Definitions and pathophysiology of the patent foramen ovale: broad overview

Spectral Doppler interrogation of the patent foramen ovale-a window to left heart hemodynamics

Spectral Doppler interrogation of flow across a patent foramen ovale (PFO) allows recording of the instantaneous pressure gradient between left and right atrium (RA). The assessment of RA pressure using the size and collapsibility of the inferior vena cava would thus allow estimation of left atrial (LA) pressure. In this article, we illustrate the value of spectral Doppler interrogation of flow across the PFO by transthoracic echocardiography as a novel and simple tool for the assessment of LA pressure and left cardiac hemodynamics in addition to the conventional noninvasive parameters.

The new patent foramen ovale occluder FIGULLA in complex septal anatomy: a case series

BACKGROUND

The appropriate treatment strategy for secondary stroke prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) remains challenging. The aim of this study was to describe a case series of patients with PFO and complex septal anatomy who underwent percutaneous correction using a FIGULLA (Occlutech) septal occluder (FSO).

PATIENTS

Ten consecutive patients (6 females, 4 males, mean age 41.6 ± 16.0 years, range 17-52 years; group 1) with cryptogenetic stroke and/or transient cerebral ischemia and complex septal anatomy, as defined by intraprocedural transesophageal echocardiogram (TEE) were compared with a group of 25 patients (10 females, 15 males, mean age 43.7 ± 12.3 years; group 2) with usual tunnel-like PFO anatomy in whom PFO was closed by an Amplatzer septal occluder (ASO; AGA).

RESULTS

No significant differences were noted between group 1 and group 2 for immediate success rate, residual intraprosthetic shunt at the end of the procedure, discharge, 1, 6 and 12 months follow up, number of attempts, procedure time, fluoroscopy time, or cardiac complication (atrial arrhythmias, device embolism). The only significant difference was shown for delivery sheath size (11 ± 2 versus 9 ± 1 F) and incidence of local hematoma (30% versus 12%) between group 1 and group 2, without any clinical consequence (need of transfusion) or increase in length of stay.

CONCLUSION

FSO shows high performance in patients with PFO and complex septal anatomy when compared with patients with PFO and uncomplicated atrial anatomy treated by ASO. Its favorable behavior is probably related to fabric features such as the total amount of metal and the presence of titanium.

Double-edged sword in the heart: trapped deep venous thrombus in a patent foramen ovale

Trapped thrombus in a patent foramen ovale is a rare condition. Echocardiography is the main tool for diagnosis and for determination of the treatment to choose. There are a number of treatment options for trapped deep venous thrombus in a patent foramen ovale, including surgical thrombectomy, thrombolytics, and anticoagulant therapy. All patients should be evaluated individually, because the systemic and pulmonary thromboembolism risk of all treatment options is like a 'double-edged sword'. Here, we report a case of a patient with trapped thrombus in the patent foramen ovale detected by echocardiography, and successfully treated with surgical thrombectomy under extracorporeal circulation.

A case of limb ischemia secondary to paradoxical embolism

Paradoxical embolism is rarely considered a cause for acute limb ischemia. Although patent foramen ovales (PFOs) are often seen in young patients with stroke, clinicians may not consider evaluation for PFOs in young patients with acute peripheral ischemia. We present a 47-year-old patient presenting with lower extremity ischemia secondary to paradoxical embolism. This case highlights the importance of evaluating for paradoxical embolism in otherwise-unexplained cases of acute limb ischemia.

Percutaneous closure of patent foramen ovale: a case series and literature review

Patent foramen ovale (PFO) is an anatomical variant of the interatrial septum with an overall prevalence of 27% in autopsy studies. PFOs have a potential role in causation of stroke, platypneaorthodeoxia, decompression sickness, right to left shunt and migraine headaches. Data regarding percutaneous closure of PFO in low volume tertiary care centers is lacking. Retrospective review of 14 percutaneous PFO closures done in our facility from March 2005 to August 2006 was performed for efficacy of procedure and safety. All patients received clopidogrel for a period of 3 months, and aspirin and subacute bacterial endocarditis prophylaxis for 6 months. Mean age of the study population was 54 years. Fifty percent (7 of 14) of patients experienced an atrial septal aneurysm and 14% (2 patients) exhibited a hypercoagulable state. The indication for closure in 13 patients was transient ischemic attacks or strokes, while one patient had persistent hypoxia due to a severe right to left shunt at PFO. Patients received either a CardioSEAL or Amplatzer device. Deployment rate was 100%. All patients completed a minimum of 6 months of follow-up, with a mean follow-up time of 14.9 +/- 7.6 months. No immediate or late bleeding complication occurred in any patient. One patient developed paroxysmal atrial fibrillation and one patient developed thrombotic complications at 7 months post-procedure secondary to the progression of her anal carcinoma and subsequently died. Pending the results of the four large randomized trials that are enrolling patients, percutaneous closure of PFO for cryptogenic strokes is an attractive alternative to lifelong anticoagulation with relatively few complications, even in low volume centers. There are many challenges in the management of this subset of patients, the foremost being the selection of a target patient population. Role of PFO in migraines is less clear.

Evaluating Cardiac Sources of Embolic Stroke with MRI

The evaluation of patients with stroke includes identifying its etiology in order to appropriately tailor therapy. Currently, the diagnostic work-up includes imaging of the brain, the arteries of the head and neck, the aorta, and the heart. Traditional methods of imaging include magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), duplex ultrasound, and transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). While echocardiography remains a cornerstone in the field of cardiac imaging, MRI is increasingly able to assess for the most common causes of cardioembolic stroke such as left atrial/left atrial appendage thrombus, left ventricular thrombus, aortic atheroma, cardiac masses and patent foramen ovale. This review will focus on the advantages and limitations of echocardiography and cardiac magnetic resonance (CMR) imaging in diagnosing patients suspected of having an embolic stroke and the role these modalities play in clinical practice today.

Unusual presentation of a patient with arrhythmogenic right ventricular dysplasia treated with a Glenn shunt

Clinically, arrhythmogenic right ventricular dysplasia (ARVD) usually presents with ventricular arrhythmias, and unusual presentations were reported as acute coronary syndrome, heart failure and electrical storm. Taking all this different presentations and treatments in to account, we report a case of ARVD presenting with central cyanosis and clubbing simulating congenital heart disease. Besides this unusual presentation, the patient underwent also an unusual operation for this kind of abnormality, which cured the cyanosis completely.

Imaging of Pulmonary Embolism: Self–Assessment Module

The educational objectives for this self-assessment module on imaging of pulmonary embolism are for the participant to exercise, self-assess, and improve his or her understanding of the evaluation of patients with suspected pulmonary embolism using CT angiography; gain familiarity with nonembolic conditions that may be found in patients who are studied with CT angiography for suspected pulmonary embolism; and gain familiarity with the phenomenon of paradoxical embolism, its manifestations on CT angiography, and its radiologic differential diagnosis.

Radiological Reasoning: Pulmonary Embolism—Thinking Beyond the Clots

OBJECTIVE

We discuss the CT findings in a case of pulmonary embolism complicated by paradoxical embolism in a patient with a patent foramen ovale and atrial septal aneurysm.

CONCLUSION

When confronted with a case of pulmonary embolism on CT, besides evaluating the extent of pulmonary artery occlusion, the radiologist should examine the cardiovascular system to identify any unsuspected underlying or associated conditions.