Hypoxia – ABC CARDIOL

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A Constellation of Stroke and Hypoxemia Post ICD Lead Extraction: Role of Patent Foramen Ovale

Ashish H. Shah et al. Petra Jenkins Heiko Schneider

A 78-year-old woman with known ischemic cardiomyopathy underwent elective implantable cardioverter defibrillator (ICD) lead extraction and a new lead implantation. Within 2 hours post-procedure, she experienced expressive dysphasia and right hemiplegia, which was confirmed to be due to an ischemic stroke on a brain CT scan. Additionally, the patient developed resting hypoxemia with oxygen saturation of 87-88% on room air that only partially improved with high-flow oxygen.

Further investigation revealed a right-to-left shunt through a patent foramen ovale (PFO) on a trans-thoracic echocardiogram (TTE). Previous TTE examinations over the past 5 years did not show any valvular pathology or right-to-left shunt through the PFO. The patient was on direct oral anticoagulant therapy for atrial fibrillation, which was electively stopped 2 days before the procedure, and low molecular weight heparin was initiated as a bridging therapy.

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Case Report

Patent Foramen Ovale: An Unusual Cause of Refractory Hypoxemia

Inês Miranda et al. Christopher Strong Pedro Póvoa

Case Report

We report the case of a 70-year-old woman with a history of cryptogenic ischemic stroke for which she underwent intravenous fibrinolysis with no neurological sequelae. She had no known history of pulmonary or heart disease.

Approximately 1.5 years later, she presented to the Emergency Department (ED) with a one-week history of cough, fatigue, and shortness of breath. She denied fever, chest pain, orthopnea, or paroxysmal nocturnal dyspnea.

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Research Letter

An Unusual Cause of Hypoxemia after Orthopedic Surgery on an Elderly Patient

Pedro Carvalho et al. Daniela Meireles José Luís Martins Marco Costa Ana Briosa Neves

Introduction

Various conditions can cause post-operative hypoxemia, especially in elderly patients. However, a new symptomatic cardiac shunt is a very rare and unexpected complication in this setting. This study presents a case of refractory hypoxemia after orthopedic surgery due to right-to-left (R-L) shunt via a patent foramen ovale (PFO).

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Editorial

Plexiform Lesions in Pulmonary Arterial Hypertension: Are we Getting Closer to Manage with More Patience and Rigor?

Hugo Hyung Bok Yoo

Pulmonary arterial hypertension (PAH) is a progressive and a life-threatening condition characterized by high pulmonary blood pressure, remodeling of small pulmonary blood vessels and increased vascular resistance leading to right heart failure. According to the 6th World Symposium on Pulmonary Hypertension, PAH is defined by concomitant elevation of three parameters: mean pulmonary arterial pressure (mPAP) > 20 mmHg; pulmonary arterial wedge pressure (PAWP) ≤15 mm Hg; pulmonary vascular resistance (PVR) ≥ 3 Wood Units.

The right heart failure is due to a persistent remodeling that gradually obstructs and obliterates the peripheral pulmonary arteries that causes vasoconstriction and increases right ventricle afterload. Many efforts have been made to treat PAH. However, there are still few successful and promising pharmacological treatments for this devasting disease, as a consequence, PAH-related survival remains disappointing. Thus, several researches on pulmonary hypertension pathophysiology have focused on a better comprehension of the angioproliferation process and plexiform lesions. The role of increased blood flow in the pulmonary vascular bed is considered one of the main triggering factors to the development of pulmonary vascular remodeling.^–

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Research Letter

Pericardial Affections in Patients with COVID-19: A Possible Cause of Hemodynamic Deterioration

Fábio Fernandes et al. Felix José Alvarez Ramires Fábio Danziato Fernandes Marcus Vinicius Simões … Evandro Tinoco Mesquita Charles Mady

Introduction

The clinical course of the SARS-CoV-2 infection is characterized by respiratory symptoms, fever, cough, sore throat, fatigue, and complications related to the acute respiratory distress syndrome. However, some patients with initially mild symptoms can present clinical deterioration approximately one week after onset of the symptoms.

The acute progression of COVID-19 can be divided into 3 different phases: early infection, pulmonary phase, and hyperinflammation, and significant overlaps between these phases can occur.

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Clinicoradiological Correlation

Case 3/2020 – Pulmonary Atresia, Interventricular Communication and Anomalous Origin of the Right Pulmonary Artery from the Ascending Aorta developing after Prior Left Central Shunt, in a Symptomatic 40-year-old Adult.

Edmar Atik et al. Maria Angélica Binotto Alessandra Costa Barreto

Complementary examinations

Electrocardiogram: Sinus rhythm, signs of right cavity overload, with apiculate P wave + 70º, QRS complex showing predominance of S waves from V4 to V6 and axis deviated to the right (AQRS= +110°). The T wave was negative in the precordial leads with diffuse ventricular repolarization changes in all other leads ( ).

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Original Article

Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis

Aparecida de Gouvea et al. Claudio Henrique Fischer Jaquelina Sonoe Ota Arakaki Frederico José Mancuso … Paulo Brant Valdir Ambrósio Moisés Orlando Campos Filho

Abstract

Background:

Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis.

Objective:

To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS.

Methods:

cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student’s t-test and the chi-square test (p < 0.05).

Results:

cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09).

Conclusion:

In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.

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Clinicoradiological Session

Case 4/2017 – Double-Chambered Right Ventricle with Dextrocardia and Hypoxemia Due to Atrial Shunt in a 4-Year-Old Girl

Edmar Atik et al. José Fernando Cavalini

Clinical data

A premature female twin (33-week gestation), weighing at birth 1935 g, remained hospitalized for one month due to the diagnosis of atrial septal defect (ASD) + ventricular septal defect (VSD) + persistence of ductus arteriosus (PDA). The patient gained less weight than the average children, but maintained full and similar activity, receiving furosemide and captopril, up to the age of 3 years, when her mother noticed cyanosis.

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