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A Woman in Her 30s With Acute Refractory Hypoxemia and a History of Intravenous Drug Use. Chest 2018; 150:e129-e131. [PMID: 27832896 DOI: 10.1016/j.chest.2016.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 02/16/2016] [Accepted: 04/05/2016] [Indexed: 10/20/2022] Open
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2
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Patel PA, Hall A, Augoustides JGT, Patel S, Feinman JW, Weber B, Gutsche JT, Fabbro M, Maldonado Y. Dynamic Shunting Across a Patent Foramen Ovale in Adult Cardiac Surgery-Perioperative Challenges and Management. J Cardiothorac Vasc Anesth 2017; 32:542-549. [PMID: 29223721 DOI: 10.1053/j.jvca.2017.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew Hall
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Beth Weber
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
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3
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Khanijo S, Koenig S. A 42-year-old man presenting with progressive shortness of breath and severe hypoxemia. Chest 2015; 147:e83-e85. [PMID: 25732476 DOI: 10.1378/chest.14-1416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sameer Khanijo
- Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore-LIJ, New Hyde Park, NY..
| | - Seth Koenig
- Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore-LIJ, New Hyde Park, NY
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4
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Hypoxemia in a patient with pulmonary arterial hypertension: getting to the heart of the matter. Ann Am Thorac Soc 2015; 11:836-40. [PMID: 24936696 DOI: 10.1513/annalsats.201401-006cc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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5
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Bassett GC, Lin JW, Tran MM, Sistino JJ. Evaluating the potential risks of bubble studies during echocardiography. Perfusion 2014; 30:219-23. [DOI: 10.1177/0267659114539182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Cardiac shunts are often identified using bubble studies in echocardiography, with agitated saline. Previous studies have recommended various safe amounts of agitated saline. This poses a potential risk for air microembolism. The purpose of this study was to quantify the bubbles created by various quantities of agitated saline. Methods: A closed circuit was constructed with a HeartMate pneumatic ventricular assist pump and a cardiotomy reservoir to remove air during recirculation. One empty 10 mL syringe and one 10 mL syringe containing 1 mL of air and 9 mL of saline were attached to a three-way stopcock. The air/saline bolus was then agitated between the two syringes five times to create bubbles and injected into the tubing proximal to the HeartMate. An EDAC bubble detector sensor was attached prior to the saline injection site and distal to the HeartMate I to measure the size and volume of the bubbles. This technique was repeated using 0.5 mL of air and 9.5 mL of saline bolus and 2 mL of air and 8 mL of saline bolus. Each bolus was tested 20 times. Results: This study identifies the potential risks of air administration and proposes a safer air volume to agitate for the administration of a bubble study. Conclusions: Further studies should be conducted to create either a guideline or a standard for agitated saline administration by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) in order to minimize the risk of air microembolism
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Affiliation(s)
- GC Bassett
- Medical University of South Carolina, Charleston, USA
| | - JW Lin
- Medical University of South Carolina, Charleston, USA
| | - MM Tran
- Medical University of South Carolina, Charleston, USA
| | - JJ Sistino
- Medical University of South Carolina, Charleston, USA
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6
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Importance of Adequately Performed Valsalva Maneuver to Detect Patent Foramen Ovale during Transesophageal Echocardiography. J Am Soc Echocardiogr 2013; 26:1337-43. [DOI: 10.1016/j.echo.2013.07.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 02/06/2023]
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7
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Baglini R, Baldari D, Amaducci A, D'Ancona G. The new patent foramen ovale occluder FIGULLA in complex septal anatomy: a case series. Ther Adv Cardiovasc Dis 2012; 7:21-6. [PMID: 23238514 DOI: 10.1177/1753944712468628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Roberto Baglini
- Department of Interventional Cardiology, IsMeTT, University of Pittsburgh European Centre, via Tricomi 1, 90100 Palermo, Italy.
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8
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Percutaneous patent foramen ovale closure: outcomes with the Premere and Amplatzer devices. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:164-169. [DOI: 10.1016/j.carrev.2010.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 05/23/2010] [Accepted: 06/03/2010] [Indexed: 11/24/2022]
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9
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Hubail Z, Lemler M, Ramaciotti C, Moore J, Ikemba C. Diagnosing a Patent Foramen Ovale in Children. Stroke 2011; 42:98-101. [DOI: 10.1161/strokeaha.110.595876] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Purpose—
Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of a patent foramen ovale in adults. In children, acoustic windows on transthoracic echocardiography (TTE) are better than in adults; thus, an invasive TEE may not be necessary. Our goal was to assess the validity of TTE with agitated saline injection for the diagnosis of a patent foramen ovale in children using TEE as the gold standard.
Methods—
Fifty consecutive pediatric patients >1 year of age referred for TEE were prospectively enrolled. Imaging included 2-dimensional, color Doppler, and agitated saline contrast injections with and without Valsalva by TTE followed by TEE. Interpreters of the TTE were blinded to TEE results. Studies were categorized as “inconclusive” if the TTE images were inadequate for definitive diagnosis by the blinded interpreter.
Results—
TTE results were considered conclusive in 43 of 50 (86%) patients. Among the 43 conclusive studies, the 2 modalities disagreed in 1 patient. TTE had a positive predictive value of 100%, negative predictive value 97%, sensitivity of 88%, and specificity of 100% for detecting a patent foramen ovale.
Conclusions—
TTE with agitated saline injection is diagnostic for the assessment of atrial septal integrity in the majority of children.
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Affiliation(s)
- Zakariya Hubail
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Matthew Lemler
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Claudio Ramaciotti
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Jay Moore
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Catherine Ikemba
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
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10
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Abstract
In adults, patent foramen ovale or other potential intracardiac shunts are established risk factors for stroke via paradoxical embolization. Stroke is less common in children and risk factors differ. The authors examined the literature on intracardiac shunting and stroke in children, identifying the methods employed, the prevalence of detectible intracardiac shunts, associated conditions, and treatments. PubMed searches with keywords related to intracardiac shunting and stroke in children identified articles of interest. Additional articles were identified via citations in these articles or in reviews. The authors found that studies of intracardiac shunting in children with stroke are limited. No controlled studies were identified. Detection methods vary and the prevalence of echocardiographically detectible intracardiac shunting appears lower than reported in adults and autopsy studies. Defining the role of intracardiac shunting in pediatric stroke will require controlled studies with unified detection methods in populations stratified by additional risk factors for paradoxical embolization. Optimal treatment is unclear.
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Affiliation(s)
- Michael M Dowling
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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11
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Sharaf M, Rajaram M, Mulji A. Intracardiac shunt with hypoxemia caused by right ventricular dysfunction following pericardiocentesis. Can J Cardiol 2008; 24:e60-2. [PMID: 18787727 DOI: 10.1016/s0828-282x(08)70673-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Significant hypoxemia can result from right-to-left intracardiac shunting through a patent foramen ovale, an atrial septal defect or a ventricular septal defect. Pulmonary embolus, congenital heart disease and pericardial tamponade are well-recognized causes of right-to-left shunting. However, right-to-left shunting can also follow pericardiocentesis. A case of profound hypoxemia caused by right ventricular hypokinesis precipitated by pericardial tap is reported. This under-recognized entity can be responsible for significant morbidity in the critical care setting. The clinical presentation, natural history, diagnosis and treatment of hypoxemia caused by intracardiac shunt following pericardiocentesis are discussed.
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Affiliation(s)
- Mahmoud Sharaf
- McMaster University, Hamilton General Hospital, Hamilton, Canada.
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12
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ECG-Gated Cardiac CT Angiography Using 64-MDCT for Detection of Patent Foramen Ovale. AJR Am J Roentgenol 2008; 190:929-33. [DOI: 10.2214/ajr.07.3140] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Mareedu RK, Shah MS, Mesa JE, McCauley CS. Percutaneous closure of patent foramen ovale: a case series and literature review. Clin Med Res 2007; 5:218-26. [PMID: 18086906 PMCID: PMC2275750 DOI: 10.3121/cmr.2007.764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Ravi K Mareedu
- Department of Internal Medicine, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, Wisconsin 54449, USA
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14
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Kerut EK, Lee S, Fox E. Diagnosis of an anatomically and physiologically significant patent foramen ovale. Echocardiography 2007; 23:810-5. [PMID: 16999706 DOI: 10.1111/j.1540-8175.2006.00318.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Edmund Kenneth Kerut
- Departments of Physiology and Pharmacology, LSU Health Sciences Center, 1111 Medical Center Boulevard, New Orleans, LA 70072, USA.
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15
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Attaran RR, Ata I, Kudithipudi V, Foster L, Sorrell VL. Protocol for optimal detection and exclusion of a patent foramen ovale using transthoracic echocardiography with agitated saline microbubbles. Echocardiography 2006; 23:616-22. [PMID: 16911341 DOI: 10.1111/j.1540-8175.2006.00272.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Agitated saline bubble studies in conjunction with echocardiography, in particular transesophageal echocardiography, are currently the principal means in the diagnosis of patent foramen ovale (PFO). We describe techniques and guidelines for the detection and exclusion of a PFO. The potential for misinterpretation of these bubble studies exists and therefore, several false positive and false negative scenarios are illustrated and discussed.
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Affiliation(s)
- Robert R Attaran
- Sarver Heart Center, University of Arizona Affiliated Hospitals, Tucson, Arizona 85724, USA
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Harrison D, Lloyd-Smith R, Khazei A, Hunte G, Lepawsky M. Controversies in the medical clearance of recreational scuba divers: updates on asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale. Curr Sports Med Rep 2006; 4:275-81. [PMID: 16144586 DOI: 10.1097/01.csmr.0000306222.19714.33] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary care and sports medicine physicians are frequently consulted on medical clearance for prospective recreational divers. We discuss four common and controversial medical conditions--asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale--as they relate to fitness to dive. For each condition we review the relevant anatomy and physiology, current recommendations, and the pertinent medical literature. Finally, we offer evidence-based recommendations regarding fitness to dive for potential divers with these conditions.
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Affiliation(s)
- David Harrison
- Department of Family Practice, Student Health Service, University of British Columbia, M334-2211 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
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Maldjian PD, Anis A, Saric M. Radiological Reasoning: Pulmonary Embolism—Thinking Beyond the Clots. AJR Am J Roentgenol 2006; 186:S219-23. [PMID: 16498137 DOI: 10.2214/ajr.05.1622] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Pierre D Maldjian
- Department of Radiology, University Hospital, UMDNJ-NJ Medical School, 150 Bergen St., UH C-320, Newark, NJ 07103-2406, USA.
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