Platypnea-orthodeoxia Syndrome Research Articles

759 Platypnoea orthodeoxia syndrome following middle-lower bilobectomy: a case report

Abstract Aims PlatypneaOrthodeoxiasyndrome (POS) is a rare clinical condition characterized by dyspnoea and arterial desaturation, typically occurring in orthostatism and vanishing in a supine position. The real pathophysiologic triggers are still not completely understood. Methods and results In January 2021, a 76-year-old female patient was admitted to our department for the management of a large mass in the right lung (69 × 54 × 76 cm). Pre-operative Computed Tomography (CT)-scan showed a lesion of the right lower lobe, with suspected infiltration of posterior costal pleura and bronchoscopy revealed distal occlusion of intermedious bronchus. Surgical treatment was planned: extrapleural lower bilobectomy with the removal of the VI rib to reduce intracavity space was performed, using postero-lateral thoracotomy approach. On the third post-operative day, an acute neurologic deficit with left-sided paralysis, associated with desaturation and hypotension, occurred during a new attempt to mobilize the patient. Nonetheless the patient showed complete resolution of symptoms in supine position. A new similar episode of severe desaturation (SO2 80%) was observed in the 7th post-operative day. Arterial blood gas test showed PO2 37 mmHg; PCO2 27 mmHg; SO2 80.3%, pH 7.61, tHb 12.4 g/dl; O2Hb 78.4%. CT pulmonary angiography excluded a suspicious of pulmonary embolism. A right to left atrial shunt was suspected. Contrast-enhanced transcranial Doppler ultrasound showed microembolic signals in the basal cerebral arteries. Transoesophageal echocardiography was performed, confirming an interatrial septum with an exuberant hyperdynamic movement and showing an abundant passage of contrast from the right atrium to the left, even without the Valsalva manoeuvre, compatible with an important patent foramen ovale (PFO). Patient was referred to the cardiac Catheterization Laboratory for percutaneous closure of PFO. The device was successfully placed via right femoral venous catheter access and on transesophageal echocardiogram guidance. The procedure was performed without any complications. The implanted device was noted to be in a stable position with trivial residual inter-atrial shunting immediately after the procedure. The day after implantation, positional discomfort improved remarkably and the patient was able to stand-up with no symptoms, maintaining normal saturation (SaO2 100%). The patient was discharged and sent home on the third post-implantation day. The 4 month follow-up examination showed a good andstable condition. Conclusions Platypnoea Orthodeoxia Syndrome after lobectomy is a rare cause of postoperative dyspnoea/hypoxia.It is the result of right-to-left shunt via interatrial communication. Mediastinal relocation, stretching of the atrial septum are among the functional elements necessary for the clinical manifestations. It is essential to have a high index of suspicion to detect POS in patient with dyspnoea given the subtle and positional nature of the symptoms. Physicians should always consider POS in patients with unexplained dyspnoea; hence the treatment modalities could alleviate symptoms and be potentially curative.

Mechanisms of platypnea-orthodeoxia syndrome.

Platypnea orthodeoxia syndrome (POS) is a clinical entity described in the middle of the last century. It is characterized by dyspnea and hypoxemia triggered by standing and relieved with recumbency. The diagnosis is predominately clinical. The degree of hypoxemia is variable; however, the diagnostic criteria include the decrease in arterial oxygen pressure more than 4 mmHg or oxygen saturation more than 5%. Even though many diseases cause this syndrome, there are only two responsible mechanisms, intracardiac, and intrapulmonary shunts. The coexistence of diverse structural and physiological abnormalities joined to gravitational forces that induce blood shunt after standing is crucial in each mechanism. The intracardiac mechanism is characterized by right to left blood shunt through atrial septal communications and, the right atrium pressure could be normal or increased. In addition, some patients have one or more coexistent aortic, spinal, or intracardiac alterations. The intrapulmonary mechanism is less frequent and is caused by parenchymal or vascular pathologies. Transthoracic echocardiogram is the first diagnostic modality; however, understanding the pathophysiology is the key for a rational diagnostic approach and subsequent diagnostic studies. Treatment is possible and effective in the majority of intracardiac mechanisms and some intrapulmonary. This review focuses on the pathophysiologic mechanisms of POS and their diagnostic workup.

Platypnoea-Orthodeoxia Syndrome in COVID-19.

Platypnoea-orthodeoxia syndrome (POS) is a possible and rare condition associated with SARS-CoV-2 pneumonia.A prompt diagnosis of POS is important in order to start careful and adequate oxygen supplementation.Clinical data on COVID-19 evolution in patients with POS and possible therapeutic and rehabilitative strategies are not available in the literature.

Postoperative Hemidiaphragmatic Paralysis and Platypnea-Orthodeoxia Syndrome.

How to cite this articleLong MT, Grate J, Bradley KV. Postoperative Hemidiaphragmatic Paralysis and Platypnea–Orthodeoxia Syndrome. Indian J Crit Care Med 2021;25(8):951–953.

Persistent pathology of the patent foramen ovale: a review of the literature

A patent foramen ovale (PFO) is an interatrial shunt, with a prevalence of 20-34% in the general population. While most people do not have secondary manifestations of a PFO, some reported sequelae include ischaemic stroke, migraine, platypnoea-orthodeoxia syndrome and decompression illness. Furthermore, in some cases, PFO closure should be considered for patients before neurosurgery and for patients with concomitant carcinoid syndrome. Recent trials support PFO closure for ischaemic stroke patients with high risk PFOs and absence of other identified stroke mechanisms. While PFOs can be associated with migraine with auras, with some patients reporting symptomatic improvement after closure, the evidence from randomised controlled trials is less clear in supporting the use of PFO closure for migraine treatment. PFO closure for other indications such as platypnoea-orthodeoxia syndrome, decompression illness and paradoxical embolism are based largely on case series with good clinical outcomes. PFO closure can be performed as a day surgical intervention with high procedural success and low risk of complications.

Platypnea-Orthodeoxia Syndrome Years after Acute Pulmonary Embolism

Platypnea-Orthodeoxia syndrome (POS) is a rare condition in which dyspnoea and arterial oxygen desaturation are present in the upright position, while in the supine position, they are alleviated. It is observed in the presence of an anatomical (intra- or extracardiac) communication between the right and left heart causing a right-to-left shunt. POS is most frequently caused by a patent foramen ovale (PFO) and usually, the clinical assessment and a transthoracic echocardiograms with bubble study are enough to reach the diagnosis. The only possible treatment of POS is the percutaneous closure of the defect. We describe two cases of POS due to a PFO which manifested itself years after an episode of acute pulmonary embolism (PE), a finding never reported to date in the literature. Few cases describe the relationship between PE and POS, but these conditions may be more closely related than we currently think.

Platypnea-orthodeoxia syndrome: comprehensive analysis by multimodal imaging.

Platypnea-orthodeoxia syndrome: comprehensive analysis by multimodal imaging.

Cardiac Platypnoea-Orthodeoxia Syndrome – Supine and Upright Transoesophageal Echocardiography

A 56-year-old lady presented with a 2-month history of progressive dyspnoea and fatigue (New York Heart Association [NYHA] III), on a background of B cell lymphoma complicated by thrombocytopaenia (baseline platelet count 50 109/L). A computed tomography (CT) chest demonstrated no cause to account for the patient’s dyspnoea. However during the CT it was noted on pulse oximetry the patient’s hypoxia resolved in the supine position.

Retraction: De Vecchis, R., et al. Platypnea-Orthodeoxia Syndrome: Multiple Pathophysiological Interpretations of a Clinical Picture Primarily Consisting of Orthostatic Dyspnea. J. Clin. Med. 2016, 5, 85.

The journal retracts the article "Platypnea-Orthodeoxia Syndrome: Multiple Pathophysiological Interpretations of a Clinical Picture Primarily Consisting of Orthostatic Dyspnea" by De Vecchis, R [...].

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

A Case Report about Persistent Left Superior Vena Cava: Is it Always Asymptomatic?

A persistent left superior vena cava (PLSVC) is a rare malformation which affects approximately 0.3% - 0.5% of the population and it is presented along with a right-sided superior vena cava in 82.2% of the cases reported [1]. Clinicians diagnose it incidentally by difficulties with pacemaker implantation, central venous catheterization or screening for another etiologies when it is not accompanied by other anomalies it is typically asymptomatic. W. Schummer et al. described the embryogenesis and the anatomic variations of persistent LSVC according to the positioning of a central venous catheter on the chest radiograph: type I, normal; type II, only PLSVC; type IIIa, right and left superior vena cava with connection; type IIIb, right and left superior vena cava without connection [2]. In 92% of individuals with PLSVC, the PLSVC drains into a dilated coronary sinus (CS) and rest 8% drain directly into the left atrium. PLSVC is caused by a failure in the closure of the left anterior cardinal vein during embryogenic development [3]. The coronary sinus (CS) is a vein that transmits venous blood to the right atrium though atrioventricular groove. The CS wall contains atrial myocardium. Thus, its size extensively depends on variability of blood flow and pressure. We present a variant PLSVC with unknown prevalence and a mild platypnea-orthodeoxia syndrome after recovery of COVID-19 related acute respiratory distress syndrome (ARDS).

Contrast Transcranial Doppler in Detection of Platypnea-Orthodeoxia Syndrome: A Key Clue for a Tricky Diagnosis

The platypnea-orthodeoxia syndrome (POS) is a rare clinical entity characterized by the development of dyspnea...

When sitting suffocates: arare cause of platypnoea-orthodeoxia syndrome.

Platypnoea–orthodeoxia syndrome refers to shortness of breath and oxygen desaturation in an upright position. Ventilation/perfusion mismatch is a rare cause of the same. Herein, we report a case of bilateral lower lobe tuberculosis, causing platypnoea and orthodeoxia. https://bit.ly/3jhJEQ1

Platypnoea-orthodeoxia syndrome induced by short-term weight loss: a case series.

BackgroundPlatypnoea–orthodeoxia syndrome (POS) is an uncommon condition characterized by dyspnoea and arterial desaturation in the standing or sitting position that improves in the supine position.Case summaryWe report two cases of POS caused by an atrial septal defect (ASD) and a patent foramen ovale (PFO). Both cases reported a recent decrease in body weight of more than 10 kg in a short time period. Transoesophageal echocardiography (TOE) with agitated saline bubble study revealed and a large amount of contrast bubble through the ASD (Patient 1) or the PFO (Patient 2) from the right atrium to the left atrium in the sitting position. Both patients were diagnosed by the finding of positional dyspnoea and the results of TOE using agitated saline bubble contrast.DiscussionTaken together, their presentations suggest that weight loss in a short time period could be a pathogenic factor for POS.

Non-alcoholic Fatty Liver Disease Causing Platypnea-Orthodeoxia Syndrome

Non-alcoholic fatty liver disease (NAFLD) with cryptogenic liver cirrhosis is uncommonly linked to platypnea-orthodeoxia syndrome (POS). Traditionally, this syndrome has been described in correlation to intracardiac shunting like patent foramen ovale. We report a case of a 70-year-old female, with a previous history of NAFLD and heart failure presenting with acute hypoxic respiratory failure secondary to fluid overload. Further investigations revealed cryptogenic presentation of POS, which was masked by her heart failure. The patient was not able to maintain her oxygen saturation levels in an upright position, with marked improvement when lying down. Her echocardiogram was significant for positive bubble study without any intracardiac shunt, hence making NAFLD as a cause of this rare presentation of POS a more likely diagnosis.

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.

Abstract 15398: Standing Breathless: A Case of Platypnea-Orthodeoxia Syndrome

A 67-year old women with a history of metastatic endometrial cancer, prior pulmonary embolism (PE) (on Xarelto) and mitral valve prolapse presented for 2-3 weeks of exertional dyspnea. Patient presented to oncology clinic with oxygen saturation (SpO2) in the mid-70% on room air requiring supplemental oxygen, and eventually high flow nasal cannula (HFNC). She was transferred to our cardiac intensive care unit for further management of her hypoxia. Physical exam was notable for decreasing SpO2 from supine (99%) to sitting (88%) to standing (79%). In this patient with metastatic cancer, differential diagnosis for hypoxia was broad including pneumonia, metastatic pulmonary disease, doxorubicin-induced cardiomyopathy, and PE. CT chest showed no signs of pulmonary edema, pneumonia, lung metastases, or PE. Transthoracic echocardiogram showed normal left and right ventricular function with moderate aortic regurgitation and mitral regurgitation. However, agitated saline injection showed right to left flow consistent with intraatrial shunt. Transesophageal echocardiogram confirmed large patent foramen ovale (PFO) with atrial septal aneurysm. Given physical examination findings, presence of PFO, and structural abnormalities of intraatrial septum, platypnea-orthodeoxia syndrome (POS) was considered. Right heart catheterization was completed to evaluate shunt physiology and showed unremarkable pressures (RA 1, RV 22/1, PCWP 3, PA 20/3, and LA 2). Venous oxygen saturations did not show any step-up suggesting left to right shunt. Exercise challenge did not result in any significant change in PA or PCWP pressures. Given persistent concern for POS without other clear diagnosis, patient underwent percutaneous closure of PFO with a 30mm Gore Cardioform septal occluder. Patient had resolution of her exertional hypoxia following procedure and was discharged home the next day. The case discusses 1) the importance of history of and physical exam in narrowing diagnosis, 2) utilization of multimodality imaging to evaluate intraatrial shunts, and 3) use of percutaneous methods for PFO closure.

Utility of transcranial color flow imaging for detecting high risk morphology of patent foramen ovale in patients with cerebral infarction

Abstract Background Micro-bubble test by using transcranial color flow imaging (TCCFI) is important as a screening evaluation for diagnosis of paradoxical cerebral embolism which requires the proof of right to left shunt at atrial septum. In addition, high risk features of patent foramen ovale (PFO) that may allow thrombus to easily pass through the PFO itself were previously reported. However, little is known about the association between the degrees on micro-bubble test by TCCFI and the features of high risk PFO. Purpose Our aim is to clarify the relationship between the degree of micro-bubble test in TCCFI and the morphology of PFO from transesophageal echocardiography (TEE). Methods Seventy-seven patients in whom cardiogenic embolism was strongly suspected by neurologists in Showa University from April to December in 2019 were retrospectively studied. 55 patients underwent both TCCFI and TEE with sufficient Valsalva stress. TCCFI grade of micro-bubble test was classified into 3 groups (A: none, B: small, and C: massive), in which signified “none” is no sign of micro-embolic signals (MES) within 30 seconds, “small” is 1 or more MES, and “massive” is so much MES look like a curtain (Figure). Evaluated high risk characteristics of PFO for cerebral embolism as previously reported were as follows; (1) tunnel height, (2) tunnel length, (3) total excursion distance into right and left atrium, (4) existence of Eustachian valve or Chiari network, (6) angle of PFO from inferior vena cava (7) large shunt (20 or more micro-bubbles). Results Of all TCCFI-positive patients (n=32; Group B=19, Group C=13) with cerebral embolism, PFOs were detected in 23 patients in TEE. Therefore, the sensitivity and specificity of TCCFI to PFO were 87% and 63% (AUC=0.75, p<0.001, respectively). Interestingly, all 13 patients (Group C) had manifest PFOs. Moreover, group C include 2 patients with platypnea orthodeoxia syndrome in which hypoxia in the sitting position becomes apparent. Among PFO-positive patients, tunnel height, length, total excursion distance into right and left atrium, and large shunt in TEE were significantly larger in Group C than Group B (p<0.05). Conclusions Micro-bubble test by using TCCFI may have screening advantages in predicting paradoxical cerebral embolism, high-risk morphology of PFO, and platypnea orthodeoxia syndrome. Figure 1 Funding Acknowledgement Type of funding source: None

PAY ATTENTION! AN UNUSUAL CASE OF DYSPNEA

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Platypnea-orthodeoxia is an uncommon syndrome characterized by dyspnea and hypoxemia in upright position that improves with recumbent position. It can occur due to intracardiac shunts, pulmonary arteriovenous shunts and ventilation perfusion mismatch. We present a unique and rare cause of platypnea-orthodeoxia syndrome. CASE PRESENTATION: A 68 years old man with history of coronary artery disease and COPD presented with acute onset chest pain and associated difficulty breathing. Patient did have several months’ history of exertional dyspnea which did not improve with rest this time. On presentation, patient was noted to be hypoxic with oxygen saturation of 88% and ABG showed PH 7.41, PaO2 47 mmHg and PaCO2 22.4 mmHg. Oxygen saturation improved to 94% with 3L of supplemental oxygen. EKG and troponin were unremarkable. CT PE was unremarkable for pulmonary embolism as well. IV heparin drip was started for suspected unstable angina and patient underwent cardiac catheterization that revealed non-obstructive coronary artery disease. Echocardiography showed ejection fraction of 55-60% with mild mitral and tricuspid regurgitationDuring the course of hospitalization, patient was noted to have intermittent positional hypoxemia. He had normal resting saturation on 2 L of oxygen which dropped to 88% sitting upright and dropped to 84% on 2 L of oxygen upon raising both arms. Platypnea-orthodeoxia syndrome was strongly suspected with possible intra-cardiac or intrapulmonary shunt. Meanwhile, CT chest was unremarkable for interstitial lung disease. Right heart catheterization revealed normal right atrial RA (68.9%) and pulmonary arterial PA (68.3%) saturation at rest but reduced RA (42.5%) and PA (43.2%) saturation with sitting up. Echocardiography with bubble study showed right-to-left shunting and trans-esophageal echocardiography revealed a small 0.5 cm atrial septal defect (ASD) with bidirectional shunting. Patient was diagnosed with Platypnea-orthodeoxia syndrome secondary to ASD. He was discharged home on supplemental oxygen and outpatient follow-up for ASD closure. DISCUSSION: Platypnea-orthodeoxia is a rare syndrome. Patent foramen ovale is the most common cardiac cause of platypnea-orthodeoxia syndrome followed by ASD. Transesophageal echocardiography is the best test to diagnose atrial septal defect but it is important to rule out pulmonary causes of platypnea-orthodeoxia syndrome as well. ASD is successfully treated with percutaneous closure and prognosis of is good after correction of the defect. CONCLUSIONS: Platypnea-orthodeoxia syndrome is rare syndrome but it can be easily recognized with careful history and physical examination. Reference #1: Henkin S, Negrotto S, Pollak PM, Cullen MW, O'Cochlain DF, Wright RS. Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion. Tex Heart Inst J. 2015;42(5):498-501. Published 2015 Oct 1. doi:10.14503/THIJ-14-4596 Reference #2: Kazawa S, Enomoto T, Suzuki N, et al. Platypnea-orthodeoxia Syndrome in a Patient with an Atrial Septal Defect: The Diagnosis and Choice of Treatment. Intern Med. 2017;56(2):169-173. doi:10.2169/internalmedicine.56.7728 Reference #3: PLATYPNEA ORTHODEOXIA SYNDROME: A RARE COMPLICATION OF IATROGENIC ATRIAL SEPTAL DEFECT. Bharat Avirneni, Christopher Rosse, Joseph Choo, Kalpan Desai. J Am Coll Cardiol. 2020 Mar, 75 (11 Supplement 1) 2799. DISCLOSURES: No relevant relationships by Muhammad Aamir, source=Web Response No relevant relationships by Muhammad Afzal, source=Web Response No relevant relationships by Saleha Dar, source=Web Response

PLATYPNEA-ORTHODEOXIA SYNDROME DUE TO A BIDIRECTIONAL SHUNT

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Platypnea-orthodeoxia syndrome is a rare disorder characterized by dyspnea and arterial desaturation in an upright position with improvement in the supine position (1). Our case highlights a known but rather uncommon and reversible cause of hypoxia which can potentially be misdiagnosed. CASE PRESENTATION: A 62-year-old male with a history of hypertension and type 2 diabetes mellitus presented to the emergency department with gradual, progressive, intermittent, dyspnea for 2 months, which was worse with standing and walking, and better after laying flat. The patient stated that he used to walk a few miles without any discomfort approximately one year ago. But now the dyspnea had limited his ability to walk less than one block. As per records, the patient had a cardiac catheterization 1 month back for an abnormal stress test and it showed angiographically normal coronaries and 60% ejection fraction. No recent sick contacts and no family history of cardiac conditions. Vitals on presentation revealed tachycardia, respiratory rate of 20/min, 99% O2 saturation on lying flat, and 84% on standing up which dropped to 78% after walking 10 steps. The hypoxia while standing up didn't resolve with nasal cannula oxygenation. Labs were within normal limits. Chest X-ray showed normal lung fields and normal heart shadow, CT pulmonary angiogram was normal. 2D Echocardiography with a bubble study showed a left ventricular ejection fraction of 55 % and a patent foramen ovale (PFO). Transesophageal echocardiography (TEE) showed large atrial septal defect with left-to-right shunting and no right-to-left shunting. The patient was scheduled to undergo surgical closure of the defect. DISCUSSION: PFO was found in 25 to 30 percent of individuals in an autopsy study and a community-based transesophageal echocardiography (TEE) study (2). Two required components of a PFO are an interatrial shunt or an intrapulmonary shunt as in the hepatopulmonary syndrome, and a functional component that promotes abnormal shunting when the patient rises from a recumbent to an upright position. Our patient had both these components due to a left to right shunt. CONCLUSIONS: Platypnea-orthodeoxia syndrome can be presented as mere dyspnea on effort. A clinician should check the positional change of symptoms and/or oxygenation when he or she sees a patient with dyspnea on effort of undetermined origin. Preexisting bidirectional shunting precipitated in its right-to-left component by Valsalva maneuver, coughing, or straining might explain the occurrence of a paradoxical embolism in Secundum atrial septal defect patients(3). Definitive treatment in the form of closure is recommended in such cases. Reference #1: 1. Cheng TO. Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv. 1999;47(1):64-66. https://doi.org/10.1002/(SICI1522-726X(199905)47:1<64::AID-CCD15>3.0.CO;2-6) Reference #2: 2. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17-20. https://doi.org/10.1016/s0025-6196(1260336-x) Reference #3: 3. Rigatelli G, Dell'avvocata F, Tarantini G, Giordan M, Cardaioli P, Nguyen T. Clinical, hemodynamic, and intracardiac echocardiographic characteristics of secundum atrial septal defects-related paradoxical embolism in adulthood. J Interv Cardiol. 2014;27(6):542-547. https://doi.org/10.1111/joic.12159 DISCLOSURES: No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Monarch Shah, source=Web Response