Objective Quantification of Bilateral Bubble Contrast Echocardiography Correlates with Systemic Oxygenation in Patients with Single Ventricle Circulation.

Bubble contrast echocardiography is commonly used to diagnose pulmonary arteriovenous malformations (PAVMs) in single ventricle congenital heart disease (CHD), yet previous studies inconsistently report a correlation between bubble echoes and oxygenation. In this study, we sought to re-evaluate the correlation between bubble echoes and oxygenation by assessing total bilateral shunting and unilateral shunting. We conducted a single-center, retrospective study of patients with single ventricle CHD and previous Glenn palliation who underwent a cardiac catheterization and bubble echocardiogram during the same procedure from 2011 to 2020. Spearman's rank correlation was performed to examine the relationship between total bilateral shunting and measures of systemic oxygenation, as well as unilateral shunting and ipsilateral pulmonary vein oxygenation. For all patients (n = 72), total bilateral shunting moderately correlated with peripheral oxygen saturation (SpO2) (rs = -0.44, p < 0.0001). For patients with Glenn/Kawashima circulation (n = 49), total bilateral shunting was moderately correlated (SpO2: rs = -0.38, p < 0.01). In contrast, unilateral shunting did not correlate with ipsilateral pulmonary vein oxygenation for any vein measured (p = 0.16-p > 0.99). In conclusion, the total burden of bilateral bubble shunting correlated with systemic oxygenation and may better reflect the total PAVM burden from all lung segments. Unilateral correlation may be adversely influenced by non-standardized approaches to pulmonary vein sampling.

Right Ventricular Free Wall Rupture Complicating Anterior STEMI.

Ventricular free wall rupture is a rare but devastating complication. We report right ventricular free wall rupture complicating anterior ST-segment elevation myocardial infarction caused by a wrap-around left anterior descending coronary artery. In acute cardiac tamponade, a rapid and systematic evaluation of the likely source of bleeding is paramount to prevent disastrous outcomes. (Level of Difficulty: Advanced.).

Party Balloon Inflation Maneuver During Saline Contrast Transthoracic Echocardiography to Detect Patent Foramen Ovale.

Saline contrast echocardiography requires an adequate provocation method for the detection of patent foramen ovale. The party balloon inflation maneuver during saline contrast transthoracic echocardiography is easy to explain to patients and objectively assesses the performance of provocative maneuvers by a clinician by watching balloon inflation. (Level of Difficulty: Intermediate.).

Percutaneous Closure of the Patent Foramen Ovale on Right Ventricular Mechanical Circulatory Support.

Right ventricular infarction can precipitate severe right-to-left shunting and refractory hypoxia from a previously dormant patent foramen ovale. Right ventricle mechanical circulatory support and patent foramen ovale closure can play a crucial role in the treatment of hypoxia and right ventricular recovery. We report a case of successful percutaneous patent foramen ovale closure on right ventricle mechanical circulatory support in a patient with right ventricular shock. (Level of Difficulty: Intermediate.).

Pulmonary Arteriovenous Malformation and Embolic Myocardial Infarction in a Patient With Hereditary Hemorrhagic Telangiectasia.

This report describes a case of embolic myocardial infarction secondary to a pulmonary arteriovenous malformation. Pulmonary arteriovenous malformations are rare and mostly congenital and are inherited as an autosomal dominant disorder known as hereditary hemorrhagic telangiectasia. Myocardial infarction is an uncommon complication in patients with untreated pulmonary arteriovenous malformations. (Level of Difficulty: Advanced.).

Evanescent Microbubbles After Cardiac Mechanical Support.

A 70-year-old man was successfully resuscitated, and an Impella CP was implanted. Transthoracic echocardiography showed acceptable Impella position with noticeable microbubbles in the left ventricle without device alarms. We highlight the appropriate approach in evaluating intracardiac microbubbles in critical care scenarios. (Level of Difficulty: Beginner.).

Platypnea-orthodeoxia syndrome: an unusual presentation of a complex disease.

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is an uncommon disorder characterized by dyspnea (=platypnea) and desaturation (=orthodeoxia) in upright position and improvement of symptoms and blood oxygenation in supine position. Clinical presentation is heterogeneous and often confuses the clinician. OBJECTIVES: The present case report illustrates a complicated presentation of the underlying syndrome. METHODS: Description of a POS case in a 73-year-old female with thorough workup and tailored treatment. RESULTS: In this case report, we describe a rather unusual presentation of POS, with posture-dependent hypoxemic-induced psychiatric symptoms. Further investigations revealed the presence of a patent foramen ovale with atrial septum aneurysm, an aortic root dilatation up to 41 mm and bilateral lower lobe lung emboli. The ventilation-perfusion mismatch aggravated the desaturation in upright position. Since the patient remained symptomatic after treatment of the functional trigger, we choose for the percutaneous closure of the anatomical defect. We used an Occlutech Figulla Flex II UNI 33/33 mm occluder resulting in a perfect closure of the defect. CONCLUSION: Abnormal shunting in upright position may be the result of different underlying conditions, requiring a thorough workup and a tailored treatment. In case of serious co-morbid conditions, an endovascular procedure to close a patent foramen ovale, after unsuccessful treatment of precipitating conditions, should be considered.

An Adult with Atrial Septal Defect Presenting with a Brain Abscess.

The common heart diseases resulting in a brain abscess are associated with a right to left shunt and include tetralogy of Fallot and transposition of great vessels. Atrial septal defect (ASD) is almost always associated with the left to right shunt and therefore is not a commonly considered risk factor for brain abscess. We report the case of a 29-year-old male, with no symptoms of cardiac disease, who presented with the left posterior frontal pyogenic abscess which led to the detection of a silent ASD. Our case emphasizes the need for a careful evaluation of the source of infection in patients with a brain abscess.