RESUMEN
BACKGROUND Transient atrial fibrillation (AF) following percutaneous patent foramen ovale (PFO) closure is common. Anticoagulation therapy should be considered in selected cases of prolonged AF after PFO closure, but guidelines do not provide clear recommendations on indication or choice of anticoagulant therapy for patients with post-procedural AF. CASE REPORT A 45-year-old woman presented with cryptogenic stroke verified by magnetic resonance imaging (MRI). Echocardiography revealed a PFO, which was closed percutaneously using a Gore septal occluder (25 mm). She was discharged on aspirin monotherapy (75 mg oral daily) according to institutional standard. Three weeks later, she presented with atrial fibrillation (AF). A direct oral anticoagulant (DOAC) (rivaroxaban 20 mg once daily) was initiated and aspirin was discontinued. After 4 months of follow-up, a routine echocardiography revealed large thrombi attached to both sides of the PFO occluder. CONCLUSIONS DOACs may be ineffective in preventing thrombus formation on device surfaces. Until more evidence has been provided, we suggest that DOACs are not routinely used for stroke prevention in patients following PFO closure or similar procedures within the first 3 months after device implantation.
Asunto(s)
Inhibidores del Factor Xa/uso terapéutico , Foramen Oval Permeable/cirugía , Rivaroxabán/uso terapéutico , Dispositivo Oclusor Septal , Trombosis/diagnóstico por imagen , Ecocardiografía , Femenino , Humanos , Persona de Mediana EdadRESUMEN
INTRODUCTION: The advent of electroanatomical mapping (EAM) systems for pulmonary vein isolation (PVI) has dramatically decreased radiation exposure. However, the need for some fluoroscopy remains for obtaining left atrial (LA) access. The aim was to test the feasibility of fluoroscopy-free PVI in patients with atrial fibrillation (AF) and a patent foramen ovale (PFO) guided solely by an EAM system. METHODS: Consecutive patients with AF undergoing PVI and documented PFO were studied. An EAM-guided approach without fluoroscopy and ultrasound was used. After completing the map of the right atrium, the superior vena cava and the coronary sinus, a catheter pull-down to the PFO was performed allowing LA access. The map of the LA and subsequent PVI was also performed without fluoroscopy. RESULTS: 30 patients [age 61±12 years, 73% male, ejection fraction 0.64 (0.53-0.65), LA size in parasternal long axis 38±7 mm] undergoing PVI were included. The time required for right atrial mapping including transseptal crossing was 9±4 minutes. Total procedure time was 127±37 minutes. Fluoroscopy-free PVI was feasible in 26/30 (87%) patients. In four patients, fluoroscopy was needed to access (n = 3) or to re-access (n = 1) the LA. In these four patients, total fluoroscopy time was 5±3 min and the DAP was 14.9±13.4 Gy*cm2. Single-procedure success rate was 80% (24/30) after a median follow-up of 12 months. CONCLUSION: In patients with a documented PFO, completely fluoroscopy-free PVI is feasible in the vast majority of cases.
Asunto(s)
Fibrilación Atrial/patología , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Foramen Oval Permeable/patología , Foramen Oval Permeable/cirugía , Venas Pulmonares/cirugía , Anciano , Ecocardiografía , Femenino , Fluoroscopía , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Venas Pulmonares/patología , Resultado del TratamientoRESUMEN
A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Arterias Cerebrales , Vasos Coronarios , Embolia Aérea , Foramen Oval Permeable , Oxigenoterapia Hiperbárica , Marcapaso Artificial/efectos adversos , Complicaciones Posoperatorias , Angiografía Cerebral , Arterias Cerebrales/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Ecocardiografía Transesofágica , Embolia Aérea/diagnóstico por imagen , Embolia Aérea/etiología , Embolia Aérea/terapia , Foramen Oval Permeable/diagnóstico por imagen , Foramen Oval Permeable/cirugía , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/terapiaAsunto(s)
Isquemia Encefálica/diagnóstico , Embolia Paradójica/diagnóstico , Foramen Oval Permeable/diagnóstico por imagen , Cardiopatías/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Tálamo/irrigación sanguínea , Trombosis/diagnóstico por imagen , Adulto , Angiografía , Anticoagulantes/uso terapéutico , Isquemia Encefálica/etiología , Ecocardiografía Transesofágica , Embolia Paradójica/etiología , Embolia Paradójica/terapia , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/cirugía , Cardiopatías/complicaciones , Heparina/uso terapéutico , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Imagen por Resonancia Magnética , Masculino , Embolia Pulmonar/etiología , Embolia Pulmonar/terapia , Tálamo/patología , Trombectomía/métodos , Trombosis/complicaciones , Trombosis/terapia , Tomografía Computarizada por Rayos X , Disfunción Ventricular Derecha/diagnóstico por imagenRESUMEN
We describe a case of hypotension on cardiopulmonary bypass for coronary artery bypass grafting, double valve repairs, and patent foramen ovale closure. The patient experienced vasoplegic syndrome while on cardiopulmonary bypass. He was treated with high-dose hydroxocobalamin (vitamin B12). His blood pressure responded rapidly, obviating any further vasopressor requirements.
Asunto(s)
Puente Cardiopulmonar/efectos adversos , Hidroxocobalamina/uso terapéutico , Vasoplejía/tratamiento farmacológico , Puente Cardiopulmonar/métodos , Terapia Combinada , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Foramen Oval Permeable/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Quimioterapia por Pulso , Resultado del Tratamiento , Vasoplejía/etiologíaRESUMEN
Strokes remain an uncommon but significant complication of cardiac surgery. Cerebral air embolism is the likely aetiology in the majority of cases. Hyperbaric oxygen therapy is the recognised treatment for cerebral air embolism associated with compressed air (SCUBA) diving accidents and is therefore also the standard of care for iatrogenic causes of air embolism. It follows that there is a logic in treating post-cardiac surgical stroke patients with hyperbaric oxygen. The aim of this retrospective review was to examine the outcomes of 12 such patients treated in the Christchurch Hospital hyperbaric unit and to appraise the evidence base for the use of hyperbaric oxygen therapy in this setting. Despite delays of up to 48 hours following surgery before the institution of hyperbaric oxygen therapy, 10 of the 12 patients made a full neurological recovery or were left with mild residual symptoms, with nine returning to their previous level of care. One patient remained hemiplegic and there was one early neurological death. There is a paucity of prospective data in this area, but based on sound pathophysiological principles and clinical experience, we believe that patients suffering a stroke following open cardiac surgery should be considered for hyperbaric oxygen therapy.