Undiagnosed Patent Foramen Ovale Research Articles

P044 Janus Kinase Inhibitors-a retrospective study on side effects and discontinuation reasons

Abstract Background/Aims In light of drug safety warnings for Janus kinase inhibitors (JAKi), we aimed to evaluate the occurrence of adverse events and identify reasons for discontinuation of JAKi in clinical practice. Methods Medical records of all patients prescribed JAKi in NHS Grampian from January 2021 to January 2023 for rheumatic diseases were retrospectively reviewed. Patient demographics, co-morbidities, reasons for treatment discontinuation and occurrence of adverse events (including cardiovascular events) were recorded. Results 160 patients were prescribed JAKi. 131 (81.8%) patients had rheumatoid arthritis, 16 (10%) psoriatic arthritis, five (3%) axial spondyloarthritis, three (2%) juvenile idiopathic arthritis (in adulthood), 3 (2%) undifferentiated inflammatory arthritis, one (0.6%) granulomatous polyangiitis (GPA), one (0.6%) enteropathic arthritis. Mean duration of treatment was 9.9±12 months with 34.4% on treatment for >12 months. 47.5% discontinued JAKi after an average of 7.0 ± 5.1 months. Patients discontinuing treatment were significantly older than patients who continued treatment 60.1yrs ± 11.0 vs 55.9yrs ± 12.5 respectively, p = 0.03. There were no differences between discontinuing and continuing treatment groups with respect to BMI, smoking, diabetes, cardiovascular disease, hypertension or statin use. Discontinuation rates were 66.7 % tofacitinib, 44.4 % filgotinib and 34.4 % upadacitinib. Discontinuation reasons were inefficacy (37.9 %), headache (9.2 %), infections (9.2 %) and gastrointestinal adverse effects (8.0 %). One patient discontinued JAKi due to an arterial embolism (DVT in the context of undiagnosed patent foramen ovale), three developed new onset hypertension. Common infections leading to discontinuation were urinary tract (37.5 %) and chest (25.0 %), with one case of tuberculosis. No herpes zoster infections led to JAKi discontinuation. In patients who continued treatment infections occurred in 27.1% (30% chest, 21.7%, Covid-19, 13% UTIs, 8.7% herpes zoster 8.7% otitis media). Other adverse events such as fatigue and nausea were reported in < 4 % of all patients. No malignancies were recorded. Conclusion Older patients are more likely to discontinue JAKi due to infections. Upadacitinib patients were least likely to discontinue. Treatment inefficacy, urine and chest infections were the commonest reasons for discontinuation. Disclosure J. Klein: None. J. Alexander: None. L. Robertson: Other; LR has received funding for conference attendance from UCB. R. Hollick: None.

Simultaneous arterial and venous thromboembolic events associated with COVID-19. A case report

Infections with COVID-19 can induce thrombophilia and increase the risk of thrombotic events. We describe a case of a 64- years-old male who presents with intermediate-risk pulmonary embolism and brachial artery thrombosis secondary to an undiagnosed patent foramen ovale and COVID-19 infection. The patient was successfully treated with thrombolysis and heparin infusions and was discharged home with long-term anticoagulation. Managing patients with multiple pathologies occurring concurrently requires effective inter-speciality working in order to take a holistic approach to managing the patient opposed to managing the conditions in isolation. This case report highlights how clinical guidelines can support decision making of the individual pathologies but working as a team will enable the best care.

Erratum to 'Previously Undiagnosed Patent Foramen Ovale as Cause of Hypotension and Hypoxemia in a Patient With Recent Tandem Heart LVAD Insertion' [Journal of Cardiothoracic and Vascular Anesthesia 34 (2020) 3170-3172

Erratum to 'Previously Undiagnosed Patent Foramen Ovale as Cause of Hypotension and Hypoxemia in a Patient With Recent Tandem Heart LVAD Insertion' [Journal of Cardiothoracic and Vascular Anesthesia 34 (2020) 3170-3172

Left atrial thrombus in a patient without mitral valve disease or atrial fibrillation

A 54-year-old man presented with back pain. His medical history included hypertension and gout. There was no history of heart disease or arrhythmia. The electrocardiogram showed normal sinus rhythm. Chest computed tomography demonstrated a large calcified tumor (65mm) in the left atrium (LA). The echocardiogram showed a round hyperechoic mass in the enlarged LA (56mm) attached to the atrial septum without mitral valve disease. Urgent surgery for excision of the LA mass with the atrial septum and reconstruction by autologous pericardial patch was performed. There was no pathological change in the mitral valve. Due to surgical injury to the conduction system, implantation of a permanent pacemaker was required postoperatively. Histopathological examination revealed calcification, fibrosis, and thrombus formation. LA thrombus without any history of mitral valve disease or atrial fibrillation is rare. Although the mechanism of the present case was unclear, extensive calcified LA myxoma or undiagnosed patent foramen ovale might have been associated with the disease.<Learning objective: A smooth surface, floating left atrial “ball thrombus” occurs rarely in patients with mitral valve disease or atrial fibrillation. We present a rare case of a giant round left atrial thrombus in a patient without any history of mitral valve disease or atrial fibrillation. Transesophageal echocardiogram showed that the thrombus was round, fixed to the septum, and not floating, and that its surface was calcified. This disease in this patient might have been associated with extensive calcified left atrial myxoma, paroxysmal atrial fibrillation, or undiagnosed patent foramen ovale.>

Pulmonary embolism and stroke associated with mechanical thrombectomy

Mechanical thrombectomy offers the advantage of rapid removal of venous thrombi. It allows venous obstructions to be removed and requires shorter duration of infusion of thrombolytic agents. However, aspiration of thrombi can lead to complications, particularly pulmonary embolism and hemolysis. The validity of using vena cava filters during thrombectomy in order to avoid embolism has not yet been established. The authors report a case of massive pulmonary embolism associated with ischemic stroke in a patient with a hitherto undiagnosed patent foramen ovale. The patient developed respiratory failure and neurological deficit after thrombectomy. This case raise questions about the value of the thrombectomy for the treatment of proximal vein thrombosis due to the risks of this procedure. The authors also discuss the need for vena cava filters and ruling out a patent foramen ovale in patients undergoing thrombectomy.

(311) - Case Report of Cardiac Allografts Retrieved From Human Donation After Circulatory Death (DCD) Donors - Assessment on Ex Vivo Beating Heart Perfusion Device

s S119 Organ Care System (OCS) device for 8 hrs, which allowed ex vivo beating heart assessment in working mode in addition to the standard resting mode. Functional & metabolic parameters were evaluated. The hearts were maintained in resting and working modes for 4 hours each. Results: During resting perfusion, heart 1 had favourable lactate profiles (lactate extraction) suggestive of viable myocardium, however remained > 5mmol/l. Heart 2 had an adverse lactate profile suggestive of ischaemic myocardium (Figure 1). In a working state, a left atrial pressure challenge was conducted. Heart 1 functioned better than Heart 2 (figure 1), with superior cardiac output and generated pressure. The inferiority of Heart 2 was likely the result of dual BD + DCD insult, decreased post-conditioning activation, and an undiagnosed patent foramen ovale. Conclusion: We report the first 2 DCD human hearts recovered on the OCS. Although these were not the ideal donors for DCD heart donation (donor 1 age> 50, WIT > 30 mins; Donor 2 BD + DCD, PFO), both demonstrated viability and the potential for DCD cardiac allografts. Further studies of ideal criteria DCD donors are underway.

(309) - Heart Transplantation With Organs Procured After Cardio-Circulatory Death and the Organ Care System. Assessment and Reconditioning of Hearts in a Porcine Model

s S119 Organ Care System (OCS) device for 8 hrs, which allowed ex vivo beating heart assessment in working mode in addition to the standard resting mode. Functional & metabolic parameters were evaluated. The hearts were maintained in resting and working modes for 4 hours each. Results: During resting perfusion, heart 1 had favourable lactate profiles (lactate extraction) suggestive of viable myocardium, however remained > 5mmol/l. Heart 2 had an adverse lactate profile suggestive of ischaemic myocardium (Figure 1). In a working state, a left atrial pressure challenge was conducted. Heart 1 functioned better than Heart 2 (figure 1), with superior cardiac output and generated pressure. The inferiority of Heart 2 was likely the result of dual BD + DCD insult, decreased post-conditioning activation, and an undiagnosed patent foramen ovale. Conclusion: We report the first 2 DCD human hearts recovered on the OCS. Although these were not the ideal donors for DCD heart donation (donor 1 age> 50, WIT > 30 mins; Donor 2 BD + DCD, PFO), both demonstrated viability and the potential for DCD cardiac allografts. Further studies of ideal criteria DCD donors are underway.

Influenza B Infection Complicated by Patent Foramen Ovale and High Altitude Pulmonary Edema

A 34-year-old man presented to a clinic at a ski resort in the Rocky Mountains at 9000 feet (2743 m) with shortness of breath and fatigue, a few days after arriving to altitude from sea level. He was found to be hypoxic with radiographic findings consistent with high altitude pulmonary edema (HAPE). He was treated with high flow oxygen, steroids, and calcium channel blockers and transferred to a lower altitude tertiary care hospital for intensive care unit monitoring and further treatment. During his diagnostic evaluation, he was found to have both a patent foramen ovale and influenza B infection. While patent foramen ovale is a known risk factor for HAPE, there is also some evidence that upper respiratory tract infections in general and influenza in particular may also be risk factors for HAPE. The 2 diseases may share an underlying pulmonary pathophysiology, as both cause noncardiogenic pulmonary edema and alveolar hemorrhage. We report an unusual case of influenza B virus compounded by previously undiagnosed patent foramen ovale, travel to high altitude, and subsequent development of HAPE.

Patent Foramen Ovale: A Potential Cause of Refractory Hypoxemia in Off-Pump Coronary Artery Bypass Surgery

Patent Foramen Ovale: A Potential Cause of Refractory Hypoxemia in Off-Pump Coronary Artery Bypass Surgery

Suspicious seizures: Uncommon complication of PFO/ASA

Brain abscesses have cardiac etiology in 5% of cases with valvular heart disease and endocarditis being the most common. Congenital heart disease with the risk of right to left shunt and paradoxical embolization is also a culprit. Our case describes a young patient with a prior undiagnosed patent foramen ovale (PFO), who presented with solitary brain abscess without any underlying primary source of infection. Since there was no evidence of contiguous spread of infection by computed tomography or magnetic resonance imaging scans, hematogenous spread of the streptococcal species was the most likely etiology. Transesophageal echocardiography (TEE) revealed no evidence of valvular endocarditis but did show intracardiac right-to-left shunting via a PFO. We suggest that all patients with a brain abscess of an unclear etiology caused be screened for a PFO with a TEE and bubble study.

A case of simultaneous pulmonary embolism and acute myocardial infarction secondary to a previously undiagnosed patent foramen ovale

We describe a 79-year-old male with recurrent high-grade liposarcoma who developed postoperative chest pain, dyspnea, and hypoxia suspicious for acute pulmonary embolism (PE). However, electrocardiogram (ECG) was suggestive of an acute ST-elevation myocardial infarction (MI). Heparin was initiated and emergent coronary angiography was performed, which demonstrated a "cutoff sign" in the distal left anterior descending artery (LAD) consistent with coronary embolism. A patent foramen ovale (PFO) and bilateral pulmonary emboli were subsequently identified. It was concluded that the patient had suffered an acute PE, with a portion of clot traversing the PFO and entering the LAD, resulting in a simultaneous acute ST-elevation MI. While the case described is rare, the underlying anatomical variant is common and may have practical significance. We discuss the literature regarding PFO with acute PE and paradoxical emboli.

Undiagnosed Patent Foramen Ovale Presenting as Retinal Artery Occlusion—An Emerging Association

Purpose. To report patent foramen ovale (PFO) as the cause of retinal artery occlusion in a young and previously fit male and discuss the appropriate medical and surgical management options. Methods. Interventional case report with serial fundus photographs of an 18-year-old male presenting to the eye casualty with sudden onset left visual loss. Results. Visual acuities were 6/24 left and 6/4 right with a left afferent pupillary defect. Slitlamp examination confirmed a left hemiretinal artery occlusion and subsequent cardiology review with transoesophageal echocardiography revealed patent foramen ovale which was closed surgically. Conclusions. PFO is not uncommon and is often covert but predisposes individuals to embolic events. These events may be ophthalmic with visual sequelae and so ophthalmologists, physicians, and other healthcare personnel should be aware of this important and emerging association.

Paradoxical embolism: a rare complication of thrombolysis

Paradoxical embolus is a rare complication of thrombolysis. With a high prevalence of clinically silent septal defects and widespread use of thrombolysis, recognition of the risks, clinical signs and symptoms...

Risk of air embolism from prefilled syringes

Prefilled syringes are available to provide rapid access to emergency drugs. One particular brand of prefilled syringes (Aurum Pharmaceuticals Ltd, Romford, UK) routinely contains a volume of air that must be expelled prior to usage (Fig. 7). A random sample of 10 10-ml syringes revealed a mean (SD) air volume of 0.7 (0.3) ml. While this only represents a small volume of air, the potential for administration without its expulsion is high, particularly in an emergency situation. It is reported that up to 35% of adults have an undiagnosed patent foramen ovale [1], making systemic emboli a distinct possibility. This is especially so when this air is administered via a central venous pressure (CVP) line during periods of cardiovascular instability, when there may be alterations to intracardiac pressures and consequent shunting. Although the volume of air required for a fatal embolism is not known, with 200 ml being recorded in one case [2], the volume required for significant cerebral or coronary emboli must be considerably smaller. Surely it is both desirable and simple for all air to be expelled from these syringes during the manufacturing process prior to packaging to avoid a rare, but potentially significant, adverse event. Prefilled syringe containing air bubble.

Intractable intraoperative hypoxemia secondary to pulmonary embolism in the presence of undiagnosed patent foramen ovale

The management of a patient with hip fracture during general anesthesia, who developed severe intractable hypoxemia caused by intraoperative pulmonary embolism in the presence of undiagnosed patent foramen ovale, is described. The role of urgent intraoperative transesophageal echocardiography in situations where acute perioperative pulmonary embolism/patent foramen ovale is suspected is emphasized.

Undiagnosed patent foramen ovale presenting as a cryptogenic brain abscess: Case report and review of the literature

A 43-year-old man with no significant medical history but poor oral hygiene presented with fever and new-onset tonic-clonic seizures secondary to a left parieto-occipital brain abscess defined by computed tomography, magnetic resonance imaging, and surgical evacuation. A comprehensive workup looking for a source of infection was unremarkable including computed tomography of the chest, abdomen, and pelvis; blood cultures; and a tagged white blood cell scan. A transesophageal echocardiogram bubble study revealed the presence of a patent foramen ovale (PFO) but no other abnormalities. Culture of the material obtained at surgery revealed flora commonly found in the oropharynx that responded to antibiotic therapy. A review of the literature revealed three other cases in which a brain abscess from flora commonly found in the oropharynx was associated with a PFO. We hypothesize that the underlying mechanism is a significant bacterial load from poor dentition that enters the arterial circulation through a PFO and forms the nidus for a brain abscess. Surgical evacuation is the preferred method for diagnosis and initial treatment. If a brain abscess is identified without any adjacent source of infection, a recent head trauma, or a neurosurgical procedure, then a transesophageal echocardiogram is indicated to exclude a PFO. If a PFO is found, then hematogenous spread of flora normally found in the oropharynx through a right to left shunt should be suspected. Surgical evacuation followed by intravenous antibiotics specific to the identified organisms is warranted. Once the infection is eliminated, anatomic closure of the PFO with good oral hygiene practices may be the best course of action for preventing recurrences.

Case 4—2005 Utility of Transesophageal Echocardiography in the Diagnosis of a Previously Undetected Atrial Septal Aneurysm With Shunt

EFECTS OF THE interatrial septum are among the most common congenital cardiac lesions found in adults. The foramen ovale, a fetal remnant, remains probe patent in more than one third of the general population, making it the most common congenital cardiac abnormality. Functional closure of the foramen ovale usually occurs soon after birth when the left atrial pressure rises and presses the valve of the fossa ovalis against the septum secundum. A patent foramen ovale (PFO) occurs when the foramen ovale does not anatomically seal. This relatively common entity is detectable in up to 34% of the population at postmortem examination. 1,2 The incidence has been shown to be even higher in patients with stroke. 3 Complications associated with a PFO include right-to-left shunting with refractory hypoxemia, paradoxic embolism, migraine headache, 4 transient global amnesia, 5 decompression illness with paradoxic gas embolism in divers and astronauts, 6 and orthostatic desaturation with platypnea-orthodeoxia syndrome.7 Atrial septal aneurysm (ASA) is frequently seen in association with a PFO,8 and its presence has been related to focal cerebral events including stroke and transient ischemic attacks. Because of this association, paradoxic embolism is believed to be a likely mechanism of embolism in many patients with ASA. Transesophageal echocardiography (TEE) is the modality of choice for the detection of PFO and ASA. Because of the increasingly routine use of TEE in the operating room during cardiac surgery, it can be expected that more cases of previously undiagnosed PFO and ASA will be detected. The question then becomes whether these findings should prompt further surgical intervention, particularly if the patient is asymptomatic. Unfortunately, at this time, there are no data to support the optimal approach to this clinical dilemma. The authors present a patient with a history of transient ischemic attacks (TIA) of unknown origin who was scheduled for elective off-pump coronary artery bypass (OPCAB) surgery. Preoperative diagnostic tests did not disclose the source of TIAs; however, intraoperative TEE revealed an ASA with PFO leading to alteration of the planned surgical procedure.

The impact of newly diagnosed patent foramen ovale in patients undergoing off-pump coronary artery bypass grafting: case series of eleven patients.

The increased use of transesophageal echocardiography (TEE) by anesthesiologists may lead to an increase in the intraoperative detection of previously undiagnosed patent foramen ovale (PFO). The impact of heart manipulation on interatrial shunting through a PFO during off-pump coronary artery bypass graft (CABG) has not been studied. We retrospectively studied 11 patients with PFOs who underwent off-pump CABG. TEE contrast studies and blood gas analyses were performed at baseline, during heart elevation for distal coronary arteries anastomoses, and at the end of the surgery. At baseline, 5 of 11 patients had left-to-right shunting and 2 of 11 had right-to-left shunting. Heart elevation did not result in oxygen desaturation in any patient; however, it caused the disappearance of a right-to-left shunt (n = 1), persistence of this shunt (n = 1), and the development of a new right-to-left shunt (n = 2). Return of the heart to its original position resulted in a return of TEE findings to the baseline state in all patients. This series suggests that off-pump CABG can be performed safely in the majority of patients with PFOs; however, additional investigation is needed to assure that adverse effects do not occur in a subset of patients undergoing off-pump CABG in the presence of a PFO. This case series suggests that coronary artery bypass graft surgery can be safely performed in most patients with patent foramen ovale without the use of a cardiopulmonary bypass.

Central cyanosis following coronary artery bypass graft surgery

A case of central cyanosis occurring after coronary artery bypass graft surgery is described. This was due to the development of a right ventricular infarction which facilitated shunting from right to left through a previously undiagnosed patent foramen ovale or small atrial septal defect.