Development of severe intrapulmonary shunting in a patient with carcinoid heart disease after closure of a persistent foramen ovale: a case report

Abstract Background Neuroendocrine tumors (NETs) can affect the cardiopulmonary system causing carcinoid heart disease and valve destruction. Persistent foramen ovale (PFO) occlusion is indicated in patients with carcinoid heart disease and shunt-related left-heart valve involvement. Case Summary We report the case of a 54-year-old female patient with metastatic NET originating from the small bowel. The patient was on medication with octreotide and telotristat. One year after diagnosis, cardiac involvement of carcinoid developed with regurgitation of right-sided and, due to PFO, left-sided heart valves. Closure of PFO was performed (Occlutech 16/18 mm). One year later she presented with recurrent severe dyspnoea. The PFO-occluder was in situ without residual shunt. Valvular heart disease, including left-sided disease, and metastatic spread of NET were stable. Blood gas analysis revealed arterial hypoxemia (pO2 = 44 mmHg/5.87 kPa), which was related to extensive intrapulmonary shunting (31% shunt fraction) confirmed using contrast-enhanced echocardiography. The patient was prescribed long-term oxygen supplementation as symptomatic therapy and anti-tumoral therapy was intensified with selective internal radiotherapy of the liver metastases in order to improve biochemical control of the carcinoid syndrome. Discussion An echocardiographic assessment of the presence of a PFO is recommended in patients with NET as PFO closure minimizes the risk of left-sided carcinoid valve disease. Deterioration of symptomatic status in metastasized NET might also be due to a hepatopulmonary-like physiology with intrapulmonary shunting and arterial desaturation thought to be caused by vasoactive substances secreted by the tumor. This is a rare case describing the development of this syndrome after PFO closure.

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Flow-driven right-to-left cardiac shunting in a patient with carcinoid heart disease and patent foramen ovale without elevated right atrial pressure: a case report and literature review

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa301 ◽

2020 ◽

Author(s):

Parinita Dherange ◽

Nelson Telles ◽

Kalgi Modi

Keyword(s):

Heart Disease ◽

Patent Foramen Ovale ◽

Atrial Septum ◽

Atrial Pressure ◽

Right Atrial ◽

Right Atrial Pressure ◽

Heart Catheterization ◽

Carcinoid Heart Disease ◽

Foramen Ovale ◽

Arterial Blood

Abstract Background Carcinoid heart disease is present in approximately 20% of the patients with carcinoid syndrome and is associated with poor prognosis. It usually manifests with right-sided valvular involvement including tricuspid insufficiency and pulmonary stenosis. Patent foramen ovale (PFO) is present in approximately 50% of the patients with carcinoid heart disease which is twice higher than the general population. Right-to-left shunting through a PFO can occur either due to higher right atrial pressure than left (pressure-driven) or when the venous flow is directed towards the PFO (flow-driven) in the setting of normal intracardiac pressures. We report a rare case of flow-driven right-to-left atrial shunting via PFO in a patient with carcinoid heart disease. Case summary A 54-year-old male with a metastatic neuroendocrine tumour to liver presented with progressive shortness of breath for 5 months. Patient was found to be hypoxic with oxygen saturation of 78% and examination revealed a holosystolic murmur. Arterial blood gas showed oxygen tension of 43 mmHg. A transthoracic and transoesophageal echocardiogram showed aneurysmal inter-atrial septum with a PFO, severe tricuspid regurgitation directed anteriorly towards the inter-atrial septum leading to a marked right-to-left shunt. Right heart catheterization showed right atrial pressure of 8 mmHg, mean pulmonary artery pressure of 12 mmHg, and normal oxygen saturations in the right atrium, right ventricle, and pulmonary arteries. The patient then underwent closure of the PFO along with tricuspid valve and pulmonary valve replacement at an experienced cardiovascular surgical centre and has been asymptomatic since. Conclusion Right-to-left shunting through a PFO in patients with normal right atrial pressure can be successfully treated with closure of the PFO. Thus, understanding the mechanism of intracardiac shunts is important to accurately diagnose and treat this rare and fatal condition.

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Does persistent (patent) foramen ovale closure reduce the risk of recurrent decompression sickness in scuba divers?

Diving and Hyperbaric Medicine Journal ◽

10.28920/dhm51.1.63-67 ◽

2021 ◽

Vol 51 (1) ◽

pp. 63-67

Author(s):

Björn Edvinsson ◽

◽

Ulf Thilén ◽

Niels Erik Nielsen ◽

Christina Christersson ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Decompression Sickness ◽

Foramen Ovale ◽

Residual Shunt ◽

Interatrial Communication ◽

Scuba Divers ◽

Increased Risk ◽

History Of ◽

Catheter Closure ◽

Pfo Closure

Introduction: Interatrial communication is associated with an increased risk of decompression sickness (DCS) in scuba diving. It has been proposed that there would be a decreased risk of DCS after closure of the interatrial communication, i.e., persistent (patent) foramen ovale (PFO). However, the clinical evidence supporting this is limited. Methods: Medical records were reviewed to identify Swedish scuba divers with a history of DCS and catheter closure of an interatrial communication. Thereafter, phone interviews were conducted with questions regarding diving and DCS. All Swedish divers who had had catheter-based PFO-closure because of DCS were followed up, assessing post-closure diving habits and recurrent DCS. Results: Nine divers, all with a PFO, were included. Eight were diving post-closure. These divers had performed 6,835 dives (median 410, range 140–2,200) before closure, and 4,708 dives (median 413, range 11–2,000) after closure. Seven cases with mild and 10 with serious DCS symptoms were reported before the PFO closure. One diver with a small residual shunt suffered serious DCS post-closure; however, that dive was performed with a provocative diving profile. Conclusion: Divers with PFO and DCS continue to dive after PFO closure and this seems to be fairly safe. Our study suggests a conservative diving profile when there is a residual shunt after PFO closure, to prevent recurrent DCS events.

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285Arrhythmias after transcatheter closure of persistent foramen ovale are related to the type and size of the implanted device

European Heart Journal ◽

10.1093/eurheartj/ehz747.0089 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Komar ◽

T Przewlocki ◽

P Prochownik ◽

U Gancarczyk ◽

B Sobien ◽

...

Keyword(s):

Atrial Fibrillation ◽

Lower Risk ◽

Transcatheter Closure ◽

Supraventricular Arrhythmias ◽

Foramen Ovale ◽

Av Conduction ◽

Persistent Foramen Ovale ◽

Premature Beats ◽

Pfo Closure

Abstract Transient supraventricular arrhythmias may occur in patients following persistent foramen ovale (PFO) closure. Therefore, the aim of the study was to prospectively perform 24-hour ECG monitoring to assess the electrocardiographic effects of transcatheter closure of PFO depending on the type of implanted devices. Material and methods 351 consecutive adult subjects (196 F, 155M; mean age: 40.9±15.3) were enrolled into the study to undergo PFO closure with an Amplatzer Septal Occluder - ASO (157 pts: 117 occluders – size 25; 40 pts – size 30), and Cardia device (194 pts: 163 occluders – size 25; 31 – size 30). Holter monitoring was performed on all patients before, at 1 and 12 months after the procedure. Results The success rate of PFO closure was 97.8% (351 cases from 359 qualified in TEE), in 8 cases the PFO tunnels were too small to be forced by a catheter, in one case the PFO device caused an injury of the septum and an ASD Amplatzer device was implanted. During the procedure in 3 (0.85%) cases transient supraventricular arrhythmia and in 1 (0.28%) case bradycardia to 27 bpm occurred. At 1 month: in 7 (2%) pts changes in AV conduction occurred: 1 pt (0.28%) had complete AV dissociation, 6 (1.7%) pts intermittent first degree AV block; paroxysmal atrial fibrillation (pAF) occurred in 6 (1.7%) pts, 2 of whom had pAF prior to closure. A significant increase in the number of SVE premature beats/24h was noted at 1 month after the procedure: 1167.9±409 (27–9976) compared to baseline data 60.2±44 (0–601) (p<0.0001), at 12 months the SVE number decreased to 57.2±51 (7–752) and did not differ significantly from the baseline data. There was no change in the mean number of ventricular arrhythmias/24h after the procedure. There was a significant correlation between SVE premature beats/24h at 1 month after the procedure and device size (p<0.001 r=97211). Pts with ASO device had a significantly higher number of SVE ectopy at 1 month after PFO closure (19123.9±70) compared to pts with Cardia device (811.9±324), p<0.0001. Conclusions 1. Transcatheter closure of PFO is associated with a transient increase in supraventricular premature beats and a small risk of AV conduction abnormalities and paroxysmal atrial fibrillation in the early follow-up. There is regression of periprocedural arrhythmias after 12 months of PFO closure. 2. Transcatheter closure of PFO with Cardia device is related to a lower risk of supraventricular arrhythmias in the early follow-up. 3. The smaller device is implanted the lower risk of periprocedural arrhythmias is expected.

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878 Patent foramen ovale: a new factor associated with progression of right and left carcinoid heart disease

European Journal of Echocardiography ◽

10.1016/s1525-2167(03)90999-1 ◽

2003 ◽

Vol 4 ◽

pp. S110

Author(s):

N MANSENCAL ◽

F DIGNE ◽

E MITRY ◽

J FORISSIER ◽

T JOSEPH ◽

...

Keyword(s):

Heart Disease ◽

Patent Foramen Ovale ◽

Carcinoid Heart Disease ◽

Foramen Ovale

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Acute Hypoxic and Refractory Respiratory Failure Induced by an Underlying PFO: An Unusual Case of Platypnea Orthodeoxia and Transient Complication after Transcatheter Closure

Case Reports in Critical Care ◽

10.1155/2017/4397163 ◽

2017 ◽

Vol 2017 ◽

pp. 1-4

Author(s):

Carlos Salazar ◽

Romeo A. Majano

Keyword(s):

Respiratory Failure ◽

Unusual Case ◽

Transcatheter Closure ◽

Air Embolism ◽

Hemodynamic Instability ◽

Foramen Ovale ◽

St Segment Elevation ◽

St Segment ◽

Persistent Foramen Ovale ◽

Pfo Closure

Platypnea orthodeoxia (PO) is an infrequent condition of dyspnea with hypoxemia, increased by adopting an upright position and is relieved in decubitus. This condition may occur in patients with hidden intracardiac shunts, usually across a persistent foramen ovale (PFO). The incidence of PFO in general population is quite common, around 27%; however, the concurrent presentation with PO, especially in acute refractory respiratory failure, is extremely rare. PFO closure in this setting is still the treatment of choice with significant improvement or complete resolution of symptoms after closure with an overall periprocedural complication in the first 24 hours of approximately less than 5%. A transient ST-segment elevation in the inferior leads is present in extremely rare occasions and most likely is induced by either an air embolism or a mechanically provoked spasm of coronary arteries. We report a case of an 83-year-old woman in acute hypoxic and refractory respiratory failure in whom PO was identified, most likely induced by a hidden PFO. The patient underwent percutaneous transcatheter closure and developed immediate chest pain, transient hemodynamic instability, and ST-segment elevation in the inferior leads; nevertheless, our patient recovered completely with rapid resolution of respiratory failure with no adverse clinical sequelae.

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Hypoxemia from patent foramen ovale in a 65-year-old woman with carcinoid heart disease

Canadian Medical Association Journal ◽

10.1503/cmaj.180243 ◽

2018 ◽

Vol 190 (31) ◽

pp. E933-E936 ◽

Cited By ~ 2

Author(s):

Chengyue Yang ◽

Aditya Sharma

Keyword(s):

Heart Disease ◽

Patent Foramen Ovale ◽

Carcinoid Heart Disease ◽

Foramen Ovale

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Closure of persistent foramen ovale with the BioSTAR biodegradable PFO closure device: Feasibility and long-term outcome

Scandinavian Cardiovascular Journal ◽

10.3109/14017431.2011.591819 ◽

2011 ◽

Vol 45 (5) ◽

pp. 267-272 ◽

Cited By ~ 5

Author(s):

Alexia Karagianni ◽

Putte Abrahamsson ◽

Eva Furenäs ◽

Peter Eriksson ◽

Mikael Dellborg

Keyword(s):

Closure Device ◽

Foramen Ovale ◽

Term Outcome ◽

Long Term Outcome ◽

Persistent Foramen Ovale ◽

Pfo Closure

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Five Year Follow-Up of Cryptogenic Stroke Patients Following Patent Foramen Ovale Closure

Medical Sciences Forum ◽

10.3390/iecmd2021-10313 ◽

2021 ◽

Vol 6 (1) ◽

pp. 2

Author(s):

Agnete Teivāne ◽

Kristaps Jurjāns ◽

Ainārs Rudzītis ◽

Krista Lazdovska ◽

Artūrs Balodis ◽

...

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Residual Shunt ◽

Amplatzer Occluder ◽

Cerebrovascular Events ◽

Ischemic Attack ◽

Pfo Closure

Background and Objectives: According to guidelines, patent foramen ovale (PFO) closure is recommended for secondary stroke prevention in patients with cryptogenic stroke. Paradoxial embolism from PFO-mediated right to left shunt has been described as the mechanism of stroke in these cases. The aim of the study was to determine whether PFO closure can be associated with improvement of complaints (headaches, fatigue, heart palpitations, dizziness, and visual impairment) and determine its long-term effectiveness on recurrent stroke risk reduction. Materials and Methods: A total of 103 patients were enrolled in a retrospective study and followed-up by phone up to five years after PFO closure. Standardized survey was conducted about their well-being, recurrent cerebrovascular events, and the use of prescribed medication. Patients were also followed up for residual shunts 24 h, 30 days, 1 year, and 2 years after PFO. The pathogenic ischemic stroke subtypes are determined using CCS (Causative Classification System for Ischemic Stroke). Results: Male patients accounted for 43.7% (n = 45). The mean age was—44.4 ± 13 (18–75). The most probable cause for cryptogenic stroke for 53.4% (n = 55) of patients with possible cardio-aortic embolism was PFO. Residual shunts were mostly observed in patients with Amplatzer occluder—87.5% (n = 14). There was correlation between residual shunt and increased risk of transient ischemic attack recurrence (p = 0.067). Five-years after PFO closure recurrent cerebrovascular events were reported in only 5.1% (n = 5) of patients, this difference is statistically relevant (p < 0.001). Out of 51 patients presented with complaints before PFO closure, 25.5% (n = 13) did not present with any complaints after PFO closure. Conclusions: PFO can be considered a possible risk factor for cryptogenic stroke. PFO closure is effective in reducing recurrent cerebrovascular events. Residual shunt after PFO closure increases the risk of transient ischemic attack recurrence. Amplatzer occluder device is associated with a higher risk for residual shunts after PFO closure. PFO closure can be associated with improvement of complaints.

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Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia

Journal of Interventional Cardiology ◽

10.1155/2020/1462140 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Roel J. R. Snijder ◽

Laura E. Renes ◽

Martin J. Swaans ◽

Maarten Jan Suttorp ◽

Jurrien M. Ten Berg ◽

...

Keyword(s):

General Anaesthesia ◽

Septal Defect ◽

Contrast Echocardiography ◽

Foramen Ovale ◽

Residual Shunt ◽

Safety And Efficacy ◽

Significant Difference ◽

Asd Closure ◽

Transthoracic Contrast Echocardiography ◽

Pfo Closure

Objective. To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure. Background. TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure. Methods. All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately. Results. In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE. Conclusion. Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.

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