Acute Hypoxic and Refractory Respiratory Failure Induced by an Underlying PFO: An Unusual Case of Platypnea Orthodeoxia and Transient Complication after Transcatheter 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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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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Focal ST-segment elevation without coronary occlusion: myocardial infarction with no obstructive coronary atherosclerosis associated with COVID-19—a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa532 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

Casey Meizinger ◽

Bruce Klugherz

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Respiratory Failure ◽

Coronary Atherosclerosis ◽

Myocardial Injury ◽

Cardiovascular Complications ◽

St Segment Elevation ◽

St Segment ◽

Hypoxic Respiratory Failure ◽

Artery Disease

Abstract Background While it is understood that coronavirus disease 2019 (COVID-19) is primarily complicated by respiratory failure, more data are emerging on the cardiovascular complications of this disease. A subset of COVID-19 patients present with ST-elevations on electrocardiogram (ECG) yet normal coronary angiography, a presentation that can fit criteria for myocardial infarction with no obstructive coronary atherosclerosis (MINOCA). There is little known about non-coronary myocardial injury observed in patients with COVID-19, and we present a case that should encourage further conversation and study of this clinical challenge. Case summary An 86-year-old man presented to our institution with acute hypoxic respiratory failure and an ECG showing anteroseptal ST-segment elevation concerning for myocardial infarction. Mechanic ventilation was initiated prior to presentation, and emergent transthoracic echocardiography reported an ejection fraction of 50–55%, with no significant regional wall motion abnormalities. Next, emergent coronary angiography was performed, and no significant coronary artery disease was detected. The patient tested positive for COVID-19. Despite supportive management in the intensive care unit, the patient passed away. Discussion We present a case of COVID-19 that is likely associated with MINOCA. It is crucial to understand that in COVID-19 patients with signs of myocardial infarction, not all myocardial injury is due to obstructive coronary artery disease. In the case of COVID-19 pathophysiology, it is important to consider the cardiovascular effects of hypoxic respiratory failure, potential myocarditis, and significant systemic inflammation. Continued surveillance and research on the cardiovascular complications of COVID-19 is essential to further elucidate management and prognosis.

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Short- and long-term haemodynamic consequences of transcatheter closure of atrial septal defect and patent foramen ovale

Netherlands Heart Journal ◽

10.1007/s12471-021-01543-0 ◽

2021 ◽

Author(s):

X. Jin ◽

Y. M. Hummel ◽

W. T. Tay ◽

J. F. Nauta ◽

N. S. S. Bamadhaj ◽

...

Keyword(s):

Atrial Septal Defect ◽

Diastolic Function ◽

Patent Foramen Ovale ◽

Septal Defect ◽

Transcatheter Closure ◽

Foramen Ovale ◽

Short And Long Term ◽

Interatrial Shunt ◽

Pfo Closure

Abstract Background Transcatheter atrial septal defect (ASD) and patent foramen ovale (PFO) closure might have opposite short- and long-term haemodynamic consequences compared with restricted interatrial shunt creation, which recently emerged as a potential treatment modality for patients with heart failure with preserved ejection fraction (HFpEF). Given the opposing approaches of ASD and PFO closure versus shunt creation, we investigated the early and sustained cardiac structural and functional changes following transcatheter ASD or PFO closure. Methods In this retrospective study, adult secundum-type ASD and PFO patients with complete echocardiography examinations at baseline and at 1‑day and 1‑year follow-up who also underwent transcatheter closure between 2013 and 2017 at the University Medical Centre Groningen, the Netherlands were included. Results Thirty-nine patients (mean age 48 ± standard deviation 16 years, 61.5% women) were included. Transcatheter ASD/PFO closure resulted in an early and persistent decrease in right ventricular systolic and diastolic function. Additionally, transcatheter ASD/PFO closure resulted in an early and sustained favourable response of left ventricular (LV) systolic function, but also in deterioration of LV diastolic function with an increase in LV filling pressure (LVFP), as assessed by echocardiography. Age (β = 0.31, p = 0.009) and atrial fibrillation (AF; β = 0.24, p = 0.03) were associated with a sustained increase in LVFP after transcatheter ASD/PFO closure estimated by mean E/e’ ratio (i.e. ratio of mitral peak velocity of early filling to diastolic mitral annular velocity). In subgroup analysis, this was similar for ASD and PFO closure. Conclusion Older patients and patients with AF were predisposed to sustained increases in left-sided filling pressures resembling HFpEF following ASD or PFO closure. Consequently, these findings support the current concept that creating a restricted interatrial shunt might be beneficial, particularly in elderly HFpEF patients with AF.

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Patent Foramen Ovale Closure Versus Medical Therapy in Cryptogenic Strokes and Transient Ischemic Attacks: A Meta-Analysis of Randomized Trials

Angiology ◽

10.1177/0003319718802635 ◽

2018 ◽

Vol 70 (4) ◽

pp. 325-331 ◽

Cited By ~ 5

Author(s):

Simone Vidale ◽

Filippo Russo ◽

Carlo Campana ◽

Elio Agostoni

Keyword(s):

Medical Treatment ◽

Patent Foramen Ovale ◽

Transcatheter Closure ◽

Meta Analysis ◽

Cochrane Library ◽

Transient Ischemic Attacks ◽

Foramen Ovale ◽

End Points ◽

Pfo Closure ◽

New Onset

Cryptogenic strokes account for about 25% to 40% of total ischemic strokes, and 1 of the 3 of these have a patent foramen ovale (PFO). A meta-analysis concerning the effectiveness and safety of PFO closure in cryptogenic strokes or transient ischemic attacks (TIAs) was performed. We systematically searched Medline, Embase, and the Cochrane Library through April 2018. Eligible studies were randomized clinical trials. Primary and secondary end points were, respectively, stroke or TIA and stroke recurrences. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for all end points using fixed- and random-effects meta-analyses. Data were included from 6 trials involving 3560 patients. In the pooled analysis, PFO closure was superior to medical treatment for both primary (RR: 0.39; 95% CI: 0.18-0.82; P < .02) and secondary end points (RR: 0.58; 95% CI: 0.44-0.76; P < .001). Transcatheter closure significantly increased the risk of new-onset atrial fibrillation (AF; RR: 5.74; P < .001). Percutaneous closure is superior to medical treatment in reducing stroke and TIA recurrence, even if with a significant risk increasing for new-onset AF. These findings suggest that transcatheter closure is indicated in patients with cryptogenic strokes and large PFO.

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AN UNUSUAL CASE OF NON SMALL CELL LUNG CANCER PRESENTING AS NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

CHEST Journal ◽

10.1016/j.chest.2019.08.370 ◽

2019 ◽

Vol 156 (4) ◽

pp. A323-A324

Author(s):

Umar Jamshed Sharif Khawaja ◽

Dayna Panchal ◽

Jun Chih Wang ◽

Hassaan Arshad ◽

Aishwarya Bhardwaj ◽

...

Keyword(s):

Myocardial Infarction ◽

Lung Cancer ◽

Small Cell Lung Cancer ◽

Cell Lung Cancer ◽

Unusual Case ◽

Small Cell ◽

Small Cell Lung ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

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Unusual case of massive ST-segment elevation

Cardiovascular Medicine ◽

10.4414/cvm.2012.01634 ◽

2012 ◽

Vol 15 (01) ◽

pp. 32-33

Keyword(s):

Unusual Case ◽

St Segment Elevation ◽

St Segment

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

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab494 ◽

2021 ◽

Author(s):

Dominik Schüttler ◽

Konstantinos Mourouzis ◽

Christoph J Auernhammer ◽

Konstantinos D Rizas

Keyword(s):

Heart Disease ◽

Symptomatic Therapy ◽

Carcinoid Heart Disease ◽

Foramen Ovale ◽

Residual Shunt ◽

Selective Internal Radiotherapy ◽

Intrapulmonary Shunting ◽

Persistent Foramen Ovale ◽

One Year ◽

Pfo Closure

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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An Unusual Case of Takotsubo Syndrome With Hyperaldosteronism as the Potential Cause

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2017-01117 ◽

2017 ◽

Vol 103 (1) ◽

pp. 12-15 ◽

Cited By ~ 2

Author(s):

Yuanweixiang Ou ◽

Zhengang Zhao ◽

Jiayyu Tsauo ◽

Licheng Jiang ◽

Yong Yang ◽

...

Keyword(s):

Primary Aldosteronism ◽

Unusual Case ◽

Apical Ballooning ◽

Major Contributor ◽

Case Description ◽

Takotsubo Syndrome ◽

Related Factors ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Abstract Context Catecholamine-related factors are the most popular explanation for the occurrence of Takotsubo syndrome. An aldosterone-related mechanism, however, has not been proposed. Case Description A 45-year-old male patient presenting with ST-segment elevation myocardial infarction was diagnosed with primary aldosteronism, severe hypokalemia, and Takotsubo syndrome. After excluding the known conditions of apical ballooning and the factors of vasospasm, primary aldosteronism is considered as the major contributor to the development of Takotsubo syndrome. The potential mechanisms are discussed. Conclusions The case suggests a possible hyperaldosteronism-induced and vasoconstriction-mediated mechanism in the development of Takotsubo syndrome.

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