A Case of Complex PFO Leading to Ischemic Stroke

Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.

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Comparative anatomy of the cardiac foramen ovale in the Pinnipedia

Canadian Journal of Zoology ◽

10.1139/z95-100 ◽

1995 ◽

Vol 73 (5) ◽

pp. 850-857 ◽

Cited By ~ 3

Author(s):

Alastair A. Macdonald ◽

Christopher Dixon ◽

Ian L. Boyd

Keyword(s):

Left Atrium ◽

Comparative Anatomy ◽

Pulmonary Veins ◽

Vena Cava ◽

Interatrial Septum ◽

Weddell Seal ◽

Foramen Ovale ◽

Septum Primum ◽

Lobodon Carcinophagus ◽

Short Tunnel

The structure of the cardiac foramen ovale from eight genera of pinnipeds was studied using the scanning electron microscope. Specimens were obtained from fetuses or neonates of the Californian sea lion (Zalophus californianus), Antarctic fur seal (Arctocephalus gazella), walrus (Obenus rosmarus), grey seal (Halichoerus gryphus), ringed seal (Phoca hispida), bearded seal (Erignathus barbatus), Weddell seal (Leptonychotes weddelli), and crabeater seal (Lobodon carcinophagus). In each species, the structure that permits oxygenated blood from the placenta flowing in the caudal vena cava to pass directly into the left side of the heart, the foramen ovale, when viewed from the terminal part of the caudal vena cava had the appearance of the entrance to a short tunnel. A thin fold of tissue, the developed remains of the septum primum, projected from the caudal edge of the foramen ovale into the lumen of the left atrium. It constituted about 75% of the inner surface of the tunnel, and was generally unfenestrated. The wall of the interatrial septum contributed the "floor." The distal end of the tunnel was straight-edged. In most cases the septum primum was long enough to cover the foramen ovale. The siting of pulmonary veins in the roof of the left atrium appeared to be such that drainage from them after birth would press the septum primum over the foramen opening, thereby functionally closing it. Collapses of the tunnel was seen in all the neonatal seals, and in the 1-month-old neonate the fold of tissue was anchored to the interatrial septum along the surface of the crista dividens, which lay in the left atrium. Cellular protrusions and thread formation may play a role in the closure of the foramen ovale.

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Giant left atrium mimicking right heart failure

European Heart Journal ◽

10.1093/eurheartj/ehm515 ◽

2007 ◽

Vol 29 (8) ◽

pp. 1056-1056

Author(s):

C. Castrillo ◽

A. Ortiz Rivas ◽

José R. de Berrazueta

Keyword(s):

Heart Failure ◽

Left Atrium ◽

Right Heart Failure ◽

Right Heart ◽

Giant Left Atrium

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Clarifying the anatomy of the superior sinus venosus defect

Heart ◽

10.1136/heartjnl-2021-319334 ◽

2021 ◽

pp. heartjnl-2021-319334

Author(s):

Jay Relan ◽

Saurabh Kumar Gupta ◽

Rengarajan Rajagopal ◽

Sivasubramanian Ramakrishnan ◽

Gurpreet Singh Gulati ◽

...

Keyword(s):

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Veins ◽

Interatrial Septum ◽

Sinus Venosus ◽

Caval Vein ◽

Therapeutic Implications ◽

Superior Caval Vein ◽

Inferior Pulmonary Vein ◽

The Right

ObjectivesWe sought to clarify the variations in the anatomy of the superior cavoatrial junction and anomalously connected pulmonary veins in patients with superior sinus venosus defects using computed tomographic (CT) angiography.MethodsCT angiograms of 96 consecutive patients known to have superior sinus venosus defects were analysed.ResultsThe median age of the patients was 34.5 years. In seven (7%) patients, the defect showed significant caudal extension, having a supero-inferior dimension greater than 25 mm. All patients had anomalous connection of the right superior pulmonary vein. The right middle and right inferior pulmonary vein were also connected anomalously in 88 (92%) and 17 (18%) patients, respectively. Anomalous connection of the right inferior pulmonary vein was more common in those with significant caudal extension of the defect (57% vs 15%, p=0.005). Among anomalously connected pulmonary veins, the right superior, middle, and inferior pulmonary veins were committed to the left atrium in 6, 17, and 11 patients, respectively. The superior caval vein over-rode the interatrial septum in 67 (70%) patients, with greater than 50% over-ride in 3 patients.ConclusionAnomalous connection of the right-sided pulmonary veins is universal, but is not limited to the right upper lobe. Not all individuals have over-riding of superior caval vein. In a minority of patients, the defect has significant caudal extension, and anomalously connected pulmonary veins are committed to the left atrium. These findings have significant clinical and therapeutic implications.

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Abstract 18782: Regional Action Potential Heterogeneity in the Murine Pitx2c Deficient Left Atrium

Circulation ◽

10.1161/circ.130.suppl_2.18782 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Andrew P Holmes ◽

Ting Yu ◽

Fahima Syeda ◽

Nigel A Brown ◽

Larissa Fabritz ◽

...

Keyword(s):

Action Potential ◽

Left Atrium ◽

Lateral Wall ◽

Interatrial Septum ◽

The Other ◽

Wild Type ◽

Genetic Abnormalities ◽

Mapping System ◽

Pitx2 Gene ◽

Partial Depletion

Introduction and hypothesis: Genetic abnormalities close to the Pitx2 gene correlate more strongly with atrial fibrillation (AF) than any other genetic modification. It is known that Pitx2c mRNA is expressed in the adult left atrium (LA), but its relevance for the electrical integrity of cardiomyocytes throughout the atria remains unresolved. We therefore compared regional action potential (AP) morphology in PITX2c +/- and wild type (WT) littermate mice. Methods: Transmembrane (T) and optical (O) APs were recorded from superfused intact, isolated LA paced at 100ms. TAPs were recorded from three distinct regions on the LA epicardium: 1) the junction with the interatrial septum (S), 2) the medial muscular dome (M) and 3) the lateral wall (L). OAPs were recorded using a custom murine atrial optical mapping system using the Hamamatsu ORCA flash 4 and Di-4-Anepps. Results: OAPs were shorter in Pitx2c deficient LA (AP duration (APD70); WT 13±2ms, n=4 LA vs Pitx2c +/- 9±1ms, n=4 LA, all data as mean±SEM, p<0.05). Simultaneous recordings of OAPs from multiple LA regions showed an AP gradient with longer OAPs at the septum than at the lateral wall, in both genotypes. In WT LA, TAPs were longer and of greater amplitude at the septum than in the other two regions (APD90; S 26±1ms, M 19±1mV and L 19±1ms, APA; S 81±1mV, M 76±2mV and L 76±2mV, n=6 LA, p<0.05). In Pitx2c +/- , TAPs were shorter than WT in all three regions tested and exhibited the same regional patterning (S 20±1ms, M 15±1ms and L 16±1, n=7 LA, p<0.05). The regional AP amplitude gradient was not apparent, or at least shifted more towards the lateral wall, in PITX2c +/- atria (APA; S 77±2mV, M 76±3mV and L 74±2mV, n=7 LA, ns). Conclusion: Partial depletion in Pitx2c mRNA expression causes a uniform APD shortening throughout the LA and loss of regional changes in AP amplitude. Identification of the targets downstream of Pitx2 accounting for these changes will help to better understand the mechanisms conveying AF due to reduced Pitx2 function.

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Novel technique of repairing right partial anomalous pulmonary venous connection with intact atrial septum using in situ interatrial septum as a flap in a 68-year-old-woman: a case report

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-01313-w ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Atsushi Morishita ◽

Ikuo Hagino ◽

Hideyuki Tomioka ◽

Seiichiro Katahira ◽

Takeshi Hoshino ◽

...

Keyword(s):

Pulmonary Artery ◽

Right Atrium ◽

Septal Defect ◽

Surgical Repair ◽

Interatrial Septum ◽

Pulmonary Artery Hypertension ◽

Right Heart ◽

Intact Atrial Septum ◽

The Right ◽

Anomalous Pulmonary Venous Connection

Abstract Background Partial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown. Case presentation This study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic. Conclusions The described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

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Venoarterial shunting from inferior vena cava to left atrium in atrial septal defects with normal right heart pressures

The American Journal of Cardiology ◽

10.1016/0002-9149(67)90550-4 ◽

1967 ◽

Vol 19 (2) ◽

pp. 293-300 ◽

Cited By ~ 30

Author(s):

William L. Winters ◽

Felix Cortes ◽

Michael McDonouch ◽

Ralph R. Tyson ◽

Howard Baier ◽

...

Keyword(s):

Inferior Vena Cava ◽

Left Atrium ◽

Inferior Vena ◽

Vena Cava ◽

Right Heart ◽

Septal Defects ◽

Atrial Septal Defects

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Multimodality imaging anatomy of interatrial septum and mitral annulus

Heart ◽

10.1136/heartjnl-2020-318127 ◽

2020 ◽

pp. heartjnl-2020-318127

Author(s):

Francesco Fulvio Faletra ◽

Laura Anna Leo ◽

Vera Paiocchi ◽

Susanne Schlossbauer ◽

Jagat Narula ◽

...

Keyword(s):

Adipose Tissue ◽

Multimodality Imaging ◽

Three Dimensional ◽

Mitral Annulus ◽

Ventricular Myocardium ◽

Interatrial Septum ◽

Atrial Septal Defect Closure ◽

Hinge Line ◽

Septum Primum ◽

Contraction And Relaxation

The detailed anatomy of the interatrial septum (IAS) and mitral annulus (MA) as observed on cardiac magnetic resonance, computed tomography and two-dimensional/three-dimensional transthoracic and transesophageal echocardiography is reviewed. The IAS comprises of two components: the septum primum that is membrane-like forming the floor of the fossa ovalis (FO) and the septum secundum that is a muscular rim that surrounds the FO. The latter is an enfolding of atrial wall forming an interatrial groove. Named Waterston’s groove, it is filled with adipose tissue on the epicardial side. Thus, the safest area for transseptal puncture (TSP) is within the limits of the FO floor, which provides direct interatrial access. While crossing an intact septum is a well-established procedure, TSP is a more complex and time-consuming procedure in the presence of patent foramen ovalis, aneurysmal FO or atrial septal defect closure devices. MA comprises two distinctive segments: an anterior-straight and a posterior-curved segment. The posterior MA is a thin, discontinuous fibrous ‘string’, interspersed with adipose tissue, where four components converge: the atrial and ventricular musculature, epicardial adipose tissue and the leaflet’s hinge line. In parts of where this fibrous string is deficient or absent, the posterior leaflet is inserted directly on ventricular and atrial myocardium rendering the MA less robust and producing an ‘asymmetric’ dilation. The marked vulnerability of posterior MA to calcifications might be due to its insertion on the crest of ventricular myocardium being subject to friction injury due to the contraction and relaxation of LV.

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Responses to phenethylamines and nicotine and histology of turtle atria

American Journal of Physiology-Legacy Content ◽

10.1152/ajplegacy.1959.197.4.747 ◽

1959 ◽

Vol 197 (4) ◽

pp. 747-751 ◽

Cited By ~ 3

Author(s):

Sister Marie Therese Dimond

Keyword(s):

Effective Dose ◽

Left Atrium ◽

Rate Increase ◽

Interatrial Septum ◽

Chrysemys Picta ◽

Painted Turtle ◽

Conducting Tissue ◽

Amplitude Increase ◽

The Right ◽

Chromaffin Tissue

Epinephrine (E), norepinephrine (NE), tyramine (T) and nicotine were tested at various dosage levels on different atrial regions of the heart of the eastern painted turtle, Chrysemys picta picta (Schneider), and the median effective dose determined. The three phenethylamines acted according to the following pattern in their effect on rate increase, amplitude increase, and inhibition of tonus waves: E > NE > T, except for amplitude increase in the left atrium and tonus wave inhibition in both atria, where E and NE were equal. The right sino-atrium and left atrium differed in sensitivity to the drugs. The various responses, including treppe, are consonant with the theory of the release from the tissues of a potentiating substance and a depressing substance. Histological stains for chromaffin tissue, a possible source of potentiating substance, were negative, but a differentially stained type of cardiac muscle, a possible conducting tissue, is present in regions of the sinus venosus and both atria and at the base of the interatrial septum.

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