Right-to-left Shunt Research Articles

Development and Validation of an Individualized Nomogram for Predicting Patent Foramen Ovale-Associated Stroke: Patent Foramen Ovale Morphology-Based Analysis.

We previously reported four patent foramen ovale (PFO) morphological types that influenced right-to-left shunt (RLS) grades. Herein, we aimed to study the relationship between PFO morphology and cryptogenic stroke (CS). We further developed a nomogram based on four PFO morphological types and functional parameters to guide clinicians in judging the risk of PFO-associated stroke. This was a retrospective observational study involving adult patients with PFO between January 2020 and November 2022. Patients were divided into a PFO-associated stroke group (CS group) and a group without cryptogenic stroke (non-CS group). Four types of PFO and RLS grades were analyzed. Nomograms were made to predict PFO-associated stroke using multivariable logistic regression analysis. The discrimination performance of the model was internally validated and assessed using the receiver operating characteristic. We enrolled 389 patients (male, 182 patients; female, 207 patients) with PFO, the mean age was 43.3±8.1 years. The derivation cohort comprised 293 patients (CS group, 186 patients; non-CS group, 107 patients). The predictive nomogram comprised PFO morphological types, interatrial septum (IAS) mobility distance, septum primum thickness, PFO channel length at rest, and contrast-transthoracic echocardiography (c-TTE) RLS grade during the Valsalva maneuver. A validation cohort was established (CS group, 61 patients; non-CS group, 35 patients). The model area under the curve (AUC) was 0.891 (95% confidence interval = 0.855-0.928) in the derivation cohort and 0.935 (95% confidence interval = 0.885-0.986) in the validation cohort. Calibration curve analysis showed that the nomogram had a C-index of 0.891 in the derivation cohort and 0.935 in the validation cohort. The decision curve analysis (DCA) indicated that the nomogram had clinical applicability. Adding four PFO morphological types improved the risk stratification capability for PFO-associated stroke. The nomogram can identify high or low-risk PFO individuals and select patients who will likely benefit from interventional device closure.

Anatomical Significance of the Patent Foramen Ovale by Real-Time 3D TEE in Cryptogenic Stroke and Migraine.

The transesophageal echocardiogram (TEE) is the standard imaging modality for confirming the presence or absence of patent foramen ovale. PFO is a flap valve depending on the pressure change between the left and right atrium, which can help determine whether to open. 3D-TEE was shown to optimize the visualization of PFO. There is a causal association between PFO and unexplained stroke. It seems that 3D-TEE can present a high-risk PFO morphological feature, which seems to show more than just being easier to open. In total, 134 consecutive patients with cryptogenic stroke or migraine who had suspected PFO and underwent c-TCD, TTE, and c-TEE were included in this study. TEE confirmed the PFO. The right-to-left shunt (RLS) grade of PFO at rest and abdominal compression Valsalva maneuver was detected by c-TEE. The long diameter of FO (1.74 ± 0.3vs. 1.60 ± 0.4, p = 0.039), the short diameter of FO (1.12 ± 0.3vs. 1.00 ± 0.3, p = 0.036), perimeter of FO (4.62 ± 0.7vs. 4.22 ± 1.0, p = 0.026), and area (1.80 ± 0.8vs. 1.35 ± 0.8, p = 0.05) of the FO were significantly larger in the larger RLS group. In group of CS, a larger proportion of Eustachian valve or a Chiari's network (14.3%vs. 3.5%, p = 0.036), a larger proportion of in the left funnelform (55.1%vs. 16.3%, p < 0.001), a longer length of the PFO tunnel (13.4 ± 4.4vs. 7.8 ± 2.5, p < 0.001), a lower IVC-PFO angle (16.4 ± 3.4vs. 20.3 ± 7.7, p = 0.001), a higher proportion of LA multiple exits of the tunnel (46.9%vs. 14.3%, p < 0.001). Multivariate regression analysis showed that male gender (HR: 4.026, 95% CI: 0.883-18.361, p = 0.072), age (HR: 1.076, 95% CI: 1.002-1.155, p = 0.045), the left funnelform (HR: 7.299, 95% CI: 1.585-33.618, p = 0.011), a longer length of the PFO tunnel (HR: 1.843, 95% CI: 1.404-2.418, p < 0.001) and multiple exits of the tunnel of LA (HR: 8.544, 95% CI: 1.595-45.754, p = 0.012) increased the risk of cerebral infarction. The cut-off value calculated by ROC for the diagnosis of high-risk PFO was that the length of the PFO tunnel was 12mm and the left funnelform combined with multiple exits of the left atrial (sensitivity was 92%, specificity was 90%). The area under the curve of the combined index versus PoPE score (0.932 vs. 0.736) relative to the RoPE score was statistically significant. TEE has shown outstanding advantages in displaying the specific morphological characteristics of PFO. The left funnelform, a longer length of the PFO tunnel, and multiple exits of the tunnel of LA are associated with an increasing risk of CS in anatomical PFO respect.

White matter lesions as a prognostic marker of recurrence in cryptogenic stroke with high-risk patent foramen ovale

PurposeA high-risk patent foramen ovale (PFO) could be the cause of cryptogenic stroke, and an atrial septal aneurysm (ASA) increases the risk of stroke recurrence in cryptogenic stroke patients with a patent foramen ovale (PFO). Factors related to stroke recurrence according to PFO characteristics have not been fully evaluated. MethodsData from a multicenter, observational registry of ischemic stroke patients undergoing transesophageal echocardiography were used for this study. Patients were classified into three groups: high-risk PFO, PFO with large shunt (≥20 microbubbles) or ASA; right-to-left shunt (RLS), RLS including PFO with <20 microbubbles or without ASA, or pulmonary arteriovenous fistula; and negative RLS. Cox proportional hazards regression analysis was used to explore the factors related to stroke recurrence in these three groups. ResultsIn total, 586 patients (185 females; 65.5±13.2 years) were analyzed. In cryptogenic stroke (329 patients) with median follow-up of 4.2 (interquartile range, 1.0–6.1) years, 55 patients had stroke recurrence. The negative RLS, RLS, and high-risk PFO groups included 179, 90, and 60 patients, in which stroke recurrence occurred in 5.3%, 2.5%, and 4.6% per person-year, respectively. In patients with high-risk PFO, the National Institutes of Health stroke scale score (hazard ratio [HR] 1.257 [1.034-1.530]) and periventricular hyperintensity (HR 3.369 [1.103-10.294]) were predictors of stroke recurrence on multivariable Cox hazards analysis, but no factors were related to stroke recurrence in the RLS and negative RLS groups. ConclusionPeriventricular hyperintensity was shown to predict recurrent stroke in patients with a high-risk PFO.

Impact of party balloon inflation manoeuvre during saline contrast transthoracic echocardiography to detect a patent foramen ovale: multicenter registry study

Abstract Background Paradoxical embolism due to patent foramen ovale (PFO) can cause cryptogenic stroke. Agitated saline contrast transthoracic echocardiography (ASC-TTE) is an essential diagnostic tool for PFOs, and provocation using the Valsalva manoeuvre (VM) is necessary during the examination. Although VM is the standard method, assessing whether sufficient provocation has been achieved can pose challenges for the patients and examining staff. Conversely, a party balloon inflation manoeuvre (PBIM), which we previously reported (1, 2), offered a clear visual confirmation of provocation than conventional VM and showed effectiveness in cases of inadequate provocation. However, collective evaluation of PBIM by group remains unknown. Purpose This study aimed to demonstrate the superiority of PBIM over standard provocative methods, such as conventional or inferior vena cava compression VM, during ASC-TTE. Methods This multicentre registry study was conducted across eight high-volume institutions in Japan. A total of 117 consecutive patients (62.3% men, mean age; 56.2 ± 13.8 years, as of December 31, 2023) in whom paradoxical embolism was suspected and PFO was detected by transesophageal echocardiography, underwent PBIM and standard provocative methods during ASC-TTE. We compared them using a five-point microbubble grade (none or 1–4) using the right-to-left cardiac shunt as the primary endpoint (Figure 1). Results PBIM produced microbubble upgrading in 51 (43.6%, yellow panels in Figure 2), no change in 54 (46.1%), and down-grading in 12 (10.3%, blue panels in Figure 2) patients, compared to standard provocative methods. Wilcoxon paired analysis revealed that PBIM had a significantly larger microbubble grade than the standard provocative methods (median 3.0 interquartile range (IQR) [3.0–4.0] vs 3.0 IQR [1.7–4.0], p&amp;lt;0.001). If significant right-to-left shunt was grade ≥2, which was considered as the indication of catheter PFO closure, the pairwise McNemar’s test showed diagnostic performance of significant right-to-left cardiac shunt using PBIM improved from 75.2% to 91.5% (improvement rate; 16.3%, 95% CI; 8.4–24.0, p&amp;lt;0.001). Logistic regression analysis showed insufficient balloon inflation due to inexperience and risk of paradoxical embolism score independently associated with downgrading in PBIM after adjustments for age, sex, clinically relevant variables, and other echocardiographic parameters (odds ratio (OR); 24.0, 95% interquartile range (CI); 3.3–172.1, p&amp;lt;0.01 and OR; 0.60, 95% CI; 0.39–0.91, p&amp;lt;0.05, respectively). Conclusions PBIM significantly increased the microbubble grade compared to standard provocative methods. PIBM, using a simple tool, may provide an appropriate treatment strategy for patients with potential cryptogenic stroke attributed to PFO, especially those who are falsely diagnosed as negative for significant right-to-left cardiac shunts.Primary endpointsAgreement of 5-point microbubble grade

Right-to-left-shunts in patients scheduled for neurosurgical intervention in semi-sitting position – a literature review based on two case scenarios

BackgroundNeurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position.Case presentationIn this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management.ConclusionsPerioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms.

Dynamic shunt flow alterations through patent foramen ovale during off-pump coronary artery bypass grafting induced by airway pressure changes: a case report.

Interatrial right-to-left shunt flow through a patent foramen ovale (PFO) can be caused by changes in heart position for anastomosis during off-pump coronary artery bypass (OPCAB). We herein present a case in which the direction of PFO shunt flow changed with heart position during OPCAB and the ventilation settings after sternal closure. A 66-year-old man with interstitial pneumonia underwent OPCAB. Preoperative transesophageal echocardiography revealed right-to-left shunt flow through a PFO induced by the Valsalva maneuver. During OPCAB, heart displacement resulted in right-to-left shunting and acute hypoxemia, which quickly improved with increase of inspired oxygen fraction. After chest closure, bidirectional shunt flow developed under increased airway pressure. Vigilant intraoperative monitoring with TEE and postoperative airway pressure management are important to address shunt flow and hypoxemia due to PFO.

Comparison of pulmonary artery growth between ductus stent and systemic-to-pulmonary shunt as single-ventricle palliation

ObjectiveWe aimed to compare the pulmonary artery (PA) growth between infants with univentricular hearts who underwent a ductus stenting (DS) and those who received a systemic to pulmonary shunt (SPS) as an initial palliation. MethodsAll infants with ductal-dependent pulmonary blood flow who underwent initial palliation with either a DS or SPS between 2009 and 2022 in our institution were reviewed. PA development was compared between the groups using the PA index and the symmetry index. ResultsA total of 130 patients were evaluated including 49 patients after DS and 81 after SPS. The most frequent primary diagnosis was tricuspid atresia in 27, followed by pulmonary atresia with intact ventricular septum in 19. At stage II palliation, PA index (p=0.926), right PA index (p=0.692), left PA index (p=0.297) and the symmetry index (p=0.650) were similar between the groups. At stage III Fontan completion, PA index (p=0.115), right PA index (p=0.868), and the symmetry index (p=0.144) were similar between the groups. However, left PA index (60 vs. 74mm2/m2, p=0.015) was lower, and the incidence of veno-venous collaterals (24.2 vs. 7.8%, p=0.036) was higher in DS group compared to SPS group. Freedom from PA interventions between stage II and III palliation was lower in DS group compared to SPS group (p=0.009). ConclusionsIn patients after DS in infants with univentricular heart, freedom from PA interventions after stage II was lower and the left PA index was smaller, compared to those after SPS. Long-term outcomes after the Fontan procedure should be addressed in patients after DS.

Graded Transthoracic Contrast Echocardiography After Pulmonary Arteriovenous Malformation Embolization: Can Chest CT Be Avoided in Patients With a Low-Grade Shunt?

BackgroundPulmonary arteriovenous malformations (PAVMs) are direct connections between the pulmonary artery and vein, creating right-to-left shunting (RLS). Embolization is indicated to prevent complications. Guidelines recommend follow-up chest CTs to confirm persistent occlusion and embolization of all treatable PAVMs. Graded transthoracic contrast echocardiography (TTCE) after PAVM embolization may offer a reliable alternative in a subgroup of patients while preventing radiation exposure. Research questionCan TTCE predict the need for additional embolotherapy in the post-embolization population as accurately as it does in treatment-naïve population? Study design and methodsSince 2018, follow-up after PAVM embolization at the study institution includes both TTCE and chest-CT after 6-12 months and every 3-5 years thereafter. Patients who underwent at least one follow-up TTCE and chest-CT were included. The indication for additional embolotherapy was discussed in a multidisciplinary team meeting. The primary outcome was the indication for additional embolotherapy in each RLS-grade. Additionally, the association between the RLS-grade and indication for additional embolotherapy was investigated. Results339 patients with 412 embolization procedures were included, median time to follow-up TTCE was 7.5 months. A RLS was present in 399 post-embolization TTCEs (97%): RLS grade 1 in 93 patients (23%), grade 2 in 149 patients (36%) and grade 3 in 157 patients (38%). In patients with a RLS grade 0-1, no treatable PAVMs were found on CT. In patients with RLS grade 2-3, 22 (15%) and 72 (46%) underwent additional embolizations. InterpretationThis study shows chest CT might be forgone in patients with an RLS grade 0-1 after PAVM embolization.

The impact of a residual atrial communication in patients undergoing complete repair for tetralogy of Fallot: A propensity score–matched analysis

BackgroundSurgeons may leave a residual atrial-level communication during complete repair of tetralogy of Fallot (TOF) in anticipation of restrictive right ventricle physiology or as routine practice. We investigated the impact of closing the interatrial communication at the time of definitive TOF repair. MethodsWe retrospectively reviewed TOF patients who underwent definitive repair at age <12 months between June 2000 and January 2023. Propensity score matching identified 82 patients with a patent interatrial communication and 50 patients with no interatrial communication on postoperative echocardiography (as-treated analysis). The primary endpoint was maximum vasoactive-inotropic score (VIS) as a surrogate for low cardiac output syndrome. ResultsA total of 132 patients (median age, 3.5 months; interquartile range [IQR], 1.8-5.8 months) were matched. There was no difference in maximum VIS (patent interatrial communication: 5.0 [IQR, 4.8-9.0] vs no interatrial communication: 6.0 [IQR, 5.0-8.0]; P = .78). Additionally, the duration of inotrope therapy (3.0 [IQR, 2.0-4.0] days vs 3.0 [IQR, 1.3-4.0] days; P = .57), peak lactate (2.2 [IQR, 1.9-3.0] mmol/L vs 2.3 [IQR, 1.9-3.2] mmol/L; P = .58), time to lactate clearance (0.2 [IQR, 0.0-0.3] days vs 0.1 [IQR, 0.0-0.3] days; P = .57), chest tube duration (4.0 [IQR, 3.0-6.0] days vs 4.0 [IQR, 3.0-5.0] days; P = .23), and length of intensive care unit stay (5.0 [IQR, 3.0-7.0] days vs 5.0 [IQR, 3.0-7.0] days; P = .71) were similar in the 2 groups. The median duration of follow-up was 5.5 years (IQR, 2.7-9.9 years). Among patients with a residual communication, patency rates were 93.6% at discharge and 53.7% at latest follow-up, with most having bidirectional shunting across the defect. ConclusionsClosure of the atrial-level communication during complete TOF repair does not significantly impact the immediate postoperative course or mid-term outcomes. Further investigation is warranted to better understand how patency influences long-term outcomes.

Embolic Ischemic Cortical Stroke in a Young Flight Instructor with a Small Patent Foramen Ovale

BACKGROUND: Stroke in young patients is frequently associated with a patent foramen ovale (PFO). Controversy exists over whether the PFO is a cause, a risk factor, or an incidental finding. Estimating the individualized risk of stroke recurrence has been difficult to ascertain. This has implications for aeromedical certification for pilots following stroke recovery. CASE REPORT: A 28-yr-old male flight instructor presented with sudden onset unilateral facial paresthesia, hand weakness, and blurred vision, accompanied by gradual onset bilateral headache. While the cranial symptoms resolved, left hand weakness persisted for 3 d. MRI revealed two punctate ischemic foci in the right precentral gyrus and superior parietal lobe. A transesophageal echocardiogram revealed a PFO with a small bidirectional shunt. His cardiologist and neurologist advised the PFO was unlikely to have caused his stroke and estimated an annual recurrence rate of &lt; 1.8%. He was treated medically and declined PFO closure. He was able to return to flying light-sport aircraft. However, an enduring copilot restriction for general aviation activities was placed on his Class 1 and 2 medical certificates. DISCUSSION: This case highlights the difficulty in determining individualized recurrence risks for pilots recovering from a stroke associated with a PFO. While medical treatment does reduce the risk of recurrence, PFO closure provides marginal additional benefit in certain patients with a risk of side effects. Contemporary evidence-based risk scoring systems combined with echocardiography findings may be used together to better risk stratify patients and suitability for medical aviation recertification. Rengel AC, Gericke C. Embolic ischemic cortical stroke in a young flight instructor with a small patent foramen ovale. Aerosp Med Hum Perform. 2024; 95(10):784–787.

Patent Foramen Ovale and Other Cardiopathies as Causes of Embolic Stroke With Unknown Source.

In patients with stroke caused by cardiac embolism, the responsible heart diseases include atrial fibrillation, acute myocardial infarction, sick sinus syndrome, valvular disease, and significant heart failure. When there is no clear source of the embolism, the condition is referred to as "embolic stroke with unknown source (ESUS)." Recent studies have shown that the most common cause of ESUS is a right-to-left cardiac shunt through a patent foramen ovale (PFO). However, considering that PFOs are found in up to 25% of the general population, their presence does not necessarily indicate causality. In patients with ESUS associated with a PFO, either anticoagulants or antiplatelets are used for the prevention of future strokes or transient ischemic attacks. However, it currently remains unclear which treatment is superior. Nevertheless, recent randomized clinical trials have shown that percutaneous closure of the PFO more effectively reduces the incidence of recurrent strokes compared to medical therapy alone in patients with PFO-related strokes. This benefit is especially significant when the PFO carries high-risk features, such as a large shunt or the presence of an atrial septal aneurysm. Furthermore, the effectiveness of PFO closure has been well documented in young patients (<60 years) with a high-risk PFO development. In other cases, the therapeutic decision should be made through discussion among neurologists, cardiologists, and patients. Notably, in ESUS patients without a PFO, the underlying heart condition itself may be the source of embolism, with left atrial enlargement being the most important factor. Theoretically, anticoagulants such as non-vitamin K antagonist oral anticoagulants (NOACs) would be an effective therapy in these cases. However, recent trials have failed to show that NOACs are superior to antiplatelets in preventing further strokes in these patients. This may be due to the still uncertain definition of emboligenic cardiopathy and the presence of other potential embolic sources, such as mild but emboligenic arterial diseases. Overall, further research is needed to elucidate the source of embolism and to determine an effective management strategy for patients with ESUS.

Multimodal ultrasound imaging for patent foramen ovale and pulmonary arteriovenous malformation in patients with cryptogenic stroke or migraine: A prospective diagnostic study.

Right-to-left shunt (RLS) caused by patent foramen ovale (PFO) and pulmonary arteriovenous malformations (PAVM) have been associated with a variety of diseases, and reliable techniques for detecting RLS are essential for diagnosis. This study aimed to compare the diagnostic accuracy of multimodal ultrasound imaging, including transthoracic echocardiography (TTE) plus contrast transthoracic echocardiography (CTTE) and transesophageal echocardiography (TEE) plus contrast transesophageal echocardiography (CTEE) for PFO and PAVM in patients with cryptogenic stroke or migraine. This prospective study enrolled patients with cryptogenic stroke or migraine admitted to First Hospital of Shanxi Medical University between July 2018 and April 2023. The TTE + CTTE + TEE + CTEE multimodal ultrasound imaging was defined as the gold standard. A total of 230 patients with cryptogenic stroke (108) or migraine (122) were enrolled. The TEE + CTEE generated a better area under the receiver operator characteristic (ROC) curves (AUC) than TTE + CTTE [0.995 (0.988-1.000) vs 0.975 (0.767-0.984), P < .001], indicating better identification of PFO and PAVM. The sensitivity and specificity of the TTE + CTTE were 89.4% and 85.7%, respectively, whereas the sensitivity and specificity of TEE + CTEE were 99.1% and 100%, respectively. The missed diagnosis rate of TTE + CTTE and TEE + CTEE was 65.7 % and 12.5%, respectively. The combination of TEE + CTEE may be a more reliable and sensitive tool to detect PFO and PAVM than TTE + CTTE in patients with cryptogenic stroke or migraine.

Clinical Efficacy of Transcatheter Closure of Patent Foramen Ovale with Positive Foaming Test

Background and Aims: To explore and evaluate the clinical therapeutic effect of interventional occlusion in the treatment of patent foramen ovale (PFO) with positive foaming test in the prevention and treatment of cryptogenic stroke (CS) and to provide clinical basis for individualized treatment of CS patients with PFO. Methods: A total of 151 patients who was admitted to Beijing Anzhen Nanchong Hospital Hospital from January 2019 to June 2021 were divided into two groups: drug therapy group (n = 63) and interventional occlusion + drug therapy group (n = 88). The general clinical data of the patients were collected by retrospective study, including sex, age, body weight, right to left shunt (RLS) magnitude, the degree of migraine before treatment, and telephone follow-up of all patients after treatment. Results: There was no significant difference in general clinical data (p &gt; 0.05). In the interventional occlusion + drug therapy group, the stroke recurrence rate within 6th month after operation was significantly lower than that in the drug therapy group, and the difference was statistically significant (p &lt; 0.05); The degree of migraine was lower than that in the drugs treatment group at the 3rd month after operation and the difference was statistically significant (p &lt; 0.01); The degree of migraine at the 6th month was lower than that in the drug therapy group but the difference was not statistically significant (p &gt; 0.05). The results of comprehensive generalized analysis showed that the risk of moderate or severe headache in the interventional occlusion + drug therapy group decreased by 40% (odds ratio [OR] = 0.60, p &lt; 0.05). The degree of migraine in female patients was statistically lower after three and six months postoperatively (p &lt; 0.05 and p = 0.01, respectively). Combined with generalized analysis, the risk of moderate or severe migraine in female patients was reduced by 55%. There were significant differences in the migraine before operation, migraine at the 3rd month and migraine at the 6th month in patients with three different kinds RLS grades (p &lt; 0.01, p &lt; 0.01, p &lt; 0.05). Compared with the preoperative migraine and the migraine at the 3rd month, patients with RLS grade 3 had the most obvious migraine relief at the 6th month after operation than those with RLS grade 2. Conclusion: Compared with the drug therapy, interventional occlusion + drug therapy can reduce the risk of CS recurrence, improve the prognosis and significantly reduce the degree of migraine. Patients of different genders had different degrees of migraine, women had a lighter degree of migraine and a reduced risk of moderate or severe migraine, women benefited more after treatment. Patients with different RLS grades have different postoperative migraine relief. Patients with preoperative RLS grade 3 have the most obvious postoperative migraine relief and patients with preoperative RLS grade 3 benefit more after treatment.

Perioperative Considerations for ASD Device Closure in the First Trimester: A Case of Secundum ASD with Bidirectional Shunt

Introduction: Atrial septal defect (ASD) closure during pregnancy is a complex procedure requiring careful consideration of maternal and fetal risks. This case report highlights the perioperative management of a secundum ASD with a bidirectional shunt in a patient during her first trimester. Case presentation: A 31-year-old woman, G3P2A0, presented at approximately 10-11 weeks gestation with a recently diagnosed large secundum ASD and pulmonary hypertension. She was on Sildenafil and Bisoprolol. Due to the potential risks associated with an unrepaired ASD during pregnancy, the decision was made to proceed with percutaneous ASD closure. General anesthesia was administered with meticulous hemodynamic monitoring. The procedure was successful, and the patient recovered without complications. Conclusion: ASD closure during the first trimester can be safely performed with careful planning and execution. Multidisciplinary collaboration and vigilant monitoring are crucial for optimal maternal and fetal outcomes.

Omic-signature of bronchopulmonary dysplasia associated pulmonary hypertension in

PDA and ASD are common intracardiac shunts noted in prematurely born infants. While there is evidence of persistent PDA and ASD associated with a higher risk for developing bronchopulmonary dysplasia (ICS-BPD) and pulmonary hypertension (ICS-BPD-PH), the underlying pathogenesis is poorly understood and hence challenging to identify at-risk infants. Our study goal was to evaluate transcriptomic expression and associated pathways in tracheal aspirates (TAs) of low-birth-weight infants with hemodynamically significant cardiac shunt (ICS) that develop bronchopulmonary dysplasia (ICS-BPD) and pulmonary hypertension (ICS-BPD-PH). TAs were collected from preterm infants with ICS and a diagnosis of BPD or BPD-PH from a single center. 36 TA samples including 19 ICS-BPD and 17 ICS-BPD-PH were analyzed. MiRNA expression was determined via PCR arrays, and mRNA expression via RNA seq. Data were analyzed using limma. 11 miRNAs and 10 mRNAs were differentially expressed (adjusted p < 0.05) in ICS-BPD-PH group when compared to ICS-BPD. Ingenuity Pathway Analysis identified associations with cellular growth, proliferation, death, and cell function pathways. TAs from preterm infants show differentially expressed miRNAs and mRNAs in ICS-BPD-PH when compared to ICS-BPD, an in-silico model identified target molecules that could be playing a role in BPD-PH pathogenesis in low-birth-weight infants with ICS. Pulmonary hypertension associated with severe BPD (BPD-PH) is a distinct disease in preterm infants with severe BPD and the role of intracardiac shunt (ICS) in its development is controversial and often challenging for clinical management. Our pilot study, researching specific endotyping of infants with pulmonary hypertension associated with BPD using multiomics approach has identified molecular markers and potential underlying pathways associated with this condition. These markers could aid in stratifying high risk infants with ICS that are at risk for developing BPD-PH and aid clinical management.

Clinical Significance of Mottling Rashes in Diving Decompression Sickness.

INTRODUCTION: Decompression sickness (DCS) is a medical condition caused by outgassing of dissolved nitrogen following rapid ascent by divers and aviators. Cutaneous DCS, historically termed cutis marmorata (CM), presents as a predominantly truncal reticular violaceous-to-dusky eruption. The prevailing theories for its pathogenesis include: localized cutaneous outgassing, paradoxical embolism across a right-to-left shunt (RLS), and brainstem emboli disrupting autonomic control of cutaneous microcirculation.METHODS: We conducted a systematic review of reports of cutaneous DCS to investigate relationships among CM, RLS, and neurological sequelae to better elucidate the mechanism of CM. A literature search examining reports of cutaneous DCS yielded 31 eligible studies, comprising a pooled total of 128 patients.RESULTS: Of the patients with documented workup, 84% showed evidence of RLS with CM. Subsequently 18 patients underwent percutaneous closure of intracardiac RLS with no recurrence of DCS. Of the patients with documented neurological evaluations, 57% experienced both CM and neurological DCS manifestations. The coexistence of RLS and neurological symptoms with CM was noted in numerous cases; exact percentages of overlap cannot be stated due to data unavailability.DISCUSSION: Our results indicating the striking coexistence of RLS and neurological sequelae in CM patients is supportive of the paradoxical embolism theory of pathogenesis. The frequent coincidence of CM with RLS and neurological symptoms raises concern that CM may signify vulnerability to devastating systemic gas emboli. CM has historically been considered trivial and self-limiting; however, our results support reappraisal of its clinical significance and potential reclassification to the more severe subtype.Breen ID, Stepanek J, Marks L, Yale K, Mesinkovska N, Swanson D. Clinical significance of mottling rashes in diving decompression sickness. Aerosp Med Hum Perform. 2024; 95(9):695-702.

A retrospective study: Long term prognosis in adults with PA-VSD-MAPCAs

BackgroundPulmonary Atresia, Ventricular Deptal Defect, and Major Aortopulmonary Collateral Arteries (PA-VSD-MAPCAs) is a congenital cyanotic heart defect with poor prognosis. Due to its complex and highly variable anatomy, the best treatment plan is not clear. We aimed (1) to investigate the survival of PA-VSD-MAPCAs patients according to the underlying original anatomy and treatment strategy, and (2) to evaluate life expectancy between patients with or without severe hypoplastic native pulmonary arteries (NPAs) after surgical versus non-surgical treatment. MethodsA prospectively established database of 169 PA-VSD-MAPCAs patients treated and followed up at University Hospitals Leuven was accessed. Patients were divided into three groups according to the treatment strategy. Kaplan-Meier survival curves were plotted, and Log Rank tests were used for comparison. ResultsThe overall mean survival for patients with PA-VSD-MAPCAs was 38.5 years (95%-CI: 33.1–43.9). Patients with complete intracardiac repair had the longest mean survival of 43.8 years (95%-CI: 38.1–49.6) versus the other groups (p < 0.001). A longer mean event-free survival time was found in patients with normal, well-developed NPAs (p = 0.047). Finally, patients with poorly developed or absent NPAs had worse survival rates when a surgical approach was followed. Systemic-pulmonary shunt placement or unifocalisation had limited effect on prognosis in the absence of total repair (p = 0.167). ConclusionsPatients with PA-VSD-MAPCAs who underwent complete intracardiac repair and/or with well-developed native pulmonary arteries had the best prognosis. Our analyzed data suggest that incomplete surgical repair resulted in survival rates comparable to those seen with a non-surgical approach.

Double Intervention in A Patient with Large Patent Ductus Arteriosus and Moderate Upper Muscular Ventricular Septal Defect with Bidirectional Shunt with Severe Pulmonary Hypertension

Patent ductus arteriosus (PDA) and Ventricular septal defect (VSD) are commonly encountered problems and constitute about 40% of all congenital heart lesions. The association of these two conditions in a single patient is not very uncommon. Both these conditions can be treated by placing intracardiac devices. Double interventional closure of PDA and VSD was performed in a gravely ill infant at her 3 months and 5 months of age respectively, who was suffering from recurrent pneumonia and heart failure since birth. These were lifesaving procedure for that patient which led to writing this report. Cardiovasc j 2024; 16(2): 105-109

Surgical Repair of Atrial Septal Defect with Severe Pulmonary Hypertension: A Case Report

This case report details the successful surgical repair of an atrial septal defect (ASD) in a 28-year-old female with severe pulmonary arterial hypertension (PAH), who presented with dyspnea, fatigue, and palpitations. The patient had a large secundum ASD (26 mm size) with bi-directional shunt and severe PAH, with a Pulmonary Arterial Systolic Pressure (PASP) of 107 mmHg and Mean Pulmonary Arterial Pressure (mPAP) of 57 mmHg, as revealed by echocardiography. The patient was optimized medically with diuretics, oxygen, and pulmonary vasodilators (Sildenafil &amp; Ambrisentan), and was deemed eligible for surgical closure of the ASD. A pericardial patch was used to close the defect, and the patient's postoperative recovery was uneventful. Follow-up echocardiography showed a significant reduction in mPAP and right ventricular size. Although surgical closure of an ASD with severe PAH is a high-risk procedure, it can be safely performed in carefully selected patients with appropriate preoperative evaluation, medical optimization, and careful surgical technique. Timely closure of the defect can result in a considerable improvement in the patient's hemodynamic status and quality of life. Cardiovasc j 2024; 16(2): 110-113

The relevance of vascular adjustments to hemodynamic control in the face of temperature change in Crotalus durissus.

The presence of cardiac shunts in ectothermic tetrapods is thought to be consistent with active vascular modulations for proper hemodynamic support. Local control of blood flow modulates tissue perfusion and thus systemic conductance (Gsys) is assumed to increase with body temperature (Tb) to accommodate higher aerobic demand. However, the general increase of Gsys presses for a higher right-to-left (R-L) shunt, which reduces arterial oxygen concentration. In contrast, Tb reduction leads to a Gsys decrease and a left-to-right shunt, which purportedly increases pulmonary perfusion and plasma filtration in the respiratory area. This investigation addressed the role of compensatory vascular adjustments in the face of the metabolic alterations caused by Tb change in the South American rattlesnake (Crotalus durissus). Cardiovascular recordings were performed in decerebrated rattlesnake preparations at 10, 20 and 30°C. The rise in Tb increased metabolic demand, and correlated with an augmentation in heart rate. Although cardiac output increased, systemic stroke volume reduced while pulmonary stroke volume remained stable. Although that resulted in a proportionally higher increase in pulmonary blood flow, the R-L shunt was maintained. While the systemic compliance of large arteries was the most relevant factor in regulating arterial systemic blood pressure, peripheral conductance of pulmonary circulation was the major factor influencing the final cardiac shunt. Such dynamic adjustment of systemic compliance and pulmonary resistance for shunt modulation has not been demonstrated before and contrasts with previous knowledge on shunt control.