Resource utilisation in paediatric patients with secundum atrial septal defects.

BACKGROUND: There is variation in care of secundum atrial septal defects. Defects <3 mm and patent foramen ovale are not clinically significant. Defects >3 mm are often followed clinically and may require closure. Variation in how these lesions are monitored may result in over-utilisation of routine studies and higher than necessary patient charges. PURPOSE: To determine utilisation patterns for patients with secundum atrial septal defects diagnosed within the first year of life and compare to locally developed optimal utilisation standard to assess charge savings. METHODS: This was a retrospective chart review of patients with secundum atrial septal defects diagnosed within the first year of life. Patients with co-existing cardiac lesions were excluded. Total number of clinic visits, electrocardiograms, and echocardiograms were recorded. Total charge was calculated based on our standard institutional charges. Patients were stratified based on lesion and provider type and then compared to "optimal utilisation" using analysis of variance statistical analysis. RESULTS: Ninety-seven patients were included, 40 had patent foramen ovale (or atrial septal defect <3 mm), 43 had atrial septal defects not requiring intervention and 14 had atrial septal defects requiring intervention. There was a statistically significant difference in mean charge above optimal for these lesions of $1033, $2885, and $5722 (p < 0.02), respectively. There was statistically significant variation of charge among types of provider as well. Average charge savings per patient would be $2530 with total charge savings of $242,472 if the optimal utilisation pathway was followed. CONCLUSION: Using optimal utilisation and decreasing variation could save the patient significant unnecessary charges.

Imaging Assessment of the Interatrial Septum for Transcatheter Atrial Septal Defect and Patent Foramen Ovale Closure.

Transcatheter closure of atrial septal defects and patent foramen ovale has become increasingly common with advances in device and imaging technology. The percutaneous approach is now the preferred method of closure when anatomically suitable. Two-dimensional and 3-dimensional echocardiography determines anatomic suitability by characterizing the interatrial defect and its surrounding structures, and is critical for intraprocedural guidance and postprocedure follow-up. This article provides an overview of interatrial anatomy as it pertains to interventional considerations and discusses the transthoracic, transesophageal, and intracardiac echocardiographic modalities used for periprocedural and intraprocedural imaging of the interatrial septum.

Multidisciplinary assessment of PFO with substantial right-to-left shunting and medium-term follow-up after PFO device closure: A single-center experience.

OBJECTIVES: To describe the multidisciplinary assessment of patent foramen ovale (PFO) with substantial right-to-left shunting (RLS) and medium-term follow-up after PFO closure for stroke or transient ischemic attack (TIA). BACKGROUND: PFO closure is a therapeutic option to prevent recurrent ischemic event in patients with cryptogenic stroke and TIA. The apparent lack of benefit seen in previous studies was in part due to the inclusion of patients with alternate mechanisms of stroke/TIA. However, the long-term follow-up results of RESPECT trial confirmed that PFO closure could reduce the recurrence rate of stroke compared to medical therapy. The obvious difference between RESPECT and the other studies is that RESPECT recruited more relevant patients with substantial RLS. METHODS: From May 2013 to October 2015, all subjects diagnosed as cryptogenic stroke or TIA with substantial RLS who underwent PFO closure at our institution were included. All patients underwent multidisciplinary assessment to exclude stroke/TIA with definite etiology. Baseline characteristics, clinical manifestations, procedural, and follow-up data were reviewed. RESULTS: A total of 219 consecutive patients with substantial RLS undergoing PFO closure were identified. There were no procedure-related deaths, strokes, or TIA. Mean follow-up was 2.0 ± 0.7 years. Early residual shunting was visible in 9 patients (4.1%); however, during follow-up, only 3 patients (1.4%) had residual RLS detected by contrast transthoracic echocardiography (cTTE). The annual risk of recurrent ischemic stroke or TIA was 0.457%. CONCLUSIONS: PFO closure can be performed safely and effectively in patients with cryptogenic stroke or TIA. In selected patients with substantial RLS, following appropriate multidisciplinary assessment, excellent results with low incidence of recurrent events may be achieved.

[Diving accidents]. / Tauchunfälle.

Decompression injuries occur on account of the special hyperbaric effects during the emerge phase and require superior therapeutic knowledge. Vitally important is emergency treatment with high concentrated oxygen at an early stage. Sever decompression injuries require oxygenation in a hyperbaric treatment chamber.

Embolization of patent foramen ovale closure devices: incidence, role of imaging in identification, potential causes, and management.

Transcatheter patent foramen ovale (PFO) closure is an alternative to antiplatelet or anticoagulative therapy in patients with cryptogenic stroke, and it is associated with a small incidence of periprocedural sequelae. Because embolization of PFO closure devices is a very rare procedural complication, data on its frequency, causes, and management are sparse. We sought to review the medical literature and the cases of PFO closure-device embolization at our institution with the aim of identifying likely problems and reporting potential solutions. Out of 310 adult patients who underwent transcatheter PFO closure from June 2002 through April 2011, there were 2 cases (0.6%) of PFO closure-device embolization. In both patients, hypermobile septum primum and thick septum secundum were present. In one patient, failure to use a sizing balloon might have resulted in an underestimation of the PFO's size. In both patients, device embolization was identified in a timely fashion, the embolized device was safely retrieved, and the PFO was percutaneously closed with success. The incidence of PFO closure-device embolization is very low. The cases described here underscore the importance of imaging in the identification of morphologic predispositions to closure-device malpositioning, in the recognition of impending embolization, and in the timely management of embolization.

Economy class stroke syndrome after a long drive.

Economy class stroke syndrome is a cardiovascular complication associated with long periods of travel, only a few cases have been reported after long drives, however. The patient, a 62-year-old professional driver, had driven a truck for 2 days with minimal rest. While driving, he noted left foot paresis and numbness, along with geographical disorientation. Magnetic resonance imaging of the brain revealed multiple cerebral embolisms in the bilateral cerebral hemisphere. The only complications representing a stroke risk in this patient were a patent foramen ovale and an anterior septal aneurysm, as detected by transesophageal echocardiography. The patient was diagnosed with paradoxical cerebral embolism following his long drive. This case report examines the paradoxical cerebral emboli documented in a patient following a long period of driving.

Patent foramen ovale--assessment and treatment.

A patent foramen ovale (PFO) is detectable in 20-25% of the population. Some, but not all, case control studies have found an increased incidence of PFO in patients with cryptogenic stroke. Prospective cohort studies have failed to convincingly demonstrate a link between PFO and first stroke, and evidence linking PFO to recurrent stroke is far from compelling. The rate of recurrent stroke in medically treated patients is low, but the development of devices for PFO closure has lead to enthusiasm in some quarters to pursue a strategy of device closure. Nonrandomized studies have suggested a lower risk of recurrent events with device closure but the data are heterogeneous, and potentially prone to bias. Device implantation is associated with a risk of major adverse events of between 1.5% and 2.3%, and there is a significant rate of failure to close shunts. The results of randomized trials of device closure are keenly awaited. Migraine with aura has been linked with PFO. A recent metanalysis suggested an association, but the one prospective population study did not. The well-publicized and controversial MIST Trial is the only randomized trial of device closure in migraineurs yet published, and failed to demonstrate a convincing benefit from device closure. Other conditions such as platypnea-orthodeoxia syndrome and prevention of decompression sickness in divers, may justify device closure. Evidence for a role of PFO in the etiology of cryptogenic stroke and migraine is contradictory. It is possible that some patients might benefit from PFO closure but there is scant evidence of sufficient quality to justify routine PFO closure in either group. It is essential that ongoing randomized trials of device closure are completed.

Clinical differentiation of patent foramen ovale and secundum atrial septal defect: a survey of pediatric cardiologists in Dallas, Texas, USA.

BACKGROUND: Public health birth defect surveillance registries rely on health care provider diagnosis and definition of congenital anomalies. Major anomalies are likely to have consistent diagnoses across providers; however, definition of some more common, often minor, defects can be problematic. Of particular frustration are the transient neonatal heart findings: patent ductus arteriosus, patent foramen ovale, and pulmonary artery branch stenosis. Under certain circumstances these findings may be considered true anomalies-patent foramen ovale (PFO) as a clinical finding overlaps significantly with atrial septal defect (ASD) of secundum type, the latter being considered a true congenital malformation. Some criteria must be established to separate these conditions in case ascertainment. It is therefore helpful to understand the clinical definitions of patent foramen ovale and secundum atrial septal defect. METHODS: Pediatric cardiologists in the greater Dallas, Texas metropolitan area were surveyed by telephone, fax, and/or email and asked what criteria they use to distinguish a PFO from a secundum ASD. This was an open-ended question. No baseline parameters were suggested or introduced by the interviewer. Pediatric cardiology fellowship training was identified for each physician to examine the hypothesis that graduates of a given program would use the same diagnostic criteria. RESULTS: Responses were obtained from 22 of 23 pediatric cardiologists. Four measurement criteria were identified: size of the opening, presence or absence of a flap of septal tissue, appearance of the defect on echocardiogram and presence/absence/amount of blood shunting across through the opening. Though there was overlap, diagnostic criteria differentiating PFO and secundum ASD varied among pediatric cardiologists. Two fellowship programs were well represented by the respondent population. Eight respondents were trained at Fellowship 1 and 5 at Fellowship 2. Place of fellowship training was not a strong indicator of which diagnostic criteria were used, even when graduates were in practice together. Physicians in private practice were more likely to report objective measurements as bases for their diagnostic decision. CONCLUSIONS: The pronounced variability in clinical definitions will be a problem for birth defect surveillance and research based upon the resultant database. When different physicians use different diagnostic criteria for borderline defects, it is impossible to know whether a defect ascertained and coded with a standard protocol is the same across the population. Since it is unlikely that consistent diagnostic criteria can be put in place, the surveillance program is burdened with compensating for the variability.

Cardiovascular risk assessment of the liver transplant candidate.

Liver transplantation (LT) candidates today are increasingly older, have greater medical acuity, and have more cardiovascular comorbidities than ever before. Steadily rising model for end-stage liver disease (MELD) scores at the time of transplant, resulting from high organ demand, reflect the escalating risk profiles of LT candidates. In addition to advanced age and the presence of comorbidities, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Patients with cirrhosis requiring LT usually demonstrate increased cardiac output and a compromised ventricular response to stress, a condition termed cirrhotic cardiomyopathy. These cardiac disturbances are likely mediated by decreased beta-agonist transduction, increased circulating inflammatory mediators with cardiodepressant properties, and repolarization changes. Low systemic vascular resistance and bradycardia are also commonly seen in cirrhosis and can be aggravated by beta-blocker use. These physiologic changes all contribute to the potential for cardiovascular complications, particularly with the altered hemodynamic stresses that LT patients face in the immediate post-operative period. Post-transplant reperfusion may result in cardiac death due to a multitude of causes, including arrhythmia, acute heart failure, and myocardial infarction. Recognizing the hemodynamic challenges encountered by LT patients in the perioperative period and how these responses can be exacerbated by underlying cardiac pathology is critical in developing recommendations for the pre-operative risk assessment and management of these patients. The following provides a review of the cardiovascular challenges in LT candidates, as well as evidence-based recommendations for their evaluation and management.

Migraine and patent foramen ovale: state of the science.

Migraine is a prominent cause of recurrent pain, affecting 12% of the population. In several case series, approximately 50% of migraineurs with aura were found to have patent foramen ovale (PFO). The pathophysiological mechanism is speculated to be passage of microemboli and vasoactive chemicals through the PFO, thereby evading pulmonary filtration and triggering migraine symptoms. This article presents the results of retrospective and prospective research studies documenting the effects of PFO closure on migraine symptoms and presents emerging theories on possible pathologic mechanisms that may partially explain the increased risk of ischemic stroke in the migraine population. Finally, evidence-based recommendations are presented for health care providers for managing patients who have migraine and PFO.