Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report

Left atrial septal pouch thrombus: An unusual cause of an embolic stroke

Left-atrial septal pouch (LASP) is a newly described anatomical variant caused by incomplete fusion of the septa primum and secundum. This case visualizes LASP as a potential nidus for blood stasis and cardiac embolism and highlights the need for consideration of TEE in the work up of cryptogenic stroke.

Atrial septal pouches and ridges: Morphological features and potential implications in clinical practice

Incomplete or irregular fusion of the interatrial septum may result in several anatomic variants, including atrial septal pouches and ridges, whose knowledge and recognition are still poorly widespread in clinical practice. An educational review focused on the definition, clinical significance and diagnostic work-up of these anatomic findings was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2023. Atrial septal pouches and ridges have been associated with an increased difficulty of catheter-based interventions requiring a transseptal approach, due to procedural challenges for transseptal puncture and the restricted motion of guidewires and catheters through the transseptal access. Additionally, left atrial septal pouch may serve as a thrombogenic nidus and a source of systemic embolism, mostly in the presence of factors leading to higher left atrial pressure and/or atrial blood stasis, which increase the risk of thrombus formation and embolic events, rather than for the only presence of left atrial septal pouch itself. Further investigations are needed in order to better elucidate the implications of such anatomic findings in daily clinical practice, and to provide the most appropriate decision-making strategies.

Pedal gangrene in a patient with COVID-19 treated with prone positioning and extracorporeal membrane oxygenation

Many patients hospitalized with coronavirus disease 2019 are treated with venovenous extracorporeal membrane oxygenation and prone positioning to optimize oxygenation. However, this combination can result in lower extremity tissue necrosis, especially without adequate offloading. We report the case of a 31-year-old man who required mechanical ventilation and venovenous extracorporeal membrane oxygenation secondary to complications from coronavirus disease 2019, and subsequently developed pedal dry gangrene. The patient was discharged and healed without requiring an amputation. Our institution has since revised the prone positioning protocol to address offloading the lower extremities and feet.