Successful Laparoscopic Treatment of Morgagni's Hernia in an Elderly Female Presenting as a Hypoxemic Hypercapnic Respiratory Distress

Morgagni's hernia (MH) occurs when the abdominal viscera herniates into the thoracic cavity through a congenital anatomical defect in the diaphragm, termed the foramen of Morgagni. Although it is more frequently detected in childhood, its delayed presentation in adults and the elderly could be easily overlooked due to the non-specificity of its symptoms. Here, we report the case of an elderly female who presented purely with dyspnea and desaturation, necessitating admission to the intensive care unit. Her computed tomography (CT) scan revealed the presence of MH with complete lobar collapse. Laparoscopy was successful in reducing the hernia, and the patient improved with a good prognosis. Surgical treatment for MH is advised for all cases in order to prevent the occurrence of serious complications.

Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study

INTRODUCTION

Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke.

METHODS

We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE).

RESULTS

The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]).

CONCLUSION

In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.

Change in Right-to-Left Shunt Fraction in Patients with Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Endarterectomy

BACKGROUND

Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) with accessible lesions. Breathing pure oxygen (hyperoxia) during right heart catheterization (RHC) allows for the calculation of the right-to-left shunt fraction (Qs/Qt). In the absence of intracardiac shunt, Qs/Qt can be used as a marker of ventilation-perfusion mismatch in patients with CTEPH. This study involved investigating Qs/Qt after PEA and its relation to other disease-specific outcomes.

STUDY DESIGN AND METHODS

This study is a retrospective study that focuses on patients with operable CTEPH who had Qs/Qt assessment during RHC before and 1 year after PEA. Additionally, 6 min walking distance (6MWD), WHO functional class (WHO-FC), and NT-proBNP were assessed to calculate a four-strata risk score.

RESULTS

Overall, 16 patients (6 females) with a median age of 66 years (quartiles 55; 74) were included. After PEA, an improvement in mean pulmonary artery pressure (38 [32; 41] to 24 [18; 28] mmHg), pulmonary vascular resistance (5.7 [4.0; 6.8] to 2.5 [1.4; 3.8] WU), oxygen saturation (92 [88; 93]% to 94 [93; 95]%), WHO-FC, and risk score was observed (all p < 0.05). No improvement in median Qs/Qt could be detected (13.7 [10.0; 17.5]% to 13.0 [11.2; 15.6]%, p = 0.679). A total of 7 patients with improved Qs/Qt had a significant reduction in risk score compared to those without improved Qs/Qt.

CONCLUSION

PEA did not alter Qs/Qt assessed after 1 year in operable CTEPH despite an improvement in hemodynamics and risk score, potentially indicating a persistent microvasculopathy. In patients whose shunt fraction improved with PEA, the reduced shunt was associated with an improvement in risk score.

Right-to-Left Shunt Evaluation in Cardiac Patent Foramen Ovale Using Bubble Contrast Transcranial Color-Coded Doppler: A Cryptogenic Stroke Case

Traditional diagnosis of patent foramen ovale (PFO) in the heart has involved the use of transcranial Doppler (TCD). However, TCD is essentially a blind test that cannot directly visualize the location of blood vessels. Since TCD relies on qualitative assessments by examiners, there is room for errors, such as misalignment of the ultrasound's angle of incidence with the actual blood vessels. This limitation affects the reproducibility and consistency of the examination. In this study, we presented an alternative approach for assessing right-to-left shunt (RLS) associated with PFO using contrast transcranial color-coded Doppler (C-TCCD) with bubble contrast. The patient under consideration had been diagnosed with an ischemic stroke through imaging, but the subsequent cardiac work-up failed to determine the cause. Employing C-TCCD for RLS screening revealed a confirmed RLS of Spencer's three grades. Subsequently, transesophageal echocardiography (TEE) was conducted to evaluate PFO risk factors, confirming an 8 mm PFO size, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS. The calculated high-risk PFO score was 4 points, categorizing it as a very high risk PFO. This case underscores the importance of C-TCCD screening in detecting RLS associated with PFO, especially in cryptogenic stroke patients, when identifying the underlying cause of ischemic stroke becomes challenging.

Association of patent foramen ovale with epilepsy: A hospital-based case-control study

OBJECTIVE

This study aimed to investigate the proportion of patent foramen ovale (PFO) in people with epilepsy (PWE) compared to controls without epilepsy and to assess whether PWEs with and without PFO exhibit distinctive clinical features.

METHODS

This is a case-control study conducted in a hospital. Contrast transthoracic echocardiography with a venous microbubble bolus and provocative maneuvers (Valsalva and coughing) were used to identify PFO and its right-to-left shunt (RLS) among 741 PWEs and 800 controls without epilepsy. The risk of having PFO in PWEs was explored using multiple matching methods and logistic regression with adjusted congenital factors that may affect the occurrence of PFO.

RESULTS

The proportion of PFO in PWEs and controls was 39.00% and 24.25%, respectively. After 1:1 propensity score matching, the risk of suffering PFO in PWEs was 1.71 times (OR, 1.71; 95% CI, 1.24-2.36) higher than that in controls. PWEs also had a higher risk of having a high RLS grade (βepilepsy  = 0.390, P < 0.001). Among clinical characteristics of PWEs, migraine, and drug-resistant epilepsy showed significantly different distributions between those without RLS and those with RLS grade I to III. PWEs with PFO had higher risk of suffering from migraine and drug-resistant epilepsy (OR in migraine, 2.54, 95% CI, 1.65-3.95; OR in drug-resistant epilepsy, 1.47, 95% CI, 1.06-2.03).

SIGNIFICANCE

The proportion of PFO was found to be higher in PWE than in controls without epilepsy, especially in patients with drug-resistant epilepsy, suggesting potential relationship between the two disorders. Large multicentric study will be needed to confirm this finding.

Predictive value of transesophageal echocardiography combined with contrast transthoracic echocardiography for embolic stroke of undetermined source

OBJECTIVE

In this study, we aimed to assess the predictive value of transesophageal echocardiography (TEE) combined with contrast transthoracic echocardiography (cTTE) for embolic stroke of undetermined source (ESUS).

METHODS

A total of 52 patients with ESUS were examined by TEE and cTTE. The detection rate of patent foramen ovale (PFO) and right-to-left shunt (RLS) grade were compared in patients with ESUS between cTTE alone and cTTE combined with TEE. The Risk of Paradoxical Embolism (RoPE) score, PFO diameter, and PFO length of patients with PFO-associated ESUS and non-PFO-associated ESUS were compared by cTTE alone and cTTE combined with TEE. The receiver operating characteristic (ROC) curve was utilized to determine the effect of RoPE score and PFO diameter on patients with PFO-associated ESUS.

RESULTS

The positive rate of PFO detected by cTTE alone (46.15%) was lower than that detected by cTTE combined with TEE (69.23%). The proportion of patients with RLS grade I + II + III detected by cTTE combined with TEE (69.23%) was higher than that detected by cTTE alone (46.15%). Both the RoPE score and PFO diameter were significantly greater in the patients with PFO-associated ESUS than in the patients with non-PFO-associated ESUS (p < .05). The combination of RoPE score and PFO diameter had the largest area under the ROC curve (AUC = 0.875), which was larger than the AUC alone of RoPE score (AUC = 0.819) and PFO diameter (AUC = 0.783) (p < .05).

CONCLUSION

The combination of cTTE and TEE is helpful to the diagnosis of ESUS patients caused by PFO and to judge the degree of RLS.

Case report: Anxiety and depression as initial symptoms in a patient with acute hypoxia and patent foramen ovale

The prevalence of patent foramen ovale (PFO) is 15-35% among adults. The role of right-to-left shunting through the PFO, anxiety, depression, and hypoxemia in the systemic circulation remains poorly understood. Herein, we present the case of a 52-year-old woman with no heart or lung disease, who was admitted due to anxiety for 5 months and had symptom exacerbation with dizziness for 4 days and presented with cyanosis. She was noted to have acute hypoxemia, with an oxygen saturation of 94.48% on room air, and arterial blood gas showed an oxygen tension of 65.64 mmHg. Agitated saline contrast echocardiography showed right-to-left shunting due to PFO. Arteriovenous fistula, pneumonia, pulmonary embolism, pulmonary hypertension, congestion peripheral cyanosis, ischemic peripheral cyanosis, and methemoglobin were excluded. Additionally, the patient improved by taking Paroxetine, Oxazepam, and Olanzapine. Her oxygen tension returned to 90.42 mmHg, and her symptoms resolved. In the case of severe anxiety and depression, right-to-left shunting through the PFO may cause acute systemic hypoxemia via a flow-driven mechanism, occasionally manifesting as cyanosis. When anxiety improved, hypoxia also improved. Thus, the treatment of anxiety and depression seems effective in improving hypoxemia. Notably, this is a rare report, and we hope to draw the attention of psychosomatic specialists, psychiatrists, and clinicians to seek the relationship between anxiety appearing as acute stress and PFO. This may be a new therapeutic method for treating severe anxiety disorder.

Platypnea-Orthodeoxia Syndrome: Two Case Reports

Described for the first time in the middle of the last century, platypnea-orthodeoxia syndrome (POS) is an uncommon condition of positional dyspnea and hypoxemia, triggered by standing and relieved with recumbency. It is most commonly associated with right-to-left shunting through a patent foramen ovale (PFO) or atrial septal defect, however its pathophysiology is not entirely understood. As a rare syndrome, it remains underdiagnosed in many patients. We report two different cases that illustrate the challenge of this diagnosis and therapeutic approach. In the first case, a transesophageal echocardiogram (TEE) showed interatrial communication, ostium secundum type, with bidirectional shunting. Patient underwent a successful percutaneous closure of communication, with no residual shunting and clinical improvement and no positional hypoxemia. In the second case, infectious complications were the cause of hemodynamic changes producing meaningful right-to-left pressure gradients, resulting in POS. After antibiotic treatment there was a major clinical improvement and a second TEE showed bidirectional shunting with no positional variation. It was assumed resolution of POS after treatment of infectious complications with no need for immediate surgery. These two cases, with very distinctive functional and anatomic components, illustrate the challenge of understanding the exact mechanism by which POS results in clinical symptoms. A suggestive history and positional variation of oxygen saturation are very useful clues for its diagnosis in cases of unexplained hypoxemia.

The Hypoxic Tricuspid: A Flail Tricuspid Valve With Patent Foramen Ovale

Etiologies of tricuspid regurgitation are often explored in patients with symptoms of right-sided heart failure. Blunt chest trauma is the major cause of traumatic tricuspid valve regurgitation (TTVR), a secondary type of tricuspid regurgitation. It is a rare condition; however, it may lead to severe consequences if not treated in a timely manner. TTVR should be considered in a patient presenting with chest trauma. In this case, we report a case of a young male who presented after a motor vehicle accident with secondary tricuspid valve regurgitation due to blunt chest trauma as well as a patent foramen ovale.

Synchronous multimode ultrasound for assessing right-to-left shunt: a prospective clinical study

Background

Right-to-left shunt (RLS) is associated with several conditions and causes morbidity. In this study, we aimed to evaluate the effectiveness of synchronous multimode ultrasonography in detecting RLS.

Methods

We prospectively enrolled 423 patients with high clinical suspicion of RLS and divided them into the contrast transcranial Doppler (cTCD) group and synchronous multimode ultrasound group, in which both cTCD and contrast transthoracic echocardiography (cTTE) were performed during the same process of contrast-enhanced ultrasound imaging. The simultaneous test results were compared with those of cTCD alone.

Results

The positive rates of grade II (22.0%:10.0%) and III (12.7%:10.8%) shunts and the total positive rate (82.1748%) in the synchronous multimode ultrasound group were higher than those in the cTCD alone group. Among patients with RLS grade I in the synchronous multimode ultrasound group, 23 had RLS grade I in cTCD but grade 0 in synchronous cTTE, whereas four had grade I in cTCD but grade 0 in synchronous cTTE. Among patients with RLS grade II in the synchronous multimode ultrasound group, 28 had RLS grade I in cTCD but grade II in synchronous cTTE. Among patients with RLS grade III in the synchronous multimode ultrasound group, four had RLS grade I in cTCD but grade III in synchronous cTTE. Synchronous multimode ultrasound had a sensitivity of 87.5% and specificity of 60.6% in the patent foramen ovale (PFO) diagnosis. Binary logistic regression analyses showed that age (odds ratio [OR] = 1.041) and risk of paradoxical embolism score ≥ 7 (OR = 7.798) were risk factors for stroke recurrence, whereas antiplatelets (OR = 0.590) and PFO closure with antiplatelets (OR = 0.109) were protective factors.

Conclusion

Synchronous multimodal ultrasound significantly improves the detection rate and test efficiency, quantifies RLS more accurately, and reduces testing risks and medical costs. We conclude that synchronous multimodal ultrasound has significant potential for clinical applications.

Malposition of a Femoral Tunneled Dialysis Catheter through a Patent Foramen Ovale

Patent foramen ovale (PFO) is a common congenital abnormality of high prevalence in adults. Its clinical significance is magnified in a right-to-left shunt, where paradoxical embolism can have catastrophic outcomes involving the brain, heart, mesenteric circulation, or extremities. Right-to-left shunting through a PFO is caused by increased right atrial pressure, as seen in the setting of pulmonary artery hypertension or pulmonary embolism. This case highlights the relevance of central venous catheter placement in the setting of a PFO. While the patient did not experience clinical sequelae from line placement, she was at high risk for paradoxical embolus. Recognizing the possibility of a PFO during central venous catheter placement, especially in the setting of increased right pressures, should be a consideration of all interventional radiologists.

Right-to-Left Shunt in Divers with Neurological Decompression Sickness: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers.

BACKGROUND

Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS.

METHODS

We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios.

RESULTS

Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79-5.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86-8.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10-18.17) compared to cerebral (OR: 4.96; 95% CI: 2.43-10.12) and spinal cord (OR: 2.47; 95% CI: 2.74-7.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80-2.91).

CONCLUSIONS

RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.

Relationship between right-to-left shunt, hypoxia, and epilepsy

OBJECTIVE

A right-to-left shunt (RLS) can mediate the hypoxic state, and hypoxemia is relevant for the development of drug-resistant epilepsy (DRE). The objective of this study was to identify the relationship between RLS and DRE and further investigate the contribution of RLS to the oxygenation state in patients with epilepsy (PWEs).

METHODS

We performed a prospective observational clinical study of PWEs who underwent contrast medium transthoracic echocardiography (cTTE) between January 2018 and December 2021 at West China Hospital. The collected data included demographics, clinical features of epilepsy, antiseizure medications (ASMs), RLS identified by cTTE, electroencephalography (EEG), and magnetic resonance imaging (MRI). Arterial blood gas was also assessed in PWEs with or without RLS. The association between DRE and RLS was quantified using multiple logistic regression, and the parameters of oxygen levels were furtherly analyzed in PWEs with or without RLS.

RESULTS

A total of 604 PWEs who completed cTTE were included in the analysis, of which 265 were diagnosed with RLS. The proportion of RLS was 47.2% in the group of DRE, and the proportion of RLS was 40.3% in the group of non-DRE. Having RLS was associated with DRE in multivariate logistic regression analysis (adjusted OR = 1.53, P = 0.045). In the analysis of blood gas, the partial oxygen pressure in PWEs with RLS was lower than those without RLS (88.74 mmHg versus 91.84 mmHg, P = 0.044).

SIGNIFICANCE

Right-to-left shunt could be an independent risk factor of DRE, and low oxygenation might be a possible reason.

Correlation between percutaneous patent foramen ovale closure and recurrence of unexplained syncope

Background

The relationship between patent foramen ovale (PFO) and unexplained syncope remains to be illustrated. Therefore, this study aimed to explore the outcomes and prognostic factors for syncope recurrence after PFO closure.

Methods

Patients with both large right-to-left shunting (RLS) PFO and unexplained syncope who visited the cardiovascular department of Xiangya Hospital Central South University from 1 January 2017 to 31 December 2021 were consecutively enrolled in our study. The recurrence rate of syncope was compared between the non-closure group (n = 20) and the closure group (n = 91).

Results

A total of 111 patients were finally included. After 31.11 ± 14.30 months of follow-up, only 11% of patients in the closure group had recurrent syncope, which was much lower than that of the non-closure group (11.0 vs. 35%, P = 0.018). We further investigated the possible prognostic factors for syncope recurrence in the closure group and found syncope occurring more than five times preoperatively, hypertension, and residual RLS at 12-month follow-up were significantly correlated with a higher number of recurrences.

Conclusions

PFO closure reduced the recurrence rate of unexplained syncope. The efficacy of prevention was prognosticated by factors including the presence or absence of syncope induction, the frequency of syncope episodes, and the presence or absence of hypertension. Syncope recurrence was also related to residual shunts post closure.

Persistent Left Superior Vena Cava Draining Directly Into the Left Atrium With Occluded Coronary Sinus

Combined persistent left superior vena cava entering the left atrium with a congenitally atretic coronary sinus is a rare imaging finding. In the absence of a significant right-to-left shunt, it is generally asymptomatic and can be an incidental discovery. Assessing the anatomy of the cardiac vasculature is crucial before transcutaneous cardiac procedures. (Level of Difficulty: Intermediate.).

Connection between right-to-left shunt and photosensitivity: a community-based cross-sectional study

Background

Hypersensitivity to light is a common symptom associated with dysfunction of the occipital region. Earlier studies also suggested that clinically significant right-to-left shunt (RLS) could increase occipital cortical excitability associated with the occurrence of migraine. The aim of this study was to investigate the relationship between RLS and photosensitivity.

Methods

This cross-sectional observational study included the residents aged 18-55 years living in the Mianzhu community between November 2021 and October 2022. Photosensitivity was evaluated using the Photosensitivity Assessment Questionnaire along with baseline clinical data through face-to-face interviews. After the interviews, contrast-transthoracic echocardiography (cTTE) was performed to detect RLS. Inverse probability weighting (IPW) was used to reduce selection bias. Photosensitivity score was compared between individuals with and without significant RLS using multivariable linear regression based on IPW.

Results

A total of 829 participants containing 759 healthy controls and 70 migraineurs were finally included in the analysis. Multivariable linear regression analysis showed that migraine (β = 0.422; 95% CI: 0.086-0.759; p = 0.014) and clinically significant RLS (β = 1.115; 95% CI: 0.760-1.470; p < 0.001) were related to higher photosensitivity score. Subgroup analysis revealed that clinically significant RLS had a positive effect on hypersensitivity to light in the healthy population (β = 0.763; 95% CI: 0.332-1.195; p < 0.001) or migraineurs (β = 1.459; 95% CI: 0.271-2.647; p = 0.010). There was also a significant interaction between RLS and migraine for the association with photophobia (p_interaction = 0.009).

Conclusion

RLS is associated with photosensitivity independently and might exacerbate photophobia in migraineurs. Future studies with RLS closure are needed to validate the findings.

Trial registration

This study was registered at the Chinese Clinical Trial Register, Natural Population Cohort Study of West China Hospital of Sichuan University, ID: ChiCTR1900024623, URL: https://www.chictr.org.cn/showproj.html?proj=40590.

Shunting Across a Latent Patent Foramen Ovale (PFO) in a Patient With Right Ventricular (RV) Infarction Improved With Impella

The right-to-left shunt (RTLS) through a latent patent foramen ovale (PFO) is a rare complication of right ventricle myocardial infarction (MI). Though a rare complication, the development of refractory hypoxemia after right ventricular MI should always alert clinicians to consider the possibility of shunting across PFO. Right-sided Impella (Impella RP) can be considered in such patients, which helps to decrease the elevated right heart pressure reducing the shunt, thereby providing a bridge to recovery.

[Ischemic stroke associated with patent foramen ovale: hospital database analysis]

OBJECTIVE

To analyze clinical and instrumental characteristics of patients with ischemic stroke (IS) due to paradoxical embolism according to the data of hospital registers of Moscow and Perm.

MATERIAL AND METHODS

A comprehensive study of 114 patients, aged 18 to 55 years, with IS by the mechanism of paradoxical embolism was carried out. All patients underwent clarification of the cause of IS (electrocardiography, ultrasound scanning of the brachiocephalic arteries, CT or MRI of the brain, CT or MR angiography, transthoracic and/or transesophageal echocardiography). The presence of right-left shunt blood flow (RLS) was confirmed by transcranial dopplerography with a bubble test. The clinical significance of patent foramen ovale (PFO) was assessed according to The PFO-Associated Stroke Causal Likelihood Classification System (PASCAL).

RESULTS

Clinical and instrumental characteristics of patients with IS due to paradoxical embolism were obtained from two hospital registries. In both groups, the leading trigger for the development of IS was the Valsalva phenomen (>20%), the share of other provoking factors did not exceed 10%. Significant differences between the analyzed groups related to the ultrasonic characteristics of RLS/PFO: patients with a grade 4 shunt predominated in the Research Center of Neurology (RCN) population, while patients with a grade 3 shunt predominated in the City Clinical Hospital (CCH) №4 group. At the same time, there were twice as many patients with aneurysm of the interatrial septum in the CCH №4 group. In accordance with the PASCAL classification, in 93% of RCN patients, PFO can be considered as a probable cause of IS, while in the CCH No. 4 group, a probable causal relationship was traced only in 51% of cases, in 18% of patients, the role of an anomaly in the development of stroke was unlikely.

CONCLUSION

The analysis showed that the primary screening of RLS in a regional vascular center allows classifying PFO as a probable cause of IS in only half of the patients. For a more accurate selection of patients for whom endovascular occlusion of the PFO will be most effective, an in-depth examination in a specialized hospital is recommended.

Iatrogenic Atrial Septal Defect after Intracardiac Echocardiography-Guided Left Atrial Appendage Closure: Incidence, Size, and Clinical Outcomes

BACKGROUND

The data on iatrogenic atrial septal defect (iASD) after left atrial appendage closure (LAAC), especially intracardiac echocardiography (ICE)-guided LAAC, are limited. Compared with transesophageal echocardiography (TEE)- or digital subtraction angiography (DSA)-guided LAAC, the transseptal puncture (TP) ICE-guided LAAC is more complicated. Whether or not ICE-guided TP increases the chances of iASD is controversial. We investigate the incidence, size, and clinical outcomes of iASD after ICE-guided LAAC.

METHODS

A total of 177 patients who underwent LAAC were enrolled in this study and were assigned to the ICE-guided group (group 1) and the TEE- or DSA-guided group (group 2). Echocardiography results and clinical performances at months 2 and 12 post-procedure were collected from the electronic outpatient records.

RESULTS

A total of 112 and 65 patients were assigned to group 1 and group 2, respectively. The incidence of iASD at follow-up (FU) month 2 was comparable between the groups (21.4% in group 1 vs. 15.4% in group 2, p = 0.429). At month 12 of FU, the closure rate of iASD was comparable to that of group 2 (70.6% vs. 71.4%, p = 1.000). No right-to-left (RL) shunt was observed among the iASD patients during the FU. Numerically larger iASD were observed in group 1 patients at month 2 of FU (2.8 ± 0.9 mm vs. 2.2 ± 0.8 mm, p = 0.065). No new-onset of pulmonary hypertension and iASD-related adverse events were observed. Univariable and multivariable logistic regression analysis showed that ICE-guided LAAC was not associated with the development of iASD (adjusted OR = 1.681; 95%CI, 0.634-4.455; p = 0.296).

CONCLUSIONS

The ICE-guided LAAC procedure does not increase the risk of iASD. Despite the numerically large size of the iASD, it did not increase the risk of developing adverse complications.

Can aura migraine be elicited by isolated pulmonary arteriovenous fistula?-A case report

A pulmonary arteriovenous fistula (PAVM) is an abnormal blood vessel that creates a direct connection between a pulmonary artery and its tributary vein bypassing capillary filter, establishing as a consequence of a low-resistance right-to-left shunting (RLS). The vast majority of PAVMs are congenital appearing more often in females than in males. A great number of patients with PAVMs is suffering concurrently from hereditary hemorrhagic telangiectasia (HHT) whose incidence is around 1 in 5,000. Very few cases of acquired PAVMs have been described in the literature. Paradoxical embolism through PAVMs can cause systemic desaturation, cyanosis, and serious cerebrovascular ischemic events (transient ischemic attacks, strokes, and intracranial abscess), even when the abnormal blood vessel is small (diameter <3 mm). Notably, it has been reported a high prevalence of aura migraine (MHA) symptoms in patients with PAVMs and concomitant HHT. We described in this study the case of a young aura migraineur female patient without HHT in whom isolated PAVM below the detection limit of pulmonary angiography and chest computed tomography angiography (CTA) has been documented by contrast Transthoracic and Transesophageal Echocardiography (cTTE/TEE) showing a delayed (>17 s) RLS coming from left pulmonary veins to left atrium while a patent foramen ovale (PFO), small atrial septal defects or septum primum fenestration could not be detected despite several attempts. Contrast Transcranial Doppler (cTCD) confirmed a delayed (>16 s) RLS with two short "shower" patterns corroborating the diagnosis of an extra-cardiac RLS. During the right heart catheterization and pulmonary angiography, it was impossible to cross the interatrial septum with a multipurpose catheter. The patient was finally discharged with off-label thienopyridine agents (clopidogrel 75 mg die) in terms of primary prophylaxis for paradoxical right-to-left embolization of thrombotic material ultimately. Aura migraine symptoms were nearly abolished by P2Y12 platelet inhibition, suggesting a platelet-based mechanism. During 2 years of clinical follow-up on thienopyridine therapy, the resolution of aura migraine episodes was definitively accomplished with significant improvement in her quality of life.

Residual Right-to-Left-Shunt Following Transcatheter Patent Foramen Ovale Closure: The Role of Antithrombotic Treatment

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) is a highly effective therapy for patients with left circulation thromboembolism, not attributable to other conditions.

OBJECTIVES

This retrospective cohort study investigates the impact of baseline foramen ovale anatomy on the severity of the postclosure shunt.

METHODS

Patients with PFO, who underwent percutaneous closure, were followed up for at least 5 years postimplantation. Patients were classified into two groups based on the presence of high-risk features of the baseline PFO anatomy. At the follow-up follow-up, residual right-to-left shunt was assessed for the high and non-highrisk anatomy groups, via transcranial Doppler at rest and after performing the Valsalva maneuver, with the injection of agitated saline.

RESULTS

38 patients were examined after a mean follow-up period of 9 ± 3 years after implantation. After retrospective evaluation of the baseline transthoracic and transesophageal echo studies, 14 patients with high-risk PFO anatomy were identified. The degree of the residual right-to-left shunt, as assessed by the number of microbubbles was higher in the high-risk PFO anatomy group compared to the non-high-risk group, both at rest [1.50 (IQR: 0.00-3.25) vs. 0.00 (IQR: 0.00-0.00), p < 0.001] and post-Valsalva maneuver [7.50 (IQR: 1.50- 10.25) vs. 0.00 (IQR: 0.00-3.75), p = 0.003]. Furthermore, in the high-risk group, more microbubbles were detected at rest (p = 0.008) and post-Valsalva (p = 0.002) in subjects without antiplatelet treatment compared to subjects on prolonged antiplatelet therapy.

CONCLUSION

Baseline PFO anatomy affects the severity of the residual right-to-left shunt. Prolonged antiplatelet therapy may benefit patients with high-risk anatomical features.

Pitfalls of Using Imaging Technique in the Presence of Eustachian Valve or Chiari Network: Effects on Right-to-Left Shunt and Related Influencing Factors

When patent foramen ovale (PFO) combines with the prominent Eustachian valve or Chiari network (EV/CN), contrast transthoracic echocardiography (cTTE) may miss the diagnosis of PFO. We sought to determine the characteristics of right-to-left shunt (RLS) in PFO patients with prominent EV/CN on cTTE and identify the causal factors of missed diagnosis. We consecutively enrolled 98 patients who suffered from PFO-related stroke and with prominent EV/CN. All patients were divided into the delayed and non-delayed groups according to the characteristics of RLS on cTTE. The characteristics of RLS were compared with those of 42 intrapulmonary shunt patients. The anatomical characteristics of PFO and EV/CN were analyzed in the 98 PFO patients. Upon cTTE, significantly delayed occurrence and longer duration of the RLS in the delayed group were found both at rest and during the Valsalva maneuver, similar to the intrapulmonary shunt. Multivariate logistic analysis revealed that the length of EV/CN (>19 mm) and the diameter of PFO at the left atrium aspect (<1.2 mm) were high-risk factors for missed diagnosis. In conclusion, RLS showed delayed emergence and disappearance in some of the PFO patients with prominent EV/CN. The length of EV/CN and the diameter of PFO may have been related to the missed diagnosis of PFO.

Platypnea-orthodeoxia Syndrome Due to Right Ventricular Inflow Tract Obstruction Caused by an Elongated Ascending Aorta: Usefulness of Three-dimensional Cardiac Computed Tomography Imaging in the Sitting Position

An 84-year-old woman presented with dyspnea in the sitting position. Platypnea-orthodeoxia syndrome (POS) was suspected based on arterial desaturation when her posture changed from the supine to the sitting position. Transesophageal echocardiography showed right-to-left shunting enhancement through a patent foramen ovale (PFO) in the sitting position. Three-dimensional (3D) cardiac CT in the sitting position revealed that the elongated ascending aorta compressed the right ventricular inflow tract, resulting in restricted blood flow to the right ventricle and increased right-to-left shunting. This case highlights the role of 3D-CT in the sitting position in the management of POS.

Cerebral Hemodynamics, Right-to-Left Shunt and White Matter Hyperintensities in Patients with Migraine with Aura, Young Stroke Patients and Controls

Background: Migraine with aura (MA) patients present an increased risk of cerebrovascular events. However, whether these patients present an increased white matter hyperintensities (WMHs) load compared to the general population is still under debate. Our study aimed to evaluate the relationship between cerebral hemodynamics, right-to-left shunt (RLS) and WMHs in MA patients, young patients with cryptogenic stroke or motor transient ischemic attack (TIA) and controls. Methods: We enrolled 30 MA patients, 20 young (<60 years) patients with cryptogenic stroke/motor TIA, and 10 controls. All the subjects underwent a transcranial Doppler bubble test to detect RLS and cerebral hemodynamics assessed by the breath holding index (BHI) for the middle (MCA) and posterior (PCA) cerebral arteries. Vascular risk factors were collected. The WMHs load on FLAIR MRI sequences was quantitatively assessed. Results: The stroke/TIA patients presented a higher prevalence of RLS (100%) compared with the other groups (p < 0.001). The MA patients presented a higher BHI compared with the other groups in the PCA (p = 0.010) and higher RLS prevalence (60%) than controls (30%) (p < 0.001). The WMHs load did not differ across groups. BHI and RLS were not correlated to the WMHs load in the groups. Conclusions: A preserved or more reactive cerebral hemodynamics and the presence of a RLS are likely not involved in the genesis of WMHs in MA patients. A higher BHI may counteract the risk related to their higher prevalence of RLS. These results need to be confirmed by further studies to be able to effectively identify the protective role of cerebral hemodynamics in the increased RLS frequency in MA patients.

Intramedullary spinal cord abscess associated with right-to-left shunt via right superior vena cava draining into left atrium: A case report

RATIONALE

Intramedullary spinal cord abscess (ISCA) is a rare but treatable bacterial infection of the central nervous system, and the etiology in no less than 40% of the cases is cryptogenic. Although a few cases of ISCA in individuals with a right-to-left shunt (RL shunt) have been reported, only few arguments focused on the association between RL shunt and ISCA have been provoked. The right superior vena cava (RSVC) draining into the left atrium (LA) is an uncommon systemic venous anomaly that results in an RL shunt, and this anomaly causes several types of neurological complication such as stroke or brain abscess. We report the first case of ISCA associated with RSVC-LA RL shunt.

PATIENT CONCERNS

A 36-year-old man developed progressive paraparesis, dysuria, and spontaneous pain in the lumbar region and lower extremities. Spinal magnetic resonance imaging revealed an intramedullary lesion extended from Th12 to L2 with ring-shaped gadolinium enhancement. Cerebrospinal fluid (CSF) study exhibited a marked pleocytosis, and CSF culture grew Streptococcus intermedius. Cardiovascular computed tomography angiography identified RSVC-LA RL shunt, which caused transient acute cardiac syndrome due to air embolus.

DIAGNOSES

The patient was diagnosed with ISCA associated with an RSVC-LA RL shunt.

INTERVENTIONS

The patient was treated with a combination of intravenous administration of meropenem and vancomycin in a daily dose of 6 and 2.5 g, respectively, followed by intravenous administration of ampicillin in a daily dose of 750 mg. The intravenous antibiotic therapy was continued for 37 days.

OUTCOMES

A favorable neurological outcome was obtained by the intravenous antibiotic therapy, and recurrence of infection was prevented by continuous oral antibiotic therapy for 18 months.

LESSONS

With a literature review of ISCA associated with RL shunt, we insist that screening for RSVC-LA is beneficial to patients who are diagnosed with cryptogenic ISCA as its identification leads to appropriate preventive therapy.

Images of the month 1: Ischaemic stroke due to pulmonary arteriovenous fistula

A 38-year-old man was admitted to the hospital due to a "suddenly developed right hemiplegia, unconsciousness and gaze to the right". Pulmonary arteriovenous fistulas (PAVFs) are rare but an important cause of stroke in young people, which is easy to be clinically neglected. Therefore, for young patients with pulmonary diseases and cerebral infarction, the possibility of PAVF should be considered.

Prevalence of Patent Foramen Ovale in North Indian Cryptogenic Young Strokes

BACKGROUND

: Strokes of the undetermined cause or cryptogenic strokes (CS) account for 30-40% of ischemic strokes. Paradoxical embolism secondary to patent foramen ovale (PFO) may be associated with CS. Transcranial Doppler (TCD) with bubble contrast is a noninvasive bedside tool for diagnosis of right-to-left shunt (RLS) with high sensitivity and specificity. Data on the prevalence of PFO in CS in India are lacking. We determined the prevalence of RLS likely secondary to PFO in cryptogenic young strokes of the north Indian population using TCD with bubble contrast.

PATIENTS AND METHODS

: In this hospital-based prospective cross-sectional study, TCD with bubble contrast was performed in 57 young (age 15 > 45 years) CS and 50 healthy controls for the detection of RLS. The risk of paradoxical embolism (RoPE) score was calculated from various variables such as age, presence of cortical stroke on neuroimaging, and absence of vascular risk factors.

RESULTS

: 57 young CS and 50 healthy controls were recruited. TCD with bubble contrast was positive in 31% cases vs 6% in controls (P = 0.001). All patients with TCD positive for RLS had superficial cortical infarcts (P = 0.03). The median RoPE score of our patients was 9 (range: 7-10).

CONCLUSIONS

: There is a high prevalence of RLS likely secondary to PFO in cryptogenic young strokes in north India. TCD with bubble contrast is an excellent bedside tool for the detection of RLS.

Importance of direct right-to-left shunt as high-risk patent foramen ovale associated with cryptogenic stroke

BACKGROUND

Because transcatheter closure of patent foramen ovale (PFO) has become effective for preventing cryptogenic stroke (CS), it is necessary to determine high-risk PFO associated with CS. This study aimed to clarify the importance of direct right-to-left (RL) shunt through the PFO for identifying high-risk PFO.

METHODS

We analyzed 137 patients with and without CS who were confirmed to have PFO. The timing of RL shunt through the PFO was evaluated by cardiac cycles after right atrium (RA) opacification on saline contrast transesophageal echocardiography. Direct RL shunt was defined as microbubbles crossing the PFO before and at the same time of RA opacification.

RESULTS

Cardiac cycles of microbubbles crossing the PFO were shorter in patients with CS than in those without CS (2.0 ± 2.2 vs .5 ± 1.1, p < 0.01). Direct RL shunt was more frequently observed in patients with CS than in those without CS (77% vs 29%, p < 0.01), with a sensitivity of 79% and a specificity of 71% for the association with CS. Multivariate analysis revealed that direct RL shunt was related to atrial septal aneurysm and low-angle PFO. Regarding functional features of PFO, the detection rate of CS was 50% for large RL shunt alone, and was increased to 83% when direct RL shunt was added.

CONCLUSION

Direct RL shunt was associated with CS and had the incremental value in detecting PFO associated with CS for large RL shunt. The timing of RL shunt can be valuable for identifying high-risk PFO.

Applicability of Transthoracic Contrast Echocardiography for the Diagnosis and Treatment of Idiopathic Pulmonary Arteriovenous Malformations

Objective: To explore the preferred test to screen for pulmonary arteriovenous malformations (PAVMs) and to predict the probability of interventional embolization. Methods: We performed a retrospective observational study evaluating patients with idiopathic PAVMs from 2009 to 2019. After clinical evaluation, a total of 105 patients were studied, including 71 patients with positive digital subtraction pulmonary angiography (DSPA) findings and 34 with negative DSPA findings. The following patient data were assessed: blood test, chest radiograph, transthoracic contrast echocardiography (TTCE), and DSPA findings. Results: The majority of patients with idiopathic PAVMs were female (66.2% with positive DSPA findings). We found a good κ-coefficient of 0.77 with strong consistency for inter observer agreement concerning the pulmonary right-to-left shunt (RLS) grade on TTCE, which was superior to conventional chest radiographs. The positive predictive value (PPV) of the radiographic features for PAVMs on DSPA was 0.83 (95% CI 0.64-1.0) and 0.44 for the possibility of embolization (95% CI 0.19-0.70). The PPV of the shunt grade of PAVMs on DSPA was 0.14 (95% CI 0.01-0.29) for grade 1, 0.74 (95% CI 0.60-0.88) for grade 2, and 0.97 (95% CI 0.92-1.0) for grade 3. The PPVs of pulmonary shunt grades 2 and 3 on TTCE for the possibility of embolization for PAVMs were 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively. Conclusion: TTCE is the preferred screening test for PAVMs. The pulmonary RLS grade on TTCE not only identifies the likelihood of PAVMs but also predicts the probability for embolization.

Pulmonary arteriovenous fistula diagnosed by transthoracic contrast echocardiography: A case report

We report the case of a 38-year-old woman who was admitted due to right limb numbness. A right-to-left shunt (RLS) was detected by transthoracic contrast echocardiography (cTTE), and microbubbles appeared in the left heart seven cardiac cycles after opacification of the right heart, suggesting pulmonary arteriovenous fistula. This was supported by computed tomography angiography. She underwent thoracoscopic partial right lower pneumonectomy and recovered after surgery. At 1 year follow-up, she had no relapse of stroke or cerebral infarction. This case shows the typical signs of pulmonary arteriovenous fistula on contrast-enhanced trans-thoracic echocardiography, which allowed an accurate and rapid diagnosis.

Prevalence and grade of RLS in migraine: A prospective study of 251 migraineurs by synchronous test of c-TTE and c-TCD

BACKGROUND

Right-to left shunt (RLS) is regarded as a risk factor resulting in migraine, but the relevance between the RLS and migraine remains controversial. This paper aims at investigating the prevalence and RLS grade of patent foramen ovale (PFO) in cases of migraine (including migraine with and without aura) and evaluate the relationship between PFO and migraine.

METHODS

Synchronous test of contrast transthoracic echocardiography and contrast transcranial Doppler ultrasonography was performed in 251 cases of migraine, which contains 62 cases of migraine with aura (MA) and 189 cases without aura (MO) and 275 healthy adults. Among these cases, 25 cases with migraine and 14 healthy adults were evaluated through transesophageal echocardiography.

RESULTS

(1). The prevalence of permanent RLS, total RLS, and large RLS in migraine was 11.16%, 39.04%, and 17.13%, respectively, which was significantly higher than that of the controls (P = .042, <.001, and.001, respectively). (2). Permanent RLS was detected as 7.93% of the cases in MO, 20.96% in MA, and 6.18% in controls. Total RLS was detected as 35.98% of the cases in MO, 48.38% in MA, and 23.64% in controls. Large RLS was detected as 13.76% of the cases in MO, 27.41% in MA, and 7.27% in controls. Compared with controls, the positive rate of total RLS and large RLS in MO increased (P = .004 and.022, respectively), the that of permanent RLS, total RLS, and large RLS in MA also increased (P < .001 for each of the comparisons). The positive rate of permanent RLS and large RLS in MA was remarkably higher than that in MO (P = .005 and.013, respectively). (3) The presence of large-size PFO (≥2.0 mm) of migraine showed higher than that of the controls (P = .048).

CONCLUSIONS

PFO is associated with the migraine (especially with aura), when it is permanent RLS, large RLS, and large-size PFO (≥2.0 mm).

Echocardiographic diagnosis of right-to-left shunt using transoesophageal and transthoracic echocardiography

Background

The diagnosis and quantification of right-to-left shunt (RLS) using transthoracic echocardiography (TTE) as well as transoesophageal echocardiography (TOE) have not been well established. We aimed to diagnose RLS by TOE using direct visualisation of the shunt and to compare the diagnosis with TTE diagnosis using conventional methods.

Methods and results

We evaluated 141 patients with ischaemic stroke for RLS by both non-sedation TOE and TTE using saline contrast and Valsalva manoeuvre. The amount (graded as 0 to IV) and timing of RLS were demonstrated. All patients were classified into four groups by TOE based on direct visualisation of shunt through a patent foramen ovale (PFO) or either pulmonary vein: no shunt (group 1: n=11), PFO (group 2: n=47), pulmonary RLS (group 3: n=25) and indeterminate RLS (group 4: n=58). All cases in group 3 showed delayed shunt, and all cases in group 4 had small shunt. On TTE findings, all cases with early appearing large shunt (cardiac cycles ≤3 and shunt grade ≥III) were group 2. Six of the eight patients with delayed appearing large shunt on TTE were group 3. TTE diagnosis of PFO using criteria of cardiac beats ≤3 and grade ≥II had a sensitivity of 85% and a specificity of 98% compared with TOE diagnosis using shunt visualisation.

Conclusions

Compared with TOE using shunt visualisation, TTE accurately diagnosed large PFO using criteria of cardiac cycles ≤3 and shunt grade ≥III. TTE possibly diagnosed pulmonary shunt using criteria of cardiac cycles >3 and shunt grade ≥III. Both modalities showed limitations in diagnosing small amount of RLS.

When orofacial pain needs a heart repair

Objectives

The association of chronic orofacial pain (COFP) and congenital heart disease has never previously been reported. We report the first case of COFP secondary to a right‐to‐left shunt (RLS) due to asymptomatic patent foramen ovale (PFO) in a patient with prothrombotic states.

Materials and methods

A 48‐year‐old female patient presented with a 10‐month history of left‐sided facial pain who was initially diagnosed with persistent idiopathic facial pain (PIFP) on account of its similar characteristics. Magnetic resonance imaging (MRI) of the brain revealed gliosis and carotid siphon tortuosity; in addition, hyperhomocysteinaemia due to the homozygosis mutation for 5,10 MethyleneTetraHydroFolate Reductase was identified. Transcranial doppler ultrasonography was requested from a neurology consultant which revealed a high degree of RLS. Subsequently, a cardiological evaluation was performed; the specialist requested a transesophageal echocardiography that detected an interatrial septum aneurysm with PFO.

Results

Based on the analysis of the patient's high degree of RLS, prothrombotic state and gliosis in relation to age, the cardiological consultant chose to perform a percutaneous closure of the PFO to avoid the risk of a cryptogenic stroke. After PFO closure, a complete remission of the pain was obtained.

Conclusions

The disappearance of the pain supports the possible association between RLS and COFP. PFO with RLS has been suggested as a risk factor for cryptogenic stroke, especially in association with other thromboembolic risk factors. Therefore, the early detection, in this case, could be considered a possible lifesaver. Communication between different care providers is essential when the patient presents symptoms of facial pain which are of an atypical nature.

Transcatheter reduction in size of large undesirable fenestrations following extracardiac conduit Fontan surgery with off-label use of Occlutech atrial flow regulator

Fontan surgery streamlines the systemic venous return through the pulmonary circulation before filling the systemic ventricle in univentricular hearts. The venous congestion leads to effusions, lowers cardiac output, and affects organ perfusion. Fenestrations in the Fontan circuit improve forward flow through the ventricles, lower venous pressures, and reduce perioperative morbidity. When large fenestrations cause profound hypoxia and effort intolerance, there are no current techniques to reduce their size. Atrial flow regulators with a predetermined orifice were used off-label in three borderline patients with large undesirable fenestrations following extracardiac conduit Fontan surgeries. This resulted in improved oxygenation without marked elevation of venous pressures, while retaining the patency of the decompressive fenestration.

Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors

Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO).

Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design.

Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke.

Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.

Clinical features of right-to-left shunt in the different subgroups of migraine

OBJECTIVE

Several investigations have documented an association between migraine and right-to-left shunt (RLS). However, whether there are specific clinical features that can distinguish between migraine patients with and without RLS is unclear. This study aims to explore whether there are specific clinical features that can distinguish between migraine patients with and without RLS, and to investigate the relationship between the degree of shunt and clinical parameters of headache.

METHODS

In this study, we enrolled consecutive migraineurs who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. RLS was diagnosed based on a contrast enhancement transcranial Doppler (c-TCD) examination.

RESULTS

Overall, 113 migraine with aura (MA) and 192 migraine without aura (MO) patients were included. Patients with MA and RLS (MARLS+) had a higher frequency for sensory aura symptoms than those with MA without RLS (MARLS-) (27.4% vs. 10.0%, p = .03). Patients with MO and RLS (MORLS+) presented with significantly younger initial age of migraine onset and experienced more severe pain intensity than those with MO without RLS (MORLS-) (mean ± SD, 25.6 ± 8.9 vs. 29.8 ± 12.7 years, p = .008 and 5.9 ± 1.4 vs. 5.3 ± 1.3, p = .006, respectively). There was no relationship between the degree of shunt and the clinical parameters of headache.

CONCLUSIONS

Our results indicate that MO patients presented with a younger initial age of migraine onset and that sensory aura symptoms in MA patients may predict the presence of RLS. However, we did not find support for relationship between the degree of shunt and clinical parameters of headache.

Effect of Residual Interatrial Shunt on Migraine Burden After Transcatheter Closure of Patent Foramen Ovale

OBJECTIVES

This study sought to evaluate the long-term effect of transcatheter patent foramen ovale (PFO) closure on migraineurs with and without aura and examine the effect of residual right-to-left shunt.

BACKGROUND

Many studies reported improvement in migraine symptoms after PFO closure, yet randomized trials failed to reach its clinical endpoints.

METHODS

The study retrospectively analyzed data from 474 patients who underwent transcatheter PFO closure at Massachusetts General Hospital. Patients completed a migraine burden questionnaire at baseline and at follow-up. Migraine severity is reported as migraine frequency (days/month), average duration (min), and migraine burden (days × min/month). Improvement following closure was defined as complete abolishment of symptoms or >50% reduction in migraine burden.

RESULTS

A total of 110 migraineurs who underwent PFO closure were included; 77.0% had aura and 23.0% were without aura, and 91.0% had a cryptogenic stroke. During long-term median follow-up of 3.2 (interquartile range: 2.1 to 4.9) years, there was a significant improvement in migraine symptoms in migraineurs with or without aura. Migraine burden was reduced by >50% in 87.0% of patients, and symptoms were completely abolished in 48%. Presence of aura was associated with abolishment of migraine (odds ratio: 4.30; 95% confidence interval: 1.50 to 12.30; p = 0.006). At 6 months after PFO closure, residual right-to-left shunt was present in 26% of patients. Absence of right-to-left shunt was associated with improvement in migraine burden by >50% (odds ratio: 4.60; 95% confidence interval: 1.30 to 16.10; p = 0.017).

CONCLUSIONS

Long-term follow-up after transcatheter PFO closure was associated with significant improvement in migraine burden. Aura was a predictor of abolishing symptoms. Absence of residual right-to-left shunt was a predictor of significant reduction in migraine burden.

Incidental finding of a left atrial thrombus during surgical management of a massive pulmonary embolism

A 58-year-old male presented with a hemodynamically significant pulmonary embolism. Computed tomography angiogram revealed a saddle embolus in the main pulmonary artery with extensive clot burden affecting all lobes and right heart strain. Transthoracic echocardiogram displayed a dilated right ventricle with reduced systolic function. The patient was scheduled for pulmonary embolectomy. The intraoperative transesophageal echocardiogram (TEE) demonstrated a mobile left atrial thrombus that was missed on previous imaging. After removal of the thrombi, TEE showed a patent foramen ovale (PFO). The left atrial thrombus passed across the PFO secondary to increased right heart and pulmonary pressures.

Diagnostic Yield of Early Examination for Venous Thrombosis in Patients with Cryptogenic Stroke and a Right-to-left Shunt

Objective The presence of deep venous thrombosis (DVT) in a cryptogenic stroke (CS) patient with a right-to-left shunt (RLS) may lead to the development of paradoxical embolism. The aim of the present was to investigate the prevalence of DVT and pulmonary embolism (PE) in CS patients and the clinical features of CS in relation to DVT location and the presence of PE. Methods The medical records of 903 patients with cerebral infarction were retrospectively reviewed. For patients with a diagnosis of CS, contrast saline transcranial color-coded sonography was performed to identify an RLS. DVT and PE were assessed by duplex ultrasonography and/or contrast-enhanced computed tomography. Proximal DVT (P-DVT) was defined as DVT in the popliteal, femoral, or iliac veins, and distal DVT (D-DVT) was defined as DVT at other locations. The patients were divided into three groups: CS with P-DVT and/or PE (P-DVT/PE) group; CS with D-DVT (D-DVT) group; and CS without DVT (no DVT) group. Results Seventy-two (37%) of 194 patients with CS had an RLS. The median time to first DVT examination from stroke onset was three days. Twenty-nine percent of CS patients with an RLS had DVT. The P-DVT/PE group comprised 8.3% of the CS patients with an RLS and included a larger number of patients with multi-territory infarction than the D-DVT group. The D-DVT and P-DVT/PE groups tended to be female and older, while the P-DVT/PE group tended to have pre-stroke disability. Conclusion CS patients, especially those with multi-territory lesions, should be immediately examined for DVT and PE.

Inaccurate point-of-care blood glucose measurement in a dog with secondary erythrocytosis

BACKGROUND

Point-of-care (POC) portable blood glucose meters (PBGMs) are convenient and inexpensive tools for assessing patient blood glucose concentrations. They are often used to quickly diagnose hypoglycemia or collect serial glucose readings in diabetic patients. However, POC meters have been previously identified in human and veterinary literature to be inaccurate when utilized in patients with abnormal HCT. This problem may not be reflected in manufacturer guidelines referenced by practitioners in the POC setting.

KEY FINDINGS

A 1.5-year-old dog, previously diagnosed with multiple congenital cardiac malformations, right-to-left cardiac shunting and secondary erythrocytosis, presented to a veterinary emergency center minimally responsive and without detectable pulses. PBGM measurement identified hypoglycemia. Following stabilization of the dog, serial glucose assessments showed discordant results between PBGMs and the reference laboratory biochemistry analyzer. A pathological cause for hypoglycemia was not identified and PBGM readings were determined to be erroneously low due to the dog's abnormally high HCT.

SIGNIFICANCE

This case demonstrates the limitations of using PBGMs to assess blood glucose in a dog with secondary erythrocytosis. The report emphasizes the need for judicious use of PBGMs in critically ill patients and that these glucometers may not be reliable in patients with abnormal HCT values.

Cough maneuver is superior to Valsalva maneuver for detecting mild-extent right-to-left shunt

Objective: The purpose of this study was to explore the different provocative maneuvers in detecting right-to-left shunt during contrast transthoracic echocardiography (cTTE). Methods: We evaluated 378 patients for right-to-left shunt detection by cTTE at the quiet respiration, during Valsalva maneuver (blowing into a face mask connected to a sphygmomanometer at 40 mmHg for 10 s), and during cough maneuver, performed in random order, and the degree of right-to-left shunt as the number of microbubbles in the left atrium per frame after each provocative maneuver was recorded. Results: The detection rates of right-to-left shunt for quiet respiration, Valsalva maneuver, and cough maneuver were 16%, 33%, and 38%, respectively (p < .001). The detection rate for cough maneuver was significantly higher than that for Valsalva maneuver (p < .001). There was no significant difference between Valsalva maneuver and cough maneuver in terms of detecting moderate- or severe-extent right-to-left shunt (p > .05), but cough maneuver was significantly better than Valsalva maneuver at detecting mild-extent right-to-left shunt (p = .001). Conclusions: Cough maneuver is an effective alternative to Valsalva maneuver, with a higher detection rate for mild-extent right-to-left shunt during cTTE, maybe due to its own mechanical characteristics.

Right-to-left shunts in lowlanders with COPD traveling to altitude: a randomized controlled trial with dexamethasone

Right-to-left shunts (RLS) are prevalent in patients with chronic obstructive pulmonary disease (COPD) and might exaggerate oxygen desaturation, especially at altitude. The aim of this study was to describe the prevalence of RLS in patients with COPD traveling to altitude and the effect of preventive dexamethasone. Lowlanders with COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1-2, oxygen saturation assessed by pulse oximetry (SpO2) >92%] were randomized to dexamethasone (4 mg bid) or placebo starting 24 h before ascent from 760 m and while staying at 3,100 m for 48 h. Saline-contrast echocardiography was performed at 760 m and after the first night at altitude. Of 87 patients (81 men, 6 women; mean ± SD age 57 ± 9 yr, forced expiratory volume in 1 s 89 ± 22% pred, SpO2 95 ± 2%), 39 were assigned to placebo and 48 to dexamethasone. In the placebo group, 19 patients (49%) had RLS, of which 13 were intracardiac. In the dexamethasone group 23 patients (48%) had RLS, of which 11 were intracardiac (P = 1.0 vs. dexamethasone). Eleven patients receiving placebo and 13 receiving dexamethasone developed new RLS at altitude (P = 0.011 for both changes, P = 0.411 between groups). RLS prevalence at 3,100 m was 30 (77%) in the placebo and 36 (75%) in the dexamethasone group (P = not significant). Development of RLS at altitude could be predicted at lowland by a higher resting pulmonary artery pressure, a lower arterial partial pressure of oxygen, and a greater oxygen desaturation during exercise but not by treatment allocation. Almost half of lowlanders with COPD revealed RLS near sea level, and this proportion significantly increased to about three-fourths when traveling to 3,100 m irrespective of dexamethasone prophylaxis.NEW & NOTEWORTHY The prevalence of intracardiac and intrapulmonary right-to-left shunts (RLS) at altitude in patients with chronic obstructive pulmonary disease (COPD) has not been studied so far. In a large cohort of patients with moderate COPD, our randomized trial showed that the prevalence of RLS increased from 48% at 760 m to 75% at 3,100 m in patients taking placebo. Preventive treatment with dexamethasone did not significantly reduce the altitude-induced recruitment of RLS. Development of RLS at 3,100 m could be predicted at 760 m by a higher resting pulmonary artery pressure and arterial partial pressure of oxygen and a more pronounced oxygen desaturation during exercise. Dexamethasone did not modify the RLS prevalence at 3,100 m.

Transcatheter Patent Foramen Ovale Closure Is Effective in Alleviating Migraine in a 5-Year Follow-Up

Background: The association between patent foramen ovale (PFO) and migraine has been reported. However, whether transcatheter PFO closure is effective in alleviating migraine remains controversial. The objective of this study was to investigate the efficacy of PFO closure in alleviating migraine in a 5-year follow-up.

Methods: Migraineurs with PFO from 2013 to 2015 were included and divided into PFO closure group and non-PFO closure group according to their therapy. Contrast-enhanced transcranial Doppler (c-TCD) was performed to evaluate the degree of the right-to-left shunt (RLS), and headache impact test (HIT-6) questionnaire was administered to assess the disability of migraine at 1- and 5-year follow-up.

Results: Of 192 patients, 91 patients underwent PFO closure, and 101 patients refused. The HIT-6 scores of patients in the PFO closure group were significantly lower than those of the non-PFO closure group at both 1- and 5-year follow-up. These results were more pronounced in patients younger than 45 years. Furthermore, in patients with large RLS, the HIT-6 scores of patients in the PFO closure group were significantly lower at both 1- and 5-year follow-up compared with those of the non-PFO closure group. However, in patients with moderate RLS, this difference was significant only at 5-year follow-up.

Conclusions: PFO closure is effective in alleviating migraine in the long term. This effect is more obvious when patients are younger than 45 years and RLS is large.

False negative diagnoses of critical congenital heart disease with screening neonatal pulse oximetry

BACKGROUND

False negative pulse oximeter results occur in new born infants with critical congenital heart disease who have an oximeter saturation ≥95%. Some of these infants have abnormal physical findings but others do not.

OBJECTIVES

To determine the causes of false negative results.

METHODS

Mathematical analysis of determinants of arterial oxygen saturation and discussion of oximeter bias.

RESULTS

False negative oximeter results are not rare; the sensitivity of pulse oximetry screening for critical congenital heart disease is about 80%. The high saturation may be due to a very small right-to-left shunt at the time of study, a relatively high cardiac output and mixed venous saturation, or to positive bias in oximeter readings. It may also be due to some critical congenital heart lesions that do not show desaturation at the time of testing.

CONCLUSIONS

A diagnosis of a normal heart based on a negative oximeter test is presumptive, and requires careful follow-up for 1-2 weeks after birth.

Impact of right-to-left shunt and transcatheter closure on the clinical features of migraine

Objectives: In this study, we aimed to explore the influence of right-to-left shunt (RLS) presence on the clinical features of migraine and to follow-up on the post-operative curative effect of transcatheter patent foramen ovale (PFO) closure on migraine features.Methods: A total of 103 migraine patients were divided into a mild volume RLS group, moderate volume RLS group, large volume RLS group and non-RLS group in accordance with contrast enhancement transcranial Doppler (c-TCD) findings. The Visual Analogue Scale (VAS) score, migraine frequency, migraine duration, migraine disability assessment (MIDAS) and headache impact test-6 (HIT-6) scores were compared amongst the different groups. A total of 39 patients with moderate or large RLS received transcatheter PFO closure and those patients were followed up by the same criteria.Results: The attack frequency, HIT-6 and MIDAS scores amongst the migraine patients with moderate or large RLS were significantly higher than those in patients from the mild RLS group and non-RLS group (p < .05). The transcatheter closure was successful in all patients (n = 39), and no post-operative complications were observed during the hospitalisation and follow-up period. The differences in VAS, HIT-6 and MIDAS scores as well as the headache duration were statistically significant amongst patients before and after PFO closure (p < .05).Conclusions: Moderate to large RLS significantly influenced the clinical features of migraine, and transcatheter PFO closure could significantly relieve headache symptoms in migraine patients with PFO.

Anesthetic Management of Right Single-lung Ventilation in a Patient with Anomalous Left Superior Pulmonary Venous Return for Left Pulmonary Lobectomy

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital anomaly in which one or more of the pulmonary veins are connected to the right atrium or to the systemic venous system. One lung ventilation (OLV) is required for a number of thoracic procedures. When switching to OLV, right-to-left shunt fraction increases, oxygenation is impaired, and hypoxemia may occur. Hypoxemia during OLV may affect the safety of the patient and is a challenge for the anesthesiologist and the surgeon. This case details the intraoperative anesthetic management of an elderly patient with a PAPVR who underwent single-lung ventilation for lung resection surgery.