Swiss cheese interventricular septum presenting with catastrophic stroke: the potential role of ECG-gated CTA

Ventricular septal defect is a common congenital cardiac condition that presents in a variety of morphologies. Less commonly, when an individual patient is found to have multiple ventricular septal defects, the term “Swiss cheese ventricular septal defect” is applied. Although not routinely utilized in clinical practice, Electrocardiogram (ECG)-gated computed tomographic angiography (CTA) has been shown to provide utility in detecting intracardiac shunts, demonstrating promise in preventing acute strokes secondary to a paradoxical embolus from occurring; this is especially important when atypical cardiac septa are suspected. This case seeks to illustrate how usage of ECG-gated CTA can assist in early detection and prevention of adverse outcomes resulting from an atypical presentation of a ventricular septal defect.

Large paradoxical embolus through a patent foramen ovale following arteriovenous graft thrombectomy

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5x2 cm) in the left atrium prolapsing to the right atrium via a patent foramen ovale and another thrombus (white arrow) adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.

Prevention of Paradoxical Cerebral Embolus with Protection System during Combination Right Atrial Clot Aspiration Thrombectomy and Closure of Patent Foramen Ovale

In this technical case report, we describe a 41-year-old female with a history of breast cancer who was found to have a right atrial clot attached to the tip of her Port-A-Cath. During transthoracic echocardiography to evaluate her clot, she was also noted to also have a patent foramen ovale. The decision was made to perform a simultaneous right atrial endovascular aspiration thrombectomy and patent foramen ovale closure. To minimize the risk for paradoxical embolus during clot manipulation, an intravascular embolic neuroprotection device was deployed. After the procedure, it was noted on visual inspection that the device filter contained several embolic fragments. The presence of macroscopic embolic fragments in the filter baskets highlights the role of prophylactic embolic protection when performing cardiac interventions in the setting of a patent foramen ovale, particularly in the presence of a right atrial thrombus or mass.

Antiphospholipid syndrome leading to paradoxical embolus and stroke via secundum atrial septal defect

We have presented a case of a 22-year-old man, presenting with cerebral infarct, subsequently found to have antiphospholipid syndrome (APS), deep venous thrombosis, pulmonary embolism and atrial septal defect (ASD), thereby confirming the presence of infarct due to paradoxical embolism in this patient. The importance of ASD in the patients of APS, resulting in paradoxical embolism is debatable, with recent studies undermining its importance. We have demonstrated that it does indeed happen. This would have implications in the risk assessment and management of ASD in such patients. This case report is intended to serve as a reminder of this association and the need to perform further research in this area.

Silent embolism of a large thrombus in transit through the patent foramen ovale: a case report

Background Detection of a thrombus in transit through a patent foramen ovale (PFO) is extremely rare due to the transient nature of the process. We report an unusual case of a large, paradoxical embolus in transit seen on echocardiography through a PFO that was not found upon atriotomy. Case summary An 80-year-old woman presented to the emergency room with shortness of breath and right leg pain. She was haemodynamically stable on presentation, and her physical exam was unremarkable. An ultrasound of her right leg revealed a deep vein thrombus in the posterior tibial vein, and chest computed tomography angiography showed saddle pulmonary emboli. Transthoracic echocardiogram identified a large thrombus in transit through a PFO, which was confirmed with a transoesophageal echocardiogram (TOE). She underwent an emergency embolectomy. The thrombus in transit was confirmed by TOE prior to bypass initiation; however, no thrombi were found in any chambers of the heart following atriotomy. Her postoperative recovery was uneventful. She had no focal neurological deficits or any apparent signs of large vessel embolization. Discussion Cases of silent embolism have been reported in the literature, although they are rare. To our knowledge, this is the first case of a large thrombus in transit through a PFO in an elderly female that was confirmed by an intra-operative TOE but could not be found following atriotomy, with no obvious clinical signs of embolization.

Patent Foramen Ovale Closure: State of the Art

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea–orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.