Agitated Saline Study Research Articles

Delayed Diagnosis of Right Heart Failure Due to Sinus Venosus Atrial Septal Defect, Persistent Left Superior Vena Cava and Partial Anomalous Pulmonary Venous Return

Sinus venosus atrial septal defects (SVASD) are uncommon and often underdiagnosed as they are visualised poorly on transthoracic echocardiography (TTE). A 59-year-old man was referred following worsening dyspnoea. A TTE demonstrated dilated right chambers, with torrential tricuspid regurgitation and a dilated coronary sinus. Agitated saline test raised the suspicion of both persistent left superior vena cava (PLSVC) and an intracardiac shunt, despite interrogation of the interatrial septum not demonstrating any defects. CT imaging of the thorax was performed revealing a superior SVASD alongside a PLSVC, and partial anomalous pulmonary venous return. SVASD are considerably uncommon, compared to other types of atrial septal defects (ASD). TTE has poor sensitivity in diagnosing SVASD, highlighting the importance of multimodality imaging in such cases. The purpose of this case report is to highlight unique features demonstrated on TTE, especially during the agitated saline study, which showcased the presence of a PLSVC alongside an intracardiac shunt that was undetected through conventional TTE alone.

A Multidisciplinary Algorithm for the Evaluation of Acute Neurologic Deficits Improves Management of Cryptogenic Stroke or Transient Ischemic Attack.

The appropriate diagnosis and management of cryptogenic stroke and transient ischemic attack (TIA) is challenging and requires multidisciplinary involvement. Joint societal guidelines exist to guide the comprehensive evaluation of these entities. This study aimed to implement a standardized multidisciplinary diagnostic algorithm for cryptogenic stroke/TIA. We performed a retrospective analysis of patients admitted to the largest regional military healthcare center with stroke or TIA considered to be cryptogenic at the time of discharge. We abstracted baseline demographics and rates of extra- and intracranial imaging, transthoracic and transesophageal echocardiography, and event monitor orders at the time of discharge. The incidence of event monitor results at 30 days and six months were included. A diagnostic algorithm for evaluation of cryptogenic stroke/TIA was created and disseminated hospital-wide using increased compliance with neuroimaging, echocardiography, and cardiac rhythm monitoring as primary endpoints for our intervention. Post-intervention data abstraction revealed similar rates of extra- and intracranial imaging, but significantly greater rates of transthoracic echocardiography (70% vs. 87%, p 0.0073), inclusion of agitated saline study (41% vs. 65%, p 0.0024), and event monitors ordered at discharge (18% vs. 35%, p 0.0045). At six months there was a higher rate of event monitors obtained (24% vs. 45%, p 0.001). Our study showed implementation of an evidence-based diagnostic algorithm for evaluation of cryptogenic stroke/TIA increases appropriate use of echocardiography and event monitoring.

White matter lesions predominantly located in deep white matter represent embolic etiology rather than small vessel disease

AbstractBackgroundIndividuals with cerebral small vessel disease (CSVD) usually have both periventricular and deep white matter hyperintensities (dpWMH). However, we often encounter individuals whose WMH lesions are mainly located in the corticomedullary or deep white matter with minimal periventricular WMHs (dWMH). We aimed to determine if the dWMH pattern could be attributed to embolic etiologies.MethodsWe retrospectively recruited participants who had undergone comprehensive dementia evaluation, agitated saline contrast echocardiography, and brain MRI. The participants were classified into two groups according to WMH distributions, the dWMH (WMHs in deep and corticomedullary area, with minimal periventricular WMHs) and the dpWMH (mainly periventricular WMHs with or without deep WMHs) groups. We hypothesized that dWMH is more likely associated with embolism, whereas dpWMH with CSVD. We compared the clinical characteristics, WMH distributions, and the positive rate of agitated saline study between the two groups.ResultsOf the 90 participants, 27 fulfilled the dWMH criteria and 12 met the dpWMH criteria. The dWMH group was younger (62.2±7.5 vs 78.9±7.3, p<0.001), and had a lower prevalence of hypertension (29.6% vs. 75%, p = 0.008), DM (3.7% vs. 25%, p = 0.043), and hyperlipidemia (33.3% vs. 83.3%, p = 0.043) than the dpWMH group. Regarding deep white matter lesions, the number of small lesions (<3 mm) was higher in the dWMH (10.9±9.7) than the dpWMH (3.1±6.4) group (p = 0.008), and WMHs were predominantly distributed in border‐zones of major cerebral arteries and corticomedullary areas.Most importantly, the positive rate of agitated saline was higher in the dWMH than the dpWMH group (81.5% vs. 33.3%, p = 0.003).ConclusionsThe dWMH group with younger age, fewer cardiovascular risk factors showed more border‐zone distributions, and higher positivity of agitated saline test than dpWMH group, indicating that WMH distributions mainly in the corticomedullary or deep area with minimal periventricular WMH lesions suggest embolic etiologies.

White Matter Lesions Predominantly Located in Deep White Matter Represent Embolic Etiology Rather Than Small Vessel Disease

We investigated the correlation between the deep distribution of white matter hyperintensity (WMH) (dWMH: WMH in deep and corticomedullary areas, with minimal periventricular WMH) and a positive agitated saline contrast echocardiography result. We retrospectively recruited participants with comprehensive dementia evaluations, an agitated saline study, and brain imaging. The participants were classified into two groups according to WMH-distributions: dWMH and dpWMH (mainly periventricular WMH with or without deep WMH.) We hypothesized that dWMH is more likely associated with embolism, whereas dpWMH is associated with small-vessel diseases. We compared the clinical characteristics, WMH-distributions, and positive rate of agitated saline studies between the two groups. Among 90 participants, 27 and 12 met the dWMH and dpWMH criteria, respectively. The dWMH-group was younger (62.2±7.5 vs. 78.9±7.3, p<0.001) and had a lower prevalence of hypertension (29.6% vs. 75%, p=0.008), diabetes mellitus (3.7% vs. 25%, p=0.043), and hyperlipidemia (33.3% vs. 83.3%, p=0.043) than the dpWMH-group. Regarding deep white matter lesions, the number of small lesions (<3 mm) was higher in the dWMH-group(10.9±9.7) than in the dpWMH-group (3.1±6.4) (p=0.008), and WMH was predominantly distributed in the border-zones and corticomedullary areas. Most importantly, the positive agitated saline study rate was higher in the dWMH-group than in the dpWMH-group (81.5% vs. 33.3%, p=0.003). The dWMH-group with younger participants had fewer cardiovascular risk factors, showed more border-zone-distributions, and had a higher agitated saline test positivity rate than the dpWMH-group, indicating that corticomedullary or deep WMH-distribution with minimal periventricular WMH suggests embolic etiologies.

A TALE OF TWO THROMBI

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Atrial Fibrillation is associated with an increased risk of stroke secondary to left atrial thromboembolism. Its association with venous thromboembolism from the right atria is not well established (1). We report a rare case of a patient with atrial fibrillation (AF) with concomitant pulmonary embolism (PE) and left atrial appendage (LAA) thrombus. CASE PRESENTATION: The patient is a 61-year-old female with a remote history of provoked venous thromboembolism (VTE) and essential tremor who presented with progressively worsening dyspnea and fatigue. Her blood pressure was 121/78 mm Hg, pulse was 155 beats/min, respiratory rate was 18 breaths/min, and oxygen saturation was 93% on room air. EKG showed new atrial fibrillation with a rapid ventricular rate of 130-150 beats/min. A computed tomographic scan per pulmonary embolism protocol showed multiple acute emboli within the right middle and lower lobe. RV/LV ratio was 1.0. Troponin 0.05 ng/ml and BNP was 462 pg/ml. Transthoracic echocardiogram found EF 50-55%, normal right ventricular systolic function, no wall motion abnormalities. Bilateral lower extremity dopplers were negative for DVT. The patient was started on a diltiazem drip, however, continued to remain in RVR after 48 hours. Cardioversion was planned with a transesophageal echocardiogram (TEE) however, TEE showed left atrial appendage thrombus suggestive of prolonged duration of atrial fibrillation. An agitated saline study was negative for patent foramen ovale. During her prolonged hospitalization patient was started on metoprolol and digoxin after which rate control was achieved. The patient was discharged home on anticoagulation with a plan for atrial fibrillation ablation after resolution of thrombus. DISCUSSION: The patient was found to have acute PE without any provoking cause. This could have contributed to the development of atrial fibrillation. The TEE findings including bilateral atrial enlargement and left atrial appendage thrombus suggest a longer duration of uncontrolled atrial fibrillation prior to admission, especially considering the agitated saline study was negative for an intra-atrial shunt. In essence, she had both pulmonary arterial and venous thrombus simultaneously. CONCLUSIONS: Our report suggests that management of atrial fibrillation in the setting of LAA thrombus and PE can be challenging and may require multiple AV nodal blocking agents. The significance of venous and arterial thrombi in atrial fibrillation remains unclear. Studies are needed to assess the safety and efficacy of thrombolytics and long-term outcomes in these patients. Reference #1: Friberg L, Svennberg E. A diagnosis of atrial fibrillation is not a predictor for pulmonary embolism. Thromb Res. 2020 Nov;195:238-242. doi: 10.1016/j.thromres.2020.08.019. Epub 2020 Aug 10. PMID: 32799131. DISCLOSURES: No relevant relationships by Mukul Bhattarai No relevant relationships by radhika deshpande No relevant relationships by Abhishek Kalidas Kulkarni No relevant relationships by Raj Patel No relevant relationships by Prashanth Singanallur

S2660 A Case of Hepatopulmonary Syndrome Requiring Living Donor Liver Transplantation in a Patient With Nodular Regenerative Hyperplasia and Autoimmune Lymphoproliferative Syndrome-Associated Granulomatous Hepatitis Without Cirrhosis

Introduction: Nodular regenerative hyperplasia (NRH) is a non-cirrhotic cause of portal hypertension that can rarely lead to hepatopulmonary syndrome (HPS). We report on a patient with a rare underlying Autoimmune Lymphoproliferative Syndrome (ALPS), granulomatous hepatitis, and NRH who developed HPS requiring living donor liver transplantation (LDLT). Case Description/Methods: A 34-year-old male with history of ALPS and prior diagnosis of non-necrotizing granulomatous hepatitis with perisinusoidal fibrosis, presented to our clinic for evaluation of worsened liver enzyme elevations. He was asymptomatic with labs notable for ALT 145 U/L, AST 228 U/L, ALP 308 U/L, and total bilirubin 3.0 mg/dL. His liver enzymes did not improve with a trial of high dose steroids, and repeat liver biopsy was suggestive of nodular regenerative hyperplasia. He later developed signs of portal hypertension on imaging as well as esophageal varices on upper endoscopy, with recurrent bleed requiring Transjugular Intrahepatic Portosystemic Shunting (TIPSS) placement. He then developed chronic hypoxia. Echocardiogram with agitated saline study revealed right to left intrapulmonary shunting, consistent with a diagnosis of HPS. The patient’s symptoms quickly progressed with worsening hypoxia requiring continuous oxygen therapy, PaO2 was 48 on room air. He was listed for liver transplantation with exception points for HPS (native MELD-Na = 13, listed at 27). 183 days after listing, he underwent LDLT with complete resolution of hypoxia within 25 days post-transplant. The explant confirmed the absence of cirrhosis and the presence of granulomatous hepatitis and NRH (Figure 1). Discussion: HPS is most commonly associated with cirrhosis. This case highlights a rare instance of HPS in a patient without cirrhosis, but with NRH and concomitant granulomatous hepatitis. LDLT led to a rapid reversal of his HPS.Figure 1.: Histological section of the explanted native liver revealing subtle nodules without fibrous septa composed of hepatocytes arranged in plates 1-2 cells thick (*). Hepatocytes between nodules are compressed into thin, atrophic plates (arrows). (H&E, original magnification x200).

Wide unroofed coronary sinus and cryptogenic stroke: a case report.

Background Unroofed coronary sinus (UCS) is a rare congenital cardiac anomaly in which there is complete or partial absence of the roof of the coronary sinus (CS) resulting in a communication between the right and left atria. There are four types of UCS described in the literature. While usually asymptomatic and discovered incidentally on imaging, UCS can be the source of a brain abscess or paradoxical embolism.Case summary A 62-year-old gentleman presented to the emergency department with sudden onset of right-sided weakness and subsequent unresponsiveness. His brain computed tomography (CT) was consistent with left-sided stroke. Transthoracic echocardiography was remarkable for a dilated CS and an agitated saline study was suggestive of an UCS. A gated cardiac CT with coronary angiography confirmed a wide communication between the CS and left atrium. Right heart catheterization did not show evidence of left to right shunt. He had no abnormal rhythm on telemetry monitoring throughout his hospital stay.Discussion Unroofed coronary sinus is the least prevalent form of an atrial septal defect. Unroofed coronary sinus is usually asymptomatic and is diagnosed incidentally in imaging studies, however, it should be suspected in patients with cerebral emboli or evidence of left to right shunt with unexplained arterial desaturation. Transthoracic echocardiography is the most widely used imaging modality for the diagnosis of UCS but is limited in its ability to visualize the posterior cardiac structures such as the CS and pulmonary veins. Gated cardiac CT is a great diagnostic tool for UCS.

Dilated Coronary Sinus: An Indicator of Persistent Left Superior Vena Cava

An 88-year-old male presented for a routine transthoracic echocardiogram. Dilated coronary sinus was noted, raising the suspicion for persistent left superior venous cava (PLSVC). An agitated saline study from the left upper extremity demonstrated a flow through the coronary sinus into the right ventricle in a parasternal long-axis view. A venogram from the right internal jugular vein showed the PLSVC drained into a much dilated coronary sinus (CS) that connected to the right atrium. The right superior vena cava was absent. PLSVC along with absent right superior vena cava is rare and the inadvertent CS cannulation may result in vessel perforation.

Two Cases of Primary Atrial Myopathy in Western Sydney

We describe a second case of a severe biatrial enlargement. We previously reported a similar finding in a 79-year-old male with long-standing history of myasthaenia gravis and previously known AF and heart failure with preserved ejection fraction. A 73-year-old female of Sri Lankan background presents with progressive dyspnoea and decreased exercise tolerance over the course of six months. She had no previous cardiac history and minimal comorbidities. On presentation she was haemodynamically uncompromised (BP of 140/88) and mildly tachypnoeic (respiratory rate 22). Examination revealed elevated jugular venous pulse with evidence of large V waves, a grade 4 pansystolic murmur and bi-basal crepitations. There was no hepatomegaly or lower limb oedema. Electrocardiogram revealed presence of new onset atrial fibrillation. Blood tests showed normal cardiac enzymes. Chest x-ray showed gross cardiomegaly but clear lung fields. Transthoracic echocardiogram showed grossly dilated left and right atriums (RA area 72 cm2, LA volume 107.9 ml/m2), disproportionate to the ventricular cavity. There was evidence of early thrombus in the left atrium. No evidence of intracardiac shunts was seen on agitated saline study. She proceeded to have a right heart study which showed normal pulmonary pressures. She was discharged with plans for an outpatient cardiac MRI. Severe biatrial dilatation is rare and remains a poorly understood clinical entity. The present case reflects our second experience with the condition. In both cases, a primary atrial myopathy was the primary diagnosis. We aim to compare these both rare cases and present similarities and clinical dilemmas in treating this rare cardiac disorder.

Multidisciplinary Assessment in Optimising Results of Percutaneous Patent Foramen Ovale Closure.

Percutaneous patent foramen ovale (PFO) closure is a therapeutic option to prevent recurrent cerebral ischaemia in patients with cryptogenic stroke and transient cerebral ischaemia (TIA). The apparent lack of benefit seen in previous randomised trials has, in part, reflected inclusion of patients with alternate mechanisms of stroke. The role of formal neurology involvement in accurately delineating the likely aetiology of stroke or TIA is crucial in appropriate identification of patients for device closure. Furthermore, as the benefits of device closure may accrue over time, long-term follow-up is essential to define the role of device closure in management of presumed cryptogenic stroke. We retrospectively reviewed our experience with percutaneous PFO device closure since 2005. All subjects who underwent PFO closure at John Hunter and Lake Macquarie Private Hospitals were included in the study. All patients referred for device closure following cryptogenic stroke or TIA had first undergone formal neurology review with appropriate imaging and exclusion of paroxysmal atrial arrhythmia. Patients with a history of transient ischaemic attack (TIA) are frequently referred to a specialised clinic, aimed to identify patients with conditions not referable to cerebral ischaemia, with investigations initiated by the specialist clinic to elucidate an underlying aetiology. Outcome data was derived from the Hunter New England Area Local Health District Cardiac and Stroke Outcomes Unit, in addition to review of the medical record. The Cardiac and Stroke Outcomes Unit prospectively identified all patients presenting with stroke, TIA and atrial fibrillation. One hundred and twelve consecutive patients undergoing percutaneous patent foramen ovale closure between 2005 and 2015 were identified. The average age was 42.7 years and 57 (50.9%) patients were male. Cryptogenic stroke (68.8%) and transient cerebral ischaemia (23.2%) were the most common indications for PFO closure, with the Amplatzer device used in 83 cases (74.1%). Early residual shunting was visible in seven patients (6.3%), however on follow-up agitated saline study only two patients had residual shunt (1.8%). The annual risk of recurrent stroke or TIA was 0.21%. Percutaneous patent foramen ovale closure can be performed safely and effectively in patients with paradoxical embolism. In selected patients, following appropriate multidisciplinary specialist pre-procedural assessment, excellent long-term results with low incidence of recurrent events may be achieved.

Abnormal Agitated Saline Study Results after Tetralogy of Fallot Repair

Residual intracardiac or extracardiac shunting is frequently seen in patients with repaired congenital heart disease and can cause systemic hypoxemia. We present the case of an adult with tetralogy of Fallot who underwent two corrective surgical procedures as a child with subsequent pulmonary valve replacement due to residual pulmonary insufficiency. Further details of her operative history were otherwise unknown. After being lost to follow-up for many years, she presented with unexplained cyanosis and a markedly abnormal agitated saline study on transthoracic echocardiography in which only the left heart filled after contrast administration. We review the differential diagnosis for such a presentation and discuss the utility of cardiac magnetic resonance imaging (MRI) to define the etiology. Cardiac MRI, a frequently used imaging modality to longitudinally assess adult patients with congenital heart disease, provides excellent image quality of cardiac structures and the ability to perform angiography in a variety of imaging planes. These advantages render cardiac MRI, a useful modality to determine the etiology of unexplained cyanosis in these patients as both intracardiac and extracardiac shunts can be detected.

Effectiveness of Percutaneous Closure of Patent Foramen Ovale for Hypoxemia

The aim of this study was to evaluate the ability of percutaneous patent foramen ovale (PFO) closure to improve systemic hypoxemia. Although PFO-mediated right-to-left shunt (RTLS) is associated with hypoxemia, the ability of percutaneous closure to ameliorate hypoxemia is unknown. Between 2004 and 2009, 97 patients who underwent PFO closure for systemic hypoxemia and dyspnea that was disproportionate to underlying lung disease were included for evaluation. All patients exhibited PFO-mediated RTLS as determined by agitated saline echocardiography. Procedural success was defined as implantation of a device without major complications and mild or no residual shunt at 6months. Clinical success was defined as a composite of an improvement in New York Heart Association (NYHA) functional class, reduction of dyspnea symptoms, or decreased oxygen requirement. Procedural success was achieved in 96 of 97 (99%), and clinical success was achieved in 68 of 97 (70%). The presence of any moderate or severe interatrial shunt by agitated saline study (odds ratio [OR]= 4.7; p <0.024), NYHA class at referral (OR= 2.9; p<0.0087), and 10-year increase in age (OR= 1.8; p <0.0017) increased likelihood of clinical success. In contrast, a pulmonary comorbidity (OR= 0.18; p <0.005) and male gender (OR= 0.30; p <0.017) decreased the likelihood of success. In conclusion, based on the largest single-center experience of patients referred for PFO closure for systemic hypoxemia, PFO closure was a mechanically effective procedure with an associated improvement in echocardiographic evidence of RTLS, NYHA functional class, and oxygen requirement.

Cryptogenic Stroke Associated With Patent Foramen Ovale in a Collegiate Volleyball Athlete

Cryptogenic stroke is a form of cerebral vascular accident that has an unknown origin and is rarely associated with patent foramen ovale (PFO) and migraine headaches. This is an uncommon occurrence in young, healthy, active adults, and it is increasingly rare for the episode to occur during an athletic competition. Stroke is easily recognizable with its distinct signs and symptoms, but it is also easily confused with many of its differential diagnoses, such as seizures or head trauma, if the episode occurs during an athletic competition. This case report describes the stroke episode, incidence of migraine headaches, diagnostic testing, and surgical management of a college female volleyball athlete who suffered a cryptogenic stroke associated with PFO during an athletic competition. Diagnostic testing included magnetic resonance imaging with contrast, electroencephalograph, lower extremity Doppler testing, and a transesophageal echocardiograph with agitated saline study. Surgical correction of the PFO included a cardiac catheterization percutaneous procedure based on fluoroscopic and echocardiograph imaging. After release from physicians, the athlete returned to full participation in the sport of volleyball, where she competed for the next 2 years without complications. The patient has reported no symptoms from stroke or PFO closure procedure in 3 years, and migraine headaches have decreased in severity, frequency, and duration.