekihara
- Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Cardiovascular Center, Japan
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Wadia S, Boateng S, Kenny D, Kavinsky C. Platypnea-Orthodeoxia in Patients on Hemodialysis: A New Approach to Its Pathophysiology and Implications for Treatment. Cardiology 2015; 133:213-6. [PMID: 26667002 DOI: 10.1159/000441970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/23/2015] [Indexed: 11/19/2022]
Abstract
Platypnea-orthodeoxia is a poorly understood clinical syndrome resulting in dyspnea and hypoxemia in the upright position, which diminishes with recumbency. Recognition of the disease is limited by its low prevalence and decreased awareness among clinicians. However, understanding the disease, its pathophysiology, its clinical presentation, and the possible therapeutic options is vital in the management of these patients. Here, we present 2 cases of platypnea- orthodeoxia where oxygen saturations worsened with hemodialysis. After highlighting the common features in the clinical pattern of each patient, we present a pressure-mediated pathophysiologic mechanism (in contrast to a previously reported morphologically based hypothesis) to explain the characteristic effects of hemodialysis on hypoxia in platypnea-orthodeoxia. We present a novel diagnostic approach using balloon occlusion testing when the diagnosis is unclear and illustrate how treatments can be tailored to the comorbidities of a specific patient.
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Affiliation(s)
- Subeer Wadia
- Rush University Medical Center, Chicago, Ill., USA
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49
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Mojadidi MK, Christia P, Salamon J, Liebelt J, Zaman T, Gevorgyan R, Nezami N, Mojaddedi S, Elgendy IY, Tobis JM, Faillace R. Patent foramen ovale: Unanswered questions. Eur J Intern Med 2015; 26:743-51. [PMID: 26489724 DOI: 10.1016/j.ejim.2015.09.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/26/2015] [Accepted: 09/27/2015] [Indexed: 11/29/2022]
Abstract
The foramen ovale is a remnant of the fetal circulation that remains patent in 20-25% of the adult population. Although long overlooked as a potential pathway that could produce pathologic conditions, the presence of a patent foramen ovale (PFO) has been associated with a higher than expected frequency in a variety of clinical syndromes including cryptogenic stroke, migraines, sleep apnea, platypnea-orthodeoxia, deep sea diving associated decompression illness, and high altitude pulmonary edema. A unifying hypothesis is that a chemical or particulate matter from the venous circulation crosses the PFO conduit between the right and left atria to produce a variety of clinical syndromes. Although observational studies suggest a therapeutic benefit of PFO closure compared to medical therapy alone in patients with cryptogenic stroke, 3 randomized controlled trials (RCTs) did not confirm the superiority of PFO closure for the secondary prevention of stroke. However, meta-analyses of these RCTs demonstrate a significant benefit of PFO closure over medical therapy alone. Similarly, observational studies provide support for PFO closure for symptomatic relief of migraines. But one controversial randomized study failed to replicate the results of the observational studies while another two demonstrated a partial benefit. The goal of this review is to discuss the clinical conditions associated with PFO and provide internists and primary care physicians with current data on PFO trials, and clinical insight to help guide their patients who are found to have a PFO on echocardiographic testing.
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Affiliation(s)
- Mohammad Khalid Mojadidi
- Division of Cardiology, University of Florida College of Medicine, Gainesville, FL, United States.
| | - Panagiota Christia
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
| | - Jason Salamon
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
| | - Jared Liebelt
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
| | - Tarique Zaman
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
| | - Rubine Gevorgyan
- Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Nariman Nezami
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
| | - Sanaullah Mojaddedi
- Division of Cardiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Islam Y Elgendy
- Division of Cardiology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jonathan M Tobis
- Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Robert Faillace
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, United States
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50
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Zhao E, Wei Y, Zhang Y, Zhai N, Zhao P, Liu B. A Comparison of Transthroracic Echocardiograpy and Transcranial Doppler With Contrast Agent for Detection of Patent Foramen Ovale With or Without the Valsalva Maneuver. Medicine (Baltimore) 2015; 94:e1937. [PMID: 26512622 PMCID: PMC4985435 DOI: 10.1097/md.0000000000001937] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patent foramen ovale (PFO) is a remnant of the fetal circulation exist in 20% of the general population. The purpose of our study was to compare of transthoracic echocardiography (TTE) and contrast-transcranial Doppler sonography (c-TCD) in the diagnosis and quantification of PFO with or without the Valsalva maneuver (VM).We studied 106 patients with a high clinical suspicion for PFO prospectively. Simultaneous c-TCD and TTE were conducted using agitated saline solution to detect right to left shunt (RLS). To classify RLS, mainly PFO, we applied a 4-level visual classification for c-TCD test: no occurrence of micro-embolic signals; grade I, 1 to 10 signals; grade II, 10 to 30 signals but not curtain; and grade III, curtain pattern. We used the number of micro-bubbles appeared in left atrium per frame image to define classification for TTE test: no occurrence of micro-bubbles; grade I, 1 to 10 micro-bubbles; grade II, 10 to 30 micro-bubbles; and grade III, more than 30 micro-bubbles or left atrium nearly filled with micro-bubbles or left atrial opacity. Statistical analyses were performed using SPSS Version 18.0.RLS was detected in 36.0% in c-TCD test and in 46% in TTE test at rest (P = 0.158). And during the VM, RLS was detected in 99.0% in c-TCD test and in 83.0% in TTE test (P < 0.001). Compared with the positive results of c-TCD and TTE at rest, the positive results of them with VM is more higher, respectively (all P < 0.001). The VM obviously increased the number of micro-bubbles shunting.Both c-TCD and TTE should used as initial screening tool for PFO. VM increases the size of shunt. VM resulted in detection of more RLS both in c-TCD and TTE tests.
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Affiliation(s)
- Enfa Zhao
- From the Department of Ultrasound, Second Affiliated Hospital of Medical School, Xi'an Jiao Tong University (EZ, YW, BL); Department of General Surgery, Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University (YZ); and Transcranial Doppler Sonography Laboratory, Second Affiliated Hospital of Medical School, Xi'an Jiao Tong University, Xi'an, Shaanxi, China (NZ, PZ)
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