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Zuin M, Rigatelli G, Bilato C, Bongarzoni A, Zonzin P, Casazza F, Roncon L. Risk of early clinical deterioration and 30-day mortality in pulmonary embolism intermediate-high-risk patients with patent foramen ovale. Intern Emerg Med 2024:10.1007/s11739-024-03657-w. [PMID: 38822190 DOI: 10.1007/s11739-024-03657-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/24/2024] [Indexed: 06/02/2024]
Abstract
We assess the prognostic role of patent foramen ovale (PFO) for the estimation of 30-day mortality and risk of 48-h clinical deterioration since admission, in intermediate-high-risk pulmonary embolism (PE) patients. A post-hoc analysis of intermediate-high-risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. The entire cohort was divided according to the presence or absence of PFO after transthoracic echocardiography (TTE) evaluation. Among 450 intermediate-high-risk PE patients (mean age 71.4 ± 13.8 years, 298 males), PFO was diagnosed in 68 (15.1%) cases. A higher mortality rate (29.4% vs. 3.1%, p < 0.001) as well as occurrence of clinical deterioration within 48 h from admission (38.2% vs. 3.6%, p < 0.001) were observed in intermediate-high-risk PE patients with PFO compared to those without multivariate Cox regression analysis showed that the presence of a PFO predicts 30-day mortality (HR: 3.21, 95% CI 3.16-3.27, p < 0.001) and was also associated with a significantly higher risk of 48-h clinical deterioration [HR: 2.24 (95% CI 2.20-2.29), p < 0.0001] in intermediate-high-risk PE patients. The presence of a PFO in intermediate-high-risk PE patients is associated with a higher risk of clinical deterioration within 48 h from admission and 30-day mortality.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, 44124, Ferrara, Italy.
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy.
| | | | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Amedeo Bongarzoni
- Department of Cardiology, ASST Santi Paolo E Carlo, University of Milan, Milan, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, Milan, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria Della Misericordia Hospital, Rovigo, Italy
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Takemoto K, Nakamura M, Atagi K. Concomitant acute pulmonary embolism, myocardial infarction and ischemic stroke due to paradoxical embolism from a patent foramen ovale: a case report. Oxf Med Case Reports 2021; 2021:omab101. [PMID: 34729199 PMCID: PMC8557459 DOI: 10.1093/omcr/omab101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/22/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
A patent foramen ovale (PFO) is a cause of paradoxical embolism. Although most patients with a PFO are asymptomatic, various clinical manifestations may be associated with PFO. The most important is a cryptogenic stroke. Concomitant acute pulmonary embolism (APE), acute myocardial infarction (AMI) and acute ischemic stroke (AIS) due to paradoxical embolism from a PFO are extremely rare. We describe a 77-year-old woman with a past medical history of hypertension who was transferred due to a sudden onset of dyspnea followed by cardiopulmonary arrest. Based on the patient’s medical history, transthoracic and transesophageal echocardiography, coronary angiography, and a whole-body contrasted computed tomography, we diagnosed concomitant APE, AMI and AIS caused by a paradoxical embolism from a PFO. Appropriate knowledge of the pathophysiology of this rare critical illness is important for prompt diagnosis and treatment.
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Affiliation(s)
- Kiyoshi Takemoto
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Nara City, Nara, 6308581, Japan
| | - Michitaka Nakamura
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Nara City, Nara, 6308581, Japan
| | - Kazuaki Atagi
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Nara City, Nara, 6308581, Japan
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Giordano M, Gaio G, Santoro G, Palladino MT, Sarubbi B, Golino P, Russo MG. Patent foramen ovale with complex anatomy: Comparison of two different devices (Amplatzer Septal Occluder device and Amplatzer PFO Occluder device 30/35). Int J Cardiol 2019; 279:47-50. [PMID: 30344060 DOI: 10.1016/j.ijcard.2018.10.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 09/11/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Patent foramen ovale (PFO) closure after a cryptogenic cerebral ischemic event is a routinely procedure. The most used device is Amplatzer™ PFO Occluder 25 mm, but PFOs with complex anatomy require larger device for closure. We compared Amplatzer™ Septal Occluder (ASO) device versus Amplatzer™ PFO Occluder 30 or 35 mm (A-PFO 30/35) about the safety of procedure and the presence of residual shunt during the follow-up. METHODS From June 2002 to July 2016, 355 patients (pts) with PFO undergone closure at our institution. Among these ones, 70 pts (19.7%) had a PFO with complex anatomy and a single device with greater diameter was implanted. In these cases, the following devices were used: Gore® Septal Occluder (GSO) in 4 pts; ASO device in 33 pts (group I) and A-PFO 30/35 in 33 pts (group II). Patients treated with GSO device were excluded by our analysis. RESULTS Comparing group I and group II, there weren't complications during the procedures. Two patients of group II were lost at follow-up. At last follow-up, 1 pt of group I (3%) and 10 pts of group II (32.3%) had a residual shunt (p < 0.01). 7 of 10 pts of group II and the only 1 of group I with residual shunt underwent a complete closure by Amplatzer™ Vascular Plug (AVP) devices. CONCLUSIONS ASO devices and A-PFO 30/35 devices are both safe to close complex PFO; but A-PFO 30/35 is associated with a more incidence of residual shunt.
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Affiliation(s)
- Mario Giordano
- Paediatric Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy.
| | - Gianpiero Gaio
- Paediatric Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Giuseppe Santoro
- Paediatric Cardiology and GUCH Unit, Ospedale del Cuore "G. Pasquinucci", Massa, Italy
| | - Maria Teresa Palladino
- Paediatric Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Berardo Sarubbi
- Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Maria Giovanna Russo
- Paediatric Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
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Alkhalil M, Cahill TJ, Boardman H, Choudhury RP. Concomitant pulmonary embolism and myocardial infarction due to paradoxical embolism across a patent foramen ovale: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2017; 1:ytx010. [PMID: 31020069 PMCID: PMC6177106 DOI: 10.1093/ehjcr/ytx010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/29/2017] [Indexed: 01/21/2023]
Abstract
Concomitant acute myocardial infarction (MI) and pulmonary embolism (PE) is exceedingly rare. However, establishing the diagnosis early is essential, since delay in treating the patient may lead to a potential fatal outcome. Right ventricular (RV) infarction in the setting of inferior ST-segment elevation MI (STEMI), coupled with acute massive PE confers particular risk due acute RV failure and low cardiac output, threatening survival. We report a rare case of concomitant PE and inferior STEMI in a 43-year-old woman with a history of acute chest pain. She was haemodynamically compromised, with Type I respiratory failure but lack of signs of heart failure. Early recognition of dual pathologies prompted administration of thrombolytic therapy and simultaneous right coronary artery thrombectomy to treat PE and STEMI. Prompt clinical diagnosis and delivery of targeted therapies adapted for the specific clinical presentation may have averted fatal outcome.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK.,Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
| | - Thomas J Cahill
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
| | - Henry Boardman
- Department of Cardiology, Oxford Heart Centre, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
| | - Robin P Choudhury
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK.,Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
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Coles A, Haveman-Gould B, Farooq MU, Selke KJ, Gorelick PB. A Case of Complex PFO Leading to Ischemic Stroke: A Practical Clinical Pearl for Neurohospitalists. Neurohospitalist 2016; 6:114-7. [PMID: 27366295 PMCID: PMC4906549 DOI: 10.1177/1941874415588750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.
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Affiliation(s)
- Anna Coles
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Bradley Haveman-Gould
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
| | - Muhammad U. Farooq
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
| | | | - Philip B. Gorelick
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
- Department Translational Science & Molecular Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Yerlioglu E, Krishnamoorthy V, Jeon H, Gustin A, Nicolau-Raducu R. Patent foramen ovale and intracardiac thrombus identified by transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 2011; 26:1069-73. [PMID: 21757375 DOI: 10.1053/j.jvca.2011.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Indexed: 12/17/2022]
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