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PubMed2004

Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale.

BACKGROUND: The risk of developing decompression illness (DCI) in divers with a patent foramen ovale (PFO) has not been directly determined so far; neither has it been assessed in relation to the PFO's size. METHODS: In 230 scuba divers (age 39+/-8 years), contrast trans-oesophageal echocardiography (TEE) was performed for the detection and size grading (0-3) of PFO. Prior to TEE, the study individuals answered a detailed questionnaire about their health status and about their diving habits and accidents. For inclusion into the study, > or =200 dives and strict adherence to decompression tables were required. RESULTS: Sixty-three divers (27%) had a PFO. Overall, the absolute risk of suffering a DCI event was 2.5 per 10(4) dives. There were 18 divers (29%) with, and 10 divers (6%) without, PFO who had experienced > or =1 major DCI events P=0.016. In the group with PFO, the incidence per 10(4) dives of a major DCI, a DCI lasting longer than 24 h and of being treated in a decompression chamber amounted to 5.1 (median 0, interquartile range [IQR] 0-10.0), 1.9 (median 0, IQR 0-4.0) and 3.6 (median 0, IQR 0-9.8), respectively and was 4.8-12.9-fold higher than in the group without PFO (P<0.001). The risk of suffering a major DCI, of a DCI lasting longer than 24 h and of being treated by recompression increased with rising PFO size. CONCLUSION: The presence of a PFO is related to a low absolute risk of suffering five major DCI events per 10(4) dives, the odds of which is five times as high as in divers without PFO. The risk of suffering a major DCI parallels PFO size.

Decompression Sickness↗
PubMed2004

Cystocele repair by a synthetic vaginal mesh secured anteriorly through the obturator foramen.

OBJECTIVE: Our aim was to assess the feasibility and short-term results of cystocele repair by the placement of a synthetic subvesical mesh secured anteriorly through the obturator foramen. STUDY DESIGN: Between 1 November 2001 and 31 July 2002, 30 consecutive patients with a grade 2 (n = 18, 60%) or 3 (n =12, 40%) cystocele were prospectively included in the study. RESULTS: The obturator route was feasible in all cases. No intraoperative complications arose. After a mean follow-up of 6.7 months (range: 2-12), 90% (n = 27) of the patients were cystocele grade 0, 7% (n = 2) grade 1 and failure was observed in a young patient (3%) treated without hysterectomy. Two vaginal erosions (7%) were observed at six and nine months. For the 14 patients (47%) who had sexual relations after surgery, 2 (14%) complained of anterior dyspareunia. CONCLUSION: The obturator approach is a simple and sure technique for placing a polypropylene synthetic subvesical mesh. The long term stability and tolerance of the results must be confirmed.

Adult↗
PubMed2004

Second harmonic transthoracic echocardiography: the new reference screening method for the detection of patent foramen ovale.

AIM: Transesophageal echocardiography (TEE) is still considered as the reference method for the non-invasive detection of right-to-left shunts. Echocardiographic laboratories are spending most of their time performing TEE studies to exclude a thromboembolic cardiac disease. In a considerable proportion of these patients the question can be simplified to exclude a PFO. Replacing these TEE studies by TTE would result in a considerable gain in time and money. We evaluated the value of transthoracic echocardiography with second harmonic imaging (TTE) (SH) and peripheral intravenous agitated saline solutions in the detection of patent foramen ovale (PFO) in a large cohort of patients. METHODS: In 256 consecutive patients, TEE and TTE (SH) with the consecutive administration of three intravenous contrast injections of agitated saline injections before the release phase of the Valsalva manoeuvre were performed. Semi-quantification and timing of contrast passage were assessed during both imaging modalities. A shunt was present if at least one imaging modality showed microbubbles appearing in the left atrium. PFO was defined when these bubbles appeared early and arteriovenous pulmonary malformations were suspected if bubbles appeared late after the opacification of the right atrium. Shunts were considered important when >20 bubbles were present in one frame in the left atrium or left ventricle. RESULTS: From the 256 patients, 60 presented a passage of contrast from the right to the left atrium in at least one imaging modality. PFO was detected by TEE in 53 patients and by TTE in 55 patients (sensitivity: 90.5% and specificity: 96.5% if TEE is accepted as the golden standard) (p>0.05). Considering only the important shunts TEE detected 39 important shunts and TTE 46 important shunts (sensitivity: 89.7% and specificity: 94.6%) (p>0.05). AV pulmonary malformations were detected by TEE in 7 patients and by TTE in 10 patients (sensitivity: 85.7% and specificity: 98.3%) (p>0.05). CONCLUSIONS: In this large cohort of patients TTE (SH) is as accurate as TEE for the detection of PFO and late right-to-left shunts. If the only purpose of TEE is the detection of PFO such as in young cryptogenic stroke patients and in divers, TEE can be replaced by TTE (SH).

Chi-Square Distribution↗
PubMed2005

Traditional contrast echocardiography may fail to demonstrate a patent foramen ovale: negative contrast in the right atrium may be a clue.

We describe a patient who suffered a stroke of unknown origin and presented a patent foramen ovale (PFO) at contrast echocardiography. This PFO was clearly detectable after contrast delivery in the femoral vein, while repeated contrast delivery in an antecubital vein only showed a negative contrast effect, which suggests that the blood crossing the PFO originated from the vena cava inferior. However, enhanced detection of a PFO by femoral contrast delivery, compared to antecubital injection has been published many years ago, this mode is not widely implemented yet. With this case report we would like to illustrate that the negative contrast effect may be used as an indicator that a PFO cannot be excluded and a switch to femoral contrast injection is then mandatory.

Adult↗
PubMed2006

Paradoxical embolism with a patent foramen ovale and atrial septal aneurysm.

Patent foramen ovale (PFO) and atrial septal aneurysm have been cited as potential risk factors for cryptogenic stroke. We present two cases which we propose to directly illustrate paradoxical embolisation as a mechanism of cerebrovascular accident. The diagnosis of PFO is discussed and the literature reviewed.

Echocardiography, Transesophageal↗
PubMed2006

Inferior sinus venosus defect associated with incomplete cor triatriatum dexter and patent foramen ovale.

Sinus venosus atrial septal defect (SVD) is a rare cardiac abnormality in adults. Particularly, the inferior type is difficult to depict by transthoracic echocardiography because of its infero-posterior location to the fossa ovalis. We describe the case of a 33-year-old woman whose chest X-ray taken during bronchopneumonia revealed a cardiomegaly. Further echocardiographic investigations showed an underlying inferior SVD, an incomplete cor triatriatum dexter and a large patent foramen ovale (PFO). The diagnosis was confirmed by cardiac magnetic resonance imaging (CMR) and during surgical repair.

Adult↗
PubMed2005

Caught in the act: serial, real time images of a thrombus traversing from the right to left atrium across a patent foramen ovale.

AIMS: To illustrate the association between a patent foramen ovale (PFO) and paradoxical embolization. METHODS AND RESULTS: We report a unique case of a paradoxical embolization across a PFO noted during a transesophageal echocardiographic study. Serial images demonstrate the thrombus migrating from the superior vena cava to the left atrium across the PFO. CONCLUSIONS: This case establishes the association between the PFO and paradoxical embolism unequivocally.

Aged↗
PubMed2005

Late cardiac tamponade after percutaneous closure of a patent foramen ovale.

We report the case of a 35-year-old man who had a transient ischemic cerebral attack and then underwent a percutaneous closure of the patent foramen ovale (PFO) with a Cardiastar device. One year later, the patient developed a cardiac tamponade due to an important hemorrhagic pericardial effusion. Transoesophageal echocardiography showed that one of the struts had impinged on the aortic root in the region adjacent to the transverse pericardial sinus. Therefore, we speculated that the strut had passed through the aortic wall by slow erosion, leading to the pericardial effusion. Cardiac CT and subsequent surgery confirmed the perforation of the left atrial roof and the aortic root by two struts of the device. This is the first reported case of late cardiac tamponade and underscores the importance of long-term follow-up after PFO closure device implantation.

Adult↗
PubMed2006

Platypnoea orthodeoxia in a patient with aortic root dilatation and a patent foramen ovale.

Platypnoea orthodeoxia syndrome is a rare condition in which shortness of breath and hypoxaemia occur when upright and resolve when prone. The hypoxaemia results from increased right to left shunting of deoxygenated blood, when standing, through a patent foramen ovale (PFO), atrial septal defect (ASD) or other right to left shunt, in the absence of raised right-heart pressure. We present the case of a patient with platypnoea orthodeoxia with marked shunting through a large PFO, evaluated by transesophageal and transthoracic echo.

Aged↗
PubMed2006

Large emboli on their way through the heart - first live demonstration of large paradoxical embolisms through a patent foramen ovale.

We report a case of large paradoxical embolisms through a patent foramen ovale in a patient with acquired heparin-induced thrombocytopenia type II (HIT). One large ventricular thrombus embolizing through the aortic valve was documented on videotape for the first time while performing transesophageal echocardiography. A 56-year-old man was admitted with acute respiratory failure initially believed to have an exacerbated chronic obstructive pulmonary disease. Arterial oxygen saturation was only 33%. He received antibiotic and anti-obstructive treatments and was mechanically ventilated for 7 days. Few hours after extubation, he developed recurrent severe dyspnea accompanied by acute pain and pulselessness in his left leg. Transthoracic echocardiography revealed an enlarged right ventricle and suggested the presence of free-floating thrombi both in the right and in the left-heart cavities. During transesophageal echocardiography, a large serpentine left-heart thrombus embolized through the aortic valve and disappeared. The patient developed ventricular fibrillation and underwent successful cardiopulmonary resuscitation including emergency thrombolysis with alteplase. Four hours later, the surgeon retrieved a 20-cm long thrombus from the left femoral artery.

Echocardiography↗
PubMed2006

Momentarily stuck in the foramen ovale.

An 80-year-old woman was admitted for a diagnosis of severe pulmonary embolism. A large serpentine thrombus stuck in a patent foramen ovale (PFO) completely resolved without the patient experiencing any manifestation. The right renal artery was the final destination. Thromboaspiration was unsuccessful. Three months later, the patient was diagnosed with a malignant melanoma and metastatic dissemination.

Aged, 80 and over↗
PubMed2005

Transcatheter closure of patent foramen ovale after left ventricular assist device implantation: intraoperative decision making.

The presence of a patent foramen ovale in patients with heart failure can be missed during echocardiography despite the use of provocative maneuvers. Implantation of a left ventricular assist device in these patients can result in right-to-left shunting and hypoxemia. We report the use of a percutaneous atrial septal defect closure device as an alternative to surgical closure.

Cardiopulmonary Bypass↗
PubMedDate not supplied

Undiagnosed patent foramen ovale presenting as a cryptogenic brain abscess: case report and review of the literature.

A 43-year-old man with no significant medical history but poor oral hygiene presented with fever and new-onset tonic-clonic seizures secondary to a left parieto-occipital brain abscess defined by computed tomography, magnetic resonance imaging, and surgical evacuation. A comprehensive workup looking for a source of infection was unremarkable including computed tomography of the chest, abdomen, and pelvis; blood cultures; and a tagged white blood cell scan. A transesophageal echocardiogram bubble study revealed the presence of a patent foramen ovale (PFO) but no other abnormalities. Culture of the material obtained at surgery revealed flora commonly found in the oropharynx that responded to antibiotic therapy. A review of the literature revealed three other cases in which a brain abscess from flora commonly found in the oropharynx was associated with a PFO. We hypothesize that the underlying mechanism is a significant bacterial load from poor dentition that enters the arterial circulation through a PFO and forms the nidus for a brain abscess. Surgical evacuation is the preferred method for diagnosis and initial treatment. If a brain abscess is identified without any adjacent source of infection, a recent head trauma, or a neurosurgical procedure, then a transesophageal echocardiogram is indicated to exclude a PFO. If a PFO is found, then hematogenous spread of flora normally found in the oropharynx through a right to left shunt should be suspected. Surgical evacuation followed by intravenous antibiotics specific to the identified organisms is warranted. Once the infection is eliminated, anatomic closure of the PFO with good oral hygiene practices may be the best course of action for preventing recurrences.

Adult↗
PubMed2006

Dramatic decrease in the pulmonary artery systolic pressure and disappearance of the interatrial shunt with sildenafil treatment in a patient with primary pulmonary hypertension with atrial septal aneurysm and a severe right to left shunt through the patent foramen ovale.

This report describes a patients with PPH with atrial septal aneurysm and a severe right to left shunt through the patent foramen ovale who showed a dramatic decrease in the pulmonary artery systolic pressure and interatrial shunt disappeared after sildenafil treatment.

3',5'-Cyclic-GMP Phosphodiesterases↗
PubMed2005

A large Eustachian valve is a confounder of contrast but not of color Doppler transesophageal echocardiography in detecting a right-to-left shunt across a patent foramen ovale.

BACKGROUND: Transesophageal contrast echocardiography (cTEE) is considered to be the method of choice for diagnosing patent foramen ovale (PFO), but its diagnostic accuracy compared with color Doppler guided TEE in the presence of an Eustachian valve (EV) has not been evaluated. The main aim of this study was to assess the diagnostic accuracy for PFO diagnosis of color Doppler TEE at low pulse repetition frequency. METHODS: We ascertained the presence of PFO and EV using cTEE and transthoracic contrast echocardiography (cTTE) in 292 consecutive patients (age 42+/-12 years) with cryptogenic stroke. A diagnosis of PFO was based on the observation of right-to-left shunting of contrast bubbles or by color Doppler with pulse repetition frequency of 20-30 cm/s. An EV with a diameter of >1.5 cm in the bicaval view was considered large. RESULTS: Overall 204 patients (70%) had evidence of a right-to-left shunt by either contrast echo method. Shunting was demonstrated more frequently by color Doppler than by cTEE, either spontaneously (133 vs. 92; p=0.01) or during provocative maneuvers (166 vs. 184; p=0.01). The sensitivity of color Doppler was significantly higher than that of cTEE (90% vs. 81%; p=0.01). A large EV was found in 37 patients, 31 (84%) of whom had a PFO. The presence of a large EV did not significantly influence the sensitivity of color Doppler for detecting shunting through a PFO, but the sensitivity of cTTE and cTEE was significantly reduced (from 88% to 42%, p<0.001). CONCLUSIONS: Color Doppler TEE is more accurate than traditional cTEE for PFO diagnosis and is not negatively influenced by the presence of an EV, provided that a low pulse repetition frequency is used.

Adult↗
PubMed2006

Multiple accessory pathways, dual AV nodal physiology, non-compacted myocardium and patent foramen ovale in a patient with Ebstein's anomaly: report of a case.

Ebstein's anomaly is a rare congenital cardiac disease initially described by Wilhelm Ebstein in 1866. The primary pathology involves significant apical displacement of the septal tricuspid valve leaflet and the presence of a redundant, elongated, anterior tricuspid valve leaflet. This congenital malformation has multiple known associated morphological and electrophysiological cardiac pathologies. In the present article, we report, to the best of our knowledge for the first time in the literature, a case of Ebstein's anomaly with multiple accessory bypass tracts, dual AV nodal physiology, non-compacted left ventricular myocardium and a patent foramen ovale. Indeed, complete evaluation of the left heart is required in cases of Ebstein's anomaly to accurately assess left ventricular myocardial structure.

Adult↗
PubMed2006

Accidental sizing of patent foramen ovale during atrial septal defect sizing for device.

A 21 year old lady with a 22 mm secundum atrial septal defect with adequate rims, and thin septum at the region of the fossa ovalis, but no additional atrial septal defect by transthoracic and transoesophageal echocardiogram was taken up for ASD sizing with a view to device closure. Initially, the ASD was sized to only 8 mm. However, the distal balloon was not fully opened out, and seemed to be conical with restricted opening. Inadvertent passage of sizing balloon through a patent foramen ovale (PFO) was immediately confirmed by transthoracic echocardiogram. The ASD was then recrossed and sized to 24 mm with normal opening out of the distal balloon. This was confirmed by transthoracic echocardiogram. A 28 mm ASD device was deployed across the ASD under transthoracic echocardiographic guidance with no residual flow.

Adult↗