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Franke M, Safdar Z. Acute Myocardial Infarction in the Setting of Pulmonary Hypertension due to a Patent Foramen Ovale and Paradoxical Embolism. Case Rep Pulmonol 2024; 2024:6725308. [PMID: 39055527 PMCID: PMC11272397 DOI: 10.1155/2024/6725308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 06/24/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
A 67-year-old woman with pulmonary hypertension (PH) presented with a 1-day history of worsening shortness of breath and pleuritic chest pain and was found to have a troponin T level of 3755 ng/L (ref. range 0-19 ng/L). An initial diagnostic workup in the emergency department (ED) led to an urgent left heart catheterization which revealed a 90% occlusive right coronary artery blood clot, even though a recent heart catheterization less than a month prior was completely unremarkable. Further workup led to the discovery of a patent foramen ovale (PFO) and an aneurysmal interatrial septum, suggesting the presence of a paradoxical embolism. While typically asymptomatic, a PFO is an important clinical entity that can lead to irreversible cardiac damage. Suspicion should be high for this finding in the case of an acute myocardial infarction (MI) with no clear cause, especially in a patient with elevated right heart pressures.
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Affiliation(s)
- Madeline Franke
- School of Engineering MedicineTexas A&M Health Science Center, Houston, Texas, USA
| | - Zeenat Safdar
- Houston Methodist Lung CenterHouston Methodist HospitalWeill Cornell College of Medicine, Houston, Texas, USA
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Wang LL, Xu B, Yu XQ, Zhang DZ. Severe cough and hemoptysis induced reopening of patent foramen ovale leading to significant decrease in pulmonary artery pressure in a patient with idiopathic pulmonary arterial hypertension: A case report. Heliyon 2024; 10:e25386. [PMID: 38327417 PMCID: PMC10847641 DOI: 10.1016/j.heliyon.2024.e25386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a perilous disease that precipitates right ventricular hypertrophy, induces right heart failure, and exerts deleterious ramifications on prognostic outcomes. The establishment of atrial communication can create a right-to-left shunt, thereby ameliorating hemodynamic parameters. Previous reports suggested that opening of a patent foramen ovale (PFO) was common in patients with severe PAH, but exhibited no discernible impact on long-term survival. We reported the case of a 39-year-old man with severe idiopathic PAH, who underwent reopening of the PFO due to severe cough and hemoptysis, followed by a marked amelioration in symptoms and a substantial decrease in pulmonary arterial pressure. The patient has survived for more than 12 years, persisting in World Health Organization functional class Ⅱ with mild PAH.
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Affiliation(s)
- Li-Li Wang
- Department of Cardiology, the Second Hospital of Dalian Medical University, Dalian, 116023, Liaoning, People's Republic of China
| | - Bing Xu
- Department of Pharmacy, the Second Hospital of Dalian Medical University, Dalian, 116023, Liaoning, People's Republic of China
| | - Xiao-Qing Yu
- Department of Cardiology, the Second Hospital of Dalian Medical University, Dalian, 116023, Liaoning, People's Republic of China
| | - Duan-Zhen Zhang
- Department of Cardiology, the Second Hospital of Dalian Medical University, Dalian, 116023, Liaoning, People's Republic of China
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Pasquinelly A, Delaviz H, Maklad A, Frank PW. Proposed neural crest involvement in concomitant bifid xiphoid process and atrial septal defect: A case study and review of literature. TRANSLATIONAL RESEARCH IN ANATOMY 2022. [DOI: 10.1016/j.tria.2022.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Carta AF, Lichtblau M, Berlier C, Saxer S, Schneider SR, Schwarz EI, Furian M, Bloch KE, Ulrich S. The Impact of Breathing Hypoxic Gas and Oxygen on Pulmonary Hemodynamics in Patients With Pulmonary Hypertension. Front Med (Lausanne) 2022; 9:791423. [PMID: 35223898 PMCID: PMC8878983 DOI: 10.3389/fmed.2022.791423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPure oxygen breathing (hyperoxia) may improve hemodynamics in patients with pulmonary hypertension (PH) and allows to calculate right-to-left shunt fraction (Qs/Qt), whereas breathing normobaric hypoxia may accelerate hypoxic pulmonary vasoconstriction (HPV). This study investigates how hyperoxia and hypoxia affect mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) in patients with PH and whether Qs/Qt influences the changes of mPAP and PVR.Study Design and MethodsAdults with pulmonary arterial or chronic thromboembolic PH (PAH/CTEPH) underwent repetitive hemodynamic and blood gas measurements during right heart catheterization (RHC) under normoxia [fractions of inspiratory oxygen (FiO2) 0.21], hypoxia (FiO2 0.15), and hyperoxia (FiO2 1.0) for at least 10 min.ResultsWe included 149 patients (79/70 PAH/CTEPH, 59% women, mean ± SD 60 ± 17 years). Multivariable regressions (mean change, CI) showed that hypoxia did not affect mPAP and cardiac index, but increased PVR [0.4 (0.1–0.7) WU, p = 0.021] due to decreased pulmonary artery wedge pressure [−0.54 (−0.92 to −0.162), p = 0.005]. Hyperoxia significantly decreased mPAP [−4.4 (−5.5 to −3.3) mmHg, p < 0.001] and PVR [−0.4 (−0.7 to −0.1) WU, p = 0.006] compared with normoxia. The Qs/Qt (14 ± 6%) was >10 in 75% of subjects but changes of mPAP and PVR under hyperoxia and hypoxia were independent of Qs/Qt.ConclusionAcute exposure to hypoxia did not relevantly alter pulmonary hemodynamics indicating a blunted HPV-response in PH. In contrast, hyperoxia remarkably reduced mPAP and PVR, indicating a preserved vasodilator response to oxygen and possibly supporting the oxygen therapy in patients with PH. A high proportion of patients with PH showed increased Qs/Qt, which, however, was not associated with changes in pulmonary hemodynamics in response to changes in FiO2.
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Qiu X, Lin J, Liang B, Chen Y, Liu G, Zheng J. Identification of Hub Genes and MicroRNAs Associated With Idiopathic Pulmonary Arterial Hypertension by Integrated Bioinformatics Analyses. Front Genet 2021; 12:667406. [PMID: 33995494 PMCID: PMC8117102 DOI: 10.3389/fgene.2021.636934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/22/2021] [Indexed: 01/04/2023] Open
Abstract
Objective The aim of this study is the identification of hub genes associated with idiopathic pulmonary arterial hypertension (IPAH). Materials and Methods GSE15197 gene expression data was downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were identified by screening IPAH patients and controls. The 5,000 genes with the greatest variances were analyzed using a weighted gene co-expression network analysis (WGCNA). Modules with the strongest correlation with IPAH were chosen, followed by a functional enrichment analysis. Protein–protein interaction (PPI) networks were constructed to identify hub gene candidates using calculated degrees. Real hub genes were found from the overlap of DEGs and candidate hub genes. microRNAs (miRNAs) targeting real hub genes were found by screening miRNet 2.0. The most important IPAH miRNAs were identified. Results There were 4,395 DEGs identified. WGCNA indicated that green and brown modules associated most strongly with IPAH. Functional enrichment analysis showed that green and brown module genes were mainly involved in protein digestion and absorption and proteoglycans in cancer, respectively. The top ten candidate hub genes in green and brown modules were identified, respectively. After overlapping with DEGs, 11 real hub genes were identified: EP300, MMP2, CDH2, CDK2, GNG10, ALB, SMC2, DHX15, CUL3, BTBD1, and LTN1. These genes were expressed with significant differences in IPAH versus controls, indicating a high diagnostic ability. The miRNA–gene network showed that hsa-mir-1-3p could associate with IPAH. Conclusion EP300, MMP2, CDH2, CDK2, GNG10, ALB, SMC2, DHX15, CUL3, BTBD1, and LTN1 may play essential roles in IPAH. Predicted miRNA hsa-mir-1-3p could regulate gene expression in IPAH. Such hub genes may contribute to the pathology and progression in IPAH, providing potential diagnostic and therapeutic opportunities for IPAH patients.
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Affiliation(s)
- Xue Qiu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jinyan Lin
- The First Clinical Medical School, Guangxi Medical University, Nanning, China
| | - Bixiao Liang
- The First Clinical Medical School, Guangxi Medical University, Nanning, China
| | - Yanbing Chen
- The First Clinical Medical School, Guangxi Medical University, Nanning, China
| | - Guoqun Liu
- The First Clinical Medical School, Guangxi Medical University, Nanning, China
| | - Jing Zheng
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Dk Yeak R, Liew SK. Concomitant fat embolism syndrome and pulmonary embolism in a patient with patent foramen ovale. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:465-468. [PMID: 32812879 PMCID: PMC7444874 DOI: 10.5152/j.aott.2020.20035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 01/13/2020] [Accepted: 03/01/2020] [Indexed: 11/22/2022]
Abstract
We present a rare case of a patient with concurrent fat embolism and pulmonary embolism, in a closed femur fracture with patent foramen ovale (PFO). A 24-year-old man was involved in a motor vehicle accident with a closed left midshaft femur fracture. He developed fat embolism syndrome (FES) on day 3 of admission, and plating was performed. The D-dimer concentration was also high, which raised the suspicion of pulmonary artery embolism. Computed tomography pulmonary angiography (CTPA) revealed right inferior lobar pulmonary artery embolism and FES. A transthoracic echocardiogram (TEE) was performed, which showed a PFO. The presence of a PFO in patients with pulmonary embolism increases the risk of systemic embolism. Therefore, we recommend the routine echocardiogram for patients with pulmonary embolism to exclude any cardiac defect in causing right-to-left shunts, which predisposes the patient to paradoxical embolism.
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Affiliation(s)
- Raymond Dk Yeak
- Department of Orthopaedic Surgery, University Putra Malaysia, School of Medicine and Health Sciences, Selangor, Malaysias
| | - Siew Khei Liew
- Department of Orthopaedic Surgery, University Putra Malaysia, School of Medicine and Health Sciences, Selangor, Malaysias
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Jose A, Eckman MH, Elwing JM. Anticoagulation in pulmonary arterial hypertension: a decision analysis. Pulm Circ 2019; 9:2045894019895451. [PMID: 31903185 PMCID: PMC6928543 DOI: 10.1177/2045894019895451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 01/16/2023] Open
Abstract
Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43-0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66-1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Akizuki M, Sugimura K, Aoki T, Kakihana T, Tatebe S, Yamamoto S, Sato H, Satoh K, Shimokawa H, Kohzuki M. Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension. Respirology 2019; 25:427-434. [DOI: 10.1111/resp.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Mina Akizuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Koichiro Sugimura
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Tatsuo Aoki
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Takaaki Kakihana
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Saori Yamamoto
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Haruka Sato
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Kimio Satoh
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
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Sharan L, Stackhouse K, Awerbach JD, Bashore TM, Krasuski RA. Effect of Patent Foramen Ovale in Patients With Pulmonary Hypertension. Am J Cardiol 2018; 122:505-510. [PMID: 30201113 DOI: 10.1016/j.amjcard.2018.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/06/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
Septostomy reduces right ventricular (RV) workload at the expense of hypoxemia in patients with advanced pulmonary hypertension (PH). A patent foramen ovale (PFO) may serve as a "natural" septostomy, but the incidence and impact of a PFO in PH remains uncertain. We prospectively examined echocardiograms in 404 PH patients referred for initial hemodynamic assessment. Patients included had saline bubble injection and if negative repeatinjection after Valsalva maneuver. Echocardiographic and hemodynamic data were examined. Survival was modeled using Kaplan-Meier method. Eisenmenger syndrome or known atrial shunts other than PFO were excluded: 292 patients met entry criteria. A PFO was identified in 16.8% of the entire cohort, 22.9% of pulmonary arterial hypertension (PAH) patients, and 8.6% of Dana Point group 2 PH patients. Right atrial to pulmonary capillary wedge pressure difference was lowest in the latter group (-7.9 ± 7.1 vs -1.7 ± 5.5 mm Hg for all others, p <0.01). Patients with a PFO were younger (53.9 vs 58.6 years, p = 0.02). A PFO was more often present with moderately or severely dilated (p = 0.01) or dysfunctional (p = 0.03) RVs. Six year survival was unchanged by PFO presence for all patients, including those with PAH. Proportional hazards analysis found only age and functional class independently predicted survival (p <0.01). A PFO is identified less often in Dana Point group 2 PH, likely due to inability of Valsalva maneuver to overcome right atrial to pulmonary capillary wedge pressure difference. In conclusion, the incidence of a PFO in the PH population increases with more dilated and dysfunctional RVs, suggesting that the PFO may be stretched open rather than congenital. The presence of a PFO does not impact survival in PH or PAH.
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Abstract
We present a case of a young female patient with end-stage lung failure because of pulmonary arterial hypertension who was failing maximal medical therapy and was listed for a single sequential lung transplantation. The challenge of the case was a concomitant presence of a large atrial septal defect. The novelty of our approach was a device closure of atrial septal defect before performing transplantation with the use of intraoperative venoarterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Karen Booth
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John O'Sullivan
- Department of Congenital Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John Dark
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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