Identification of candidates for PFO closure in the echocardiography laboratory

Acute unilateral vision loss from central retinal artery occlusion associated with an atrial septal aneurysm and a patent foramen ovale: a case report

BACKGROUND

Acute unilateral vision loss is an ophthalmological emergency. It can have multiple aetiologies, and physicians must be able to quickly determine the cause of the condition, as immediate intervention may prevent permanent vision loss. Acute unilateral vision loss has not previously been associated with a patent foramen ovale (PFO).

OBJECTIVE

We describe a patient who presented with painless sudden loss of vision in his left eye. He was diagnosed to have central retinal artery occlusion, likely from a paradoxical embolus associated with an atrial septal aneurysm containing a PFO. The patient underwent successful percutaneous closure of the PFO without complication. This report details the evaluation and differential diagnosis of acute unilateral vision loss. Additionally, the controversy of whether a PFO should be closed prophylactically for stroke prevention is discussed.

CONCLUSION

Acute unilateral vision loss from central retinal artery occlusion may be caused by a paradoxical embolus originating from an atrial septal aneurysm with a PFO. This case should be considered in the controversy of whether prophylactic closure of a PFO could be beneficial for primary prevention of stroke.

Catheter-directed therapies for pulmonary embolism: considerations for patients with patent foramen ovale

Pulmonary embolism can be fatal, especially in high-risk patients who have contraindications to systemic thrombolysis or surgical embolectomy. For this population, interventionalists can provide catheter-directed therapies, including catheter-directed thrombolysis and thrombectomy, using a wide array of devices. Endovascular treatment of pulmonary embolism shows great promise through fractionated thrombolytic drug delivery, fragmentation, and aspiration mechanisms with thrombectomy devices. Although successful outcomes have been reported after using these treatments, evidence is especially limited in patients with both a patent foramen ovale (PFO) and acute pulmonary embolism. In patients with PFO, it is important to consider whether catheter-directed therapy is appropriate or whether surgical embolectomy should instead be performed. An increased risk of paradoxical embolus in these patients supports the use of diagnostic echocardiography with possible surgical closure of PFO after one episode of pulmonary embolism. Percutaneous PFO closure, which can be performed at the time of catheter-based therapy, theoretically reduces risk of future paradoxical embolization, although more data are needed before making a recommendation for this specific group of patients.

Recurrent arterial ischemic strokes in a patient with patent foramen ovale and ductus arteriosus: Presentation of our management and review of the literature

Ischemic stroke in children is a relatively rare entity, relative to the adult population. The most common potential risk factors include cardiac embolism, prothrombotic states and vasculopathies. The diagnosis is concerning for the need to identify the underlying cause. Treatment of the proximate source of ischemia can often protect against future events.

We present the case of a 7-year-old patient who initially presented with an ischemic brain insult which was repeated, despite the initiation of anticoagulation therapy. The investigation revealed patent foramen ovale and patent ductus arteriosus and because of the recurrent ischemic ictuses, transcatheter closure of both defects was decided. A brief description of the literature is also presented.

Peripheral saline contrast with Valsalva and a modified Müller's maneuver may improve detection of atrial level right-to-left shunts: A preliminary observation

As part of an evaluation for source of embolism, transthoracic echocardiography with peripheral saline contrast injection during normal respirations and also Valsalva release is routinely performed to evaluate for an atrial level shunt. We present a preliminary observation of addition of a modified Müller's maneuver early during the Valsalva release. The Müller's maneuver has been described to occur with sleep apnea and will increase right-to-left shunting through a PFO. Of 34 patients, 24 were negative for a right-to-left shunt with normal respiration or Valsalva release. Of these 24 patients, 8 were then positive for a shunt by addition of a modified Müller's maneuver. One additional patient could not perform the modified Müller's maneuver. This preliminary observation suggests that in patients referred to an echocardiography laboratory for evaluation of source of embolism, adding the modified Müller's maneuver to those negative for shunting during normal respirations and Valsalva release may yield an increase in right-to-left atrial level shunt detection.