Patent Foramen Ovale: The Unresolved Questions

Patent Foramen Ovale (PFO) is a remnant of fetal circulation that could be observed in the 25% of the population worldwide. PFO is associated to numerous clinical conditions as migraines, coronary embolization, transient ischemic attacks, and stroke. The main PFO concerns are related to its correlation to stroke, in particular in young adults. Despite the impact on morbidity that PFO could have, to date there is not clear evidence about its management and treatment. In this narrative review our aim is to summarize the more recent evidence in the literature dealing with PFO, in order to provide an updated overview on this topic.

Echocardiography guided bed side balloon atrial septostomy in dextro transposed great arteries (dTGA) with intact ventricular septum (IVS): A resource limited country experience

Objective:

To determine effectiveness and safety of echocardiography guided bed side Balloon Atrial Septostomy (BAS) in dextro transposition of great Arteries (dTGA) with intact ventricular septum (IVS) at a public sector tertiary care hospital Karachi, Pakistan.

Methods:

This case series include 40 patients with echocardiographic findings of dTGA with IVS and restricted PFO (≤ 2mm) who underwent bedside BAS at department of pediatric cardiology NICVD, Karachi, Pakistan. We recorded pre and post BAS diameter of PFO/Atrial Septal Defect (ASD), oxygen saturation (SpO₂ %), and post procedure complications and outcome.

Results:

Median age was 16 days, Majority of them (n=23, 58%) were severely cyanosed with SpO₂ of 41.4±3.4% and underwent emergency BAS and remaining underwent elective procedure. An increase in SpO₂% from 46.0±6% to 81.0±3.0% (p=<0.001) and ASD size from 1.4±2.8mm to 5.45±0.4mm was observed (p=<0.001). No complication was observed in most of cases (n=28, 70%). Mean hospital stay was 3.4±1 days. Success rate was 97.5% however, one neonate died due to neonatal sepsis.

Conclusion:

Our study provides sufficient evidence that bed side balloon atrial septostomy is a safer technique, save a lot of time and resources which were required otherwise in transporting these patients to catheterization laboratory.

Branch retinal artery occlusion in a patient with patent foramen ovale

PURPOSE

To report branch retinal artery occlusion (BRAO) in a patient with patent foramen ovale (PFO).

CASE REPORT

A 29-year-old female patient was referred for sudden onset superior visual field defect in her left eye. Ocular examination revealed visual acuity of 20/32 in the affected eye along with a positive relative afferent pupillary defect. A calcified white embolus was noted at the first bifurcation of the inferior temporal artery in her left eye together with mild retinal edema. With a diagnosis of BRAO, the patient received oral acetazolamide, topical timolol, ocular massage and anterior chamber paracentesis. The visual field defect partially recovered and the embolus moved to the third bifurcation level as revealed by fundus examination. An extensive workup, including neurology, rheumatology, cardiology and hematology consultation, carotid ultrasonography, transthoracic/transesophageal echocardiography and laboratory testing was performed. All results were within normal limits except for a small-sized PFO detected by transesophageal echocardiography. Low-dose aspirin therapy was initiated and over the subsequent two years, no other embolic event occurred.

CONCLUSION

The association between PFO and BRAO has not yet been reported. Intracardiac right-to-left shunting through a PFO, accentuated by Valsalva maneuver, may predispose to embolic events while the source of initial thrombosis remains unknown.