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1.
Medicine (Baltimore) ; 98(45): e17940, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702683

RESUMO

Venous air embolism (VAE) can be observed in the right heart system on contrast-enhanced computed tomography (CT), following injection of contrast media with a power injector system. Although most VAEs are mostly asymptomatic, they may result in paradoxical air embolism (PAE).To evaluate whether the incidence of VAE on coronary CT angiography is associated with the process of preparation of the intravenous access route.We retrospectively evaluated 692 coronary CT examinations at 3 institutions. Trained CT nurses placed an intravenous cannula in the forearm. Tubes connected to the cannula were prepared in the following ways: A, using an interposed three-way cock and a 20-mL syringe filled with normal saline to collect air contamination in the tube; B, through direct connection to the power injector system without the interposed 3-way cock; and C, using an interposed three-way cock and a 100-mL normal saline drip infusion bottle system to keep the tube patent. The incidence and location of VAE and preparation of intravenous injection were assessed.The overall incidence of VAE was 55.3% (383/692), most frequently observed in the right atrium (81.5%, 312/383). Its incidence varied significantly across the 3 techniques (A: 21.6% (35/162), B: 63.2% (237/375) and C: 71.6% (111/155); P < .001). No patient demonstrated any symptom associated with VAE.Using a 3-way cock with syringe demonstrated the lowest incidence of VAE on coronary CT angiography. It is thus recommended to reduce potential complication risks related to intravenous contrast media injection.


Assuntos
Angiografia por Tomografia Computadorizada/efeitos adversos , Embolia Aérea/etiologia , Embolia Paradoxal/etiologia , Átrios do Coração/diagnóstico por imagem , Idoso , Meios de Contraste/administração & dosagem , Embolia Aérea/complicações , Embolia Aérea/epidemiologia , Embolia Paradoxal/epidemiologia , Humanos , Injeções Intravenosas/efeitos adversos , Injeções Intravenosas/instrumentação , Injeções Intravenosas/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
2.
Cardiology ; 143(1): 62-72, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31307049

RESUMO

Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.


Assuntos
Forame Oval Patente/complicações , Forame Oval Patente/terapia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Anticoagulantes/uso terapêutico , Tomada de Decisão Clínica , Ensaios Clínicos como Assunto , Eletrocardiografia , Embolia Paradoxal/complicações , Embolia Paradoxal/etiologia , Humanos , Medição de Risco , Prevenção Secundária , Dispositivo para Oclusão Septal , Telemetria
3.
Int J Cardiovasc Imaging ; 35(11): 2049-2056, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31325066

RESUMO

Left atrial (LA) enlargement is a marker of LA cardiopathy and, in patients with patent foramen ovale (PFO), is associated with an increased risk of ischemic stroke. The primary study outcome was the comparison of LA diameter between patients undergoing percutaneous PFO closure versus those treated conservatively. The secondary endpoints were the association of LA diameter with the Risk of Paradoxical Emboli (ROPE) score and the presence of Atrial septal aneurysm (ASA) and Right-To-Left Shunt (RLS). Retrospective analysis of clinical and instrumental data of 1040 subjects referred to a single tertiary center for PFO evaluation and treatment. Seven hundred and nineteen patients were enrolled: 495 patients (closure group, mean RoPE score 7.6 ± 0.8) underwent PFO closure while 224 patients (control group, mean RoPE score 4.1 ± 0.9. p < 0.001) were left to medical therapy. Preoperative LA diameter was significantly larger in closure group and reduced from 44.3 ± 9.1 to 37.3 ± 4.1 mm (p = 0.01) 1 year after the procedure to the size of controls. A larger LA diameter was associated with permanent RLS, RLS curtain pattern, ASA presence and multiple ischemic brain lesions pattern at neuroimaging. A LA diameter ≥ 43 mm was a predictor a RoPEscore > 7. In our patients' cohort, LA diameter was associated with the clinic severity of PFO and RLS. The reversal of LA enlargement after PFO closure suggests a role for RLS to induce LA cardiopathy. LA enlargement has the potential to be considered per se as an indication to transcatheter PFO repair.


Assuntos
Função do Átrio Esquerdo , Remodelamento Atrial , Cateterismo Cardíaco , Tratamento Conservador , Forame Oval Patente/terapia , Adulto , Cateterismo Cardíaco/efeitos adversos , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/etiologia , Tratamento Conservador/efeitos adversos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
4.
Medicine (Baltimore) ; 98(30): e16522, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31348266

RESUMO

INTRODUCTION: Paradoxical embolism (PDE) refers to direct passage of venous thrombi into the arterial circulation through an arteriovenous shunt. It is well-known that the pulmonary thromboembolism (PTE) can cause opening of the foramen ovale leading to paradoxical arterial embolism. Long term follow up of PDE patient over 10 years was not reported in the literature. PATIENT CONCERNS: A 57-year-old woman presented with initial symptoms of numbness/weakness and hypoxemia. Ultrasonography and pulmonary arteriography indicated pulmonary thromboembolism. DIAGNOSIS: Pulmonary embolism and paradoxical multiple arterial embolism or acute PTE concomitant with paradoxical multiple arterial embolism. INTERVENTIONS: Craniectomy and anticoagulation treatment was administered and the patient received low-dose warfarin therapy for 10 years. OUTCOMES: The patient is currently stable with no abnormalities seen in the deep veins of the bilateral lower limbs. The international normalized ratio (INR) was controlled within the range of 1.20 to 1.51. As this is a 10-year follow-up case report, the patient has responded well to the treatment and has been followed-up. The follow-up has been annual and the patient has been stable CONCLUSION:: Low intensity and persistent anticoagulation therapy can inhibit blood thrombophilia and reduce the risk of bleeding. It is noteworthy that such an approach used effectively in this patient. To best our knowledge, it is first report for long term follow up PDE patient successfully over 10 years.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval/irrigação sanguínea , Extremidade Inferior/irrigação sanguínea , Embolia Pulmonar/etiologia , Trombose Venosa/complicações , Anticoagulantes/uso terapêutico , Craniotomia/métodos , Embolia Paradoxal/terapia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/terapia , Resultado do Tratamento , Trombose Venosa/terapia
5.
J Stroke Cerebrovasc Dis ; 28(9): e135-e138, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31253482

RESUMO

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by chronic thrombi in the pulmonary arteries, causing pulmonary hypertension and right heart failure. Early and accurate diagnosis are essential for successful treatment but are often difficult because clinical signs and symptoms can be nonspecific and risk factors, such as history of venous thromboembolism, may not always be present. Here, we report a case involving a 76-year-old woman who demonstrated paradoxical cerebral embolism as the initial manifestation of CTEPH. She developed right hemiplegia without dyspnea or edema. Brain magnetic resonance imaging revealed multiple fresh infarctions, while transesophageal echocardiography revealed a patent foramen ovale. Based on these findings, she was diagnosed as having paradoxical cerebral embolism. During the search for the embolic source, right heart catheterization showed significant pulmonary hypertension and pulmonary angiography revealed chronic thrombi in the peripheral pulmonary arteries, consistent with a diagnosis of CTEPH. To our knowledge, this is the first case of CTEPH to be diagnosed with the onset of paradoxical cerebral embolism. Because CTEPH is the only potentially curable form of pulmonary hypertension, clinicians should consider paradoxical cerebral embolism as a possible initial manifestation of CTEPH.


Assuntos
Arteriopatias Oclusivas/complicações , Embolia Paradoxal/etiologia , Hipertensão Pulmonar/etiologia , Embolia Intracraniana/etiologia , Trombose/complicações , Idoso , Arteriopatias Oclusivas/diagnóstico por imagem , Doença Crônica , Angiografia por Tomografia Computadorizada , Imagem de Difusão por Ressonância Magnética , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico por imagem , Feminino , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Trombose/diagnóstico por imagem
6.
J Stroke Cerebrovasc Dis ; 28(7): e100-e101, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31006519

RESUMO

Pulmonary arteriovenous fistula (PAVF), a vessel malformation connecting the pulmonary circulation to the systemic circulation while bypassing the pulmonary capillaries, can cause paradoxical cerebral infarction. It is often associated with hereditary hemorrhagic telangiectasia (HHT), a genetic disease characterized by multiple dermal, mucosal, and visceral telangiectasia causing recurrent bleeding. Paradoxical cerebral embolism caused by PAVF without HHT is rare. Here, we report a patient with isolated PAVF who experienced an ischemic stroke caused by a paradoxical embolism from deep venous thrombosis; the patient was successfully treated with recombinant tissue plasminogen activator. She presented with a decrease in arterial oxygen saturation to 91%, and lung disease was suspected. A PAVF was subsequently found in the right S6 region using contrast computed tomography. Interventional radiologists successfully occluded the shunt using 6 microcoils. PAVF should be considered when determining the pathogenesis of cerebral ischemia in patients with hypoxia, which can be the only symptom of PAVF.


Assuntos
Fístula Arteriovenosa/complicações , Embolia Paradoxal/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Embolia Intracraniana/tratamento farmacológico , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Trombose Venosa/complicações , Idoso de 80 Anos ou mais , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/terapia , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Imagem de Difusão por Ressonância Magnética , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Embolização Terapêutica/instrumentação , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/diagnóstico por imagem , Angiografia por Ressonância Magnética , Artéria Pulmonar/diagnóstico por imagem , Veias Pulmonares/diagnóstico por imagem , Piridinas/uso terapêutico , Proteínas Recombinantes/administração & dosagem , Tiazóis/uso terapêutico , Resultado do Tratamento , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/tratamento farmacológico
7.
J Stroke Cerebrovasc Dis ; 28(6): 1636-1639, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30890394

RESUMO

BACKGROUND AND PURPOSE: The routine use of percutaneous transcatheter patent foramen ovale closure (PPFOC) to prevent recurrent stroke in patients with cryptogenic stroke is still a matter of debate after completion major randomized controlled trials (RCTs). METHODS: The fragility index of RCTs evaluating effect of PPFOC against medial therapy alone in stroke prevention was calculated to assess the robustness of statistically significant findings. RESULTS: Literature search with PubMed identifies 6 RCTs on PPFOC. Median number of patients who underwent PPFOC and medical treatment were 340 and 229, respectively. Median number of the patients lost to follow-up was 20 in PPFOC and 18 in medical group. Fragility index was 0 for 4 studies. Median fragility index was also 0 for both "stroke" (interquartile range: 0-5.3) and "combined stroke and TIA" (interquartile range: 0-2) endpoints. In all studies except CLOSE, fragility index was smaller than or equal to the number of the subjects lost to follow-up. CONCLUSIONS: Recent positive results of PFO closure studies should be interpreted cautiously because of their fragile characteristics. Routine PFO closure should be reserved for prevention of recurrence when suspicion for paradoxical embolism is high. Detailed individualized decision-making is crucial before ordering PPFOC for stroke prevention in patients with cryptogenic embolism.


Assuntos
Embolia Paradoxal/prevenção & controle , Forame Oval Patente/terapia , Fragilidade/diagnóstico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Projetos de Pesquisa , Acidente Vascular Cerebral/prevenção & controle , Tomada de Decisão Clínica , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Fragilidade/complicações , Nível de Saúde , Humanos , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
8.
Ann Thorac Surg ; 108(2): e73-e75, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30763556

RESUMO

Impending paradoxical embolism (IPDE) is the presence of a thrombus in the patent foramen ovale. Usually, IPDE is diagnosed by echocardiography or a multislice computed tomography scan and is performed during the evaluation of a patient presenting with suspected pulmonary embolism. We report 2 patients who presented with IPDE and were successfully treated with cardiac surgery and thrombolytic therapy. Thus, we focus our discussion on the diagnosis and treatment modalities of this rare entity.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Embolia Paradoxal/cirurgia , Forame Oval Patente/complicações , Embolia Pulmonar/cirurgia , Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/métodos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia
11.
Eur Rev Med Pharmacol Sci ; 22(24): 8885-8890, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30575931

RESUMO

OBJECTIVE: Paradoxical embolism represents a rare condition occurring when a thrombus originating from venous system produces pulmonary embolism and systemic embolization through an intracardiac or pulmonary shunt. The evidence of a thrombus entrapped in a patent foramen ovale (PFO) is an even more rare condition. There is uncertainty about the optimal treatment strategy. PATIENTS AND METHODS: A 58-year-old male patient was admitted to our Internal Medicine Unit with the diagnosis of bilateral bronchopneumonia. During hospitalization, the co-occurrence of chest pain and amaurosis led us to hypothesize a paradoxical embolism. RESULTS: Transthoracic echocardiography showed the presence of a thrombus stuck over the interatrial septum. A contrast-enhanced chest CT scan showed multiple pulmonary embolisms and brain CT scan documented a hypodense area, of ischemic significance, in the left occipital lobe near tentorium. In order to prevent further embolization, emergency cardiac surgery (right atriotomy, removal of thrombus and closure of the PFO, pulmonary thrombectomy) was performed without complications. CONCLUSIONS: Although rare, the evidence of a thrombus stuck in a patent foramen ovale represents a clinical emergency. The optimal therapeutic approach is still debated. The surgical correction seems to be a safe and effective option for these patients.


Assuntos
Embolia Paradoxal/cirurgia , Forame Oval Patente/complicações , Trombose/cirurgia , Ecocardiografia , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Trombose/diagnóstico por imagem , Trombose/etiologia , Tomografia Computadorizada por Raios X
13.
Ann Vasc Surg ; 53: 274.e7-274.e10, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30081165

RESUMO

Although patent foramen ovale (PFO) is a relatively common condition, the risk of paradoxical embolism is less than 2% of all arterial ischemia. We present the case of a 52-year-old man diagnosed with pulmonary thromboembolism complicated with 2 events of paradoxical emboli in the left upper and right lower limbs secondary to PFO. We also discuss some uncertainties behind the management of PFO patients after an episode of venous thromboembolism.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Extremidade Inferior/irrigação sanguínea , Embolia Pulmonar/etiologia , Extremidade Superior/irrigação sanguínea , Trombose Venosa/etiologia , Doença Aguda , Anticoagulantes/uso terapêutico , Cateterismo Cardíaco/instrumentação , Angiografia por Tomografia Computadorizada , Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/tratamento farmacológico , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/tratamento farmacológico
14.
Methodist Debakey Cardiovasc J ; 14(2): 141-146, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29977471

RESUMO

Platypnea-orthodeoxia syndrome is a rare entity characterized by dyspnea and hypoxemia in the sitting position and usually resolved by lying down. Although it is not well understood, it is thought to be associated with either intracardiac or extracardiac factors. Within the group of intracardiac etiologies, it typically occurs in the presence of right heart failure or elevated right-sided filling pressures. When right heart failure is absent, platypnea-orthodeoxia is thought to be due to either anatomic changes that produce a baffle-directing flow across an atrial defect or to posture-dependent right-to-left pressure gradients. We report this case of a patient with no prior diagnosis of heart failure who presented to our hospital with 6 months of New York Heart Association class IV dyspnea and recent paradoxical embolus across a patent foramen ovale (PFO). Platypnea-orthodeoxia syndrome was diagnosed clinically. Transesophageal echocardiography revealed bidirectional shunting across the PFO. In the catheterization laboratory, invasive hemodynamics showed normal right and left atrial pressures and normal pulmonary arterial pressures. An Amplatzer Cribiform occluder device (AGA Medical Corp.) was used to close the PFO, completely curing the patient's symptoms. This is a novel case of subacute-onset severe platypnea-orthodeoxia associated with paradoxical embolus occurring while seated in the upright position. The cause of the patient's symptoms may have been progressive kyphosis or to increased pulmonary tidal volumes. Evaluation for platypnea-orthodeoxia is important in cases of occult dyspnea because the condition may be cured by closing the anatomic defect, as it was in this case.


Assuntos
Dispneia/etiologia , Embolia Paradoxal/etiologia , Forame Oval Patente/terapia , Hemodinâmica , Hipóxia/etiologia , Postura , Idoso , Cateterismo Cardíaco/instrumentação , Dispneia/diagnóstico , Dispneia/fisiopatologia , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico , Embolia Paradoxal/fisiopatologia , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Humanos , Hipóxia/diagnóstico , Hipóxia/fisiopatologia , Masculino , Dispositivo para Oclusão Septal , Índice de Gravidade de Doença , Síndrome , Resultado do Tratamento
15.
Int J Cardiovasc Imaging ; 34(12): 1849-1861, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29956022

RESUMO

Patent foramen ovale (PFO) is a residual, oblique, slit or tunnel like communication in the atrial septum that persists into adulthood. It is usually an incidental finding with no clinical repercussions. Nevertheless, recent evidence supports the association between the presence of a PFO and a number of clinical conditions, most notably cryptogenic stroke (CS). There is enough evidence that paradoxical embolism is a mechanism which can explain this association. Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO provide great assistance in estimating the probability of paradoxical embolism. In this review, we initially describe PFO embryology and anatomy. We extensively present the available data on clinical, anatomical and hemodynamic features of PFOs which have been correlated with increased likelihood of paradoxical embolism and recent evidence of therapeutic management.


Assuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Embolia Paradoxal/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Forame Oval/diagnóstico por imagem , Embolia Paradoxal/etiologia , Embolia Paradoxal/fisiopatologia , Embolia Paradoxal/prevenção & controle , Forame Oval/embriologia , Forame Oval/fisiopatologia , Forame Oval Patente/complicações , Forame Oval Patente/fisiopatologia , Forame Oval Patente/terapia , Hemodinâmica , Humanos , Achados Incidentais , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia
17.
Asian Cardiovasc Thorac Ann ; 26(5): 413-415, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29734837

RESUMO

Paradoxical embolism through a patent foramen ovale is a very unusual event considering that this cardiac anomaly may be present in as much as 26% of the general population. We describe the case of a 68-year-old man with a pulmonary and paradoxical coronary embolism in the presence of a patent foramen ovale. The finding of a worm-shaped thrombus though the atrial septum together with the risk of further embolization through the atrial septum prompted surgical treatment.


Assuntos
Oclusão Coronária/etiologia , Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Embolia Pulmonar/etiologia , Trombose/complicações , Idoso , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/cirurgia , Ecocardiografia , Embolectomia , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/cirurgia , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Humanos , Masculino , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/cirurgia , Trombectomia , Trombose/diagnóstico por imagem , Trombose/cirurgia , Resultado do Tratamento
18.
Am J Emerg Med ; 36(8): 1527.e1-1527.e2, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29792264

RESUMO

Patent foramen ovale is frequently observed in the general population. In case of massive pulmonary embolism, the sudden increase in the right heart cavity's pressure may cause a right-to-left shunting across this foramen, which could be associated with conflicting outcomes. Herein, we report a case of reversible cardiac arrest preceded by seizures, and followed by hemodynamic stability without any vasopressor. A brain CT-scan showed a limited ischemic stroke. Initial echocardiographic assessment revealed an acute cor pulmonale and a right-to-left intracardiac shunt across a large patent foramen ovale, suggesting the diagnosis of massive pulmonary embolism that was lately confirmed by a multidetector CT-angiography. Anticoagulation therapy was rapidly complicated by a hemorrhagic transformation of the ischemic stroke leading to a fatal outcome. This case illustrates the double-edged circulatory effect of shunting across a patent foramen ovale in case of massive pulmonary embolism: it may have limited circulatory failure but caused in the meanwhile a fatal paradoxical brain embolism.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Embolia Intracraniana/etiologia , Embolia Pulmonar/etiologia , Acidente Vascular Cerebral/etiologia , Adulto , Anticoagulantes/uso terapêutico , Ecocardiografia , Evolução Fatal , Humanos , Masculino , Tomografia Computadorizada Multidetectores
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