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2.
Am J Case Rep ; 22: e933975, 2021 Oct 26.
Article in English | MEDLINE | ID: covidwho-1485493

ABSTRACT

BACKGROUND Platypnea orthodeoxia syndrome (POS) presents with positional dyspnea and hypoxemia defined as arterial desaturation of at least 5% or a drop in PaO2 of at least 4 mmHg. Causes of POS include a variety of cardiopulmonary etiologies and has been reported in patients recovering from severe COVID-19 pneumonia. However, clinical presentation and outcomes in a patient with multiple interrelated mechanisms of shunting has not been documented. CASE REPORT An 85-year-old man hospitalized for hypertensive emergency and severe COVID-19 pneumonia was diagnosed with platypnea orthodeoxia on day 28 of illness. During his disease course, the patient required supplemental oxygen by high-flow nasal cannula but never required invasive mechanical ventilation. Chest imaging revealed evolving mixed consolidation and ground-glass opacities with a patchy and diffuse distribution, involving most of the left lung. Echocardiography was ordered to evaluate for intracardiac shunt, which revealed a patent foramen ovale. Closure of the patent foramen ovale was not pursued. Management included graded progression to standing and supplemental oxygen increases when upright. The patient was discharged to a skilled nursing facility and his positional oxygen requirement resolved on approximately day 78. CONCLUSIONS The present case highlights the multiple interrelated mechanisms of shunting in patients with COVID-related lung disease and a patent foramen ovale. Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known patent foramen ovale. In patients with persistent positional oxygen requirements at follow-up, quantifying shunt fraction over time through multiple modalities can guide treatment decisions.


Subject(s)
COVID-19 , Foramen Ovale, Patent , Aged, 80 and over , Dyspnea/etiology , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnostic imaging , Humans , Hypoxia/etiology , Male , SARS-CoV-2
3.
Curr Cardiol Rep ; 23(12): 174, 2021 10 16.
Article in English | MEDLINE | ID: covidwho-1469768

ABSTRACT

PURPOSE OF REVIEW: Cryptogenic stroke represents a heterogenous but clinically important collection of stroke etiologies for which our understanding continues to grow. Here, we review our current knowledge and most recent recommendations on secondary prevention for common causes of cryptogenic stroke including paroxysmal atrial fibrillation, atrial cardiopathy, patent foramen ovale, and substenotic atherosclerotic disease as well as the under-recognized mechanisms of occult malignancy, heart failure, and, most recently, infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). RECENT FINDINGS: The results from recent observational studies and randomized clinical trials have provided greater insight into the causal relationship and attributable risk of these suspected etiologies and have identified potential strategies to reduce the rates of recurrence. However, further clinical trials are needed to confirm the benefits of specific stroke prevention strategies, including the patient populations most likely to benefit from anticoagulation. There is ongoing research aimed at both reducing the proportion of ischemic strokes classified as cryptogenic and resolving much of the clinical equipoise that still exists. The results of these studies have the potential to provide us with a better understanding of these occult mechanisms and allow for more targeted interventions.


Subject(s)
COVID-19 , Foramen Ovale, Patent , Ischemic Stroke , Stroke , Foramen Ovale, Patent/complications , Humans , SARS-CoV-2 , Stroke/etiology , Stroke/prevention & control
5.
BMJ Case Rep ; 14(10)2021 Oct 01.
Article in English | MEDLINE | ID: covidwho-1447987

ABSTRACT

Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.


Subject(s)
COVID-19 , Foramen Ovale, Patent , Echocardiography , Echocardiography, Transesophageal , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnostic imaging , Foramen Ovale, Patent/surgery , Humans , Male , Middle Aged , SARS-CoV-2
7.
Clin Appl Thromb Hemost ; 27: 10760296211002274, 2021.
Article in English | MEDLINE | ID: covidwho-1191430

ABSTRACT

The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.


Subject(s)
COVID-19/complications , Ischemic Stroke/etiology , Ischemic Stroke/therapy , SARS-CoV-2 , Adult , Aneurysm, Dissecting/complications , Anticoagulants/adverse effects , Anticoagulants/therapeutic use , Antiphospholipid Syndrome/complications , Cervical Vertebrae/blood supply , Female , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/surgery , Humans , Intracranial Thrombosis/etiology , Intracranial Thrombosis/therapy , Ischemic Stroke/prevention & control , Male , Middle Aged , Pandemics , Prognosis , Risk Factors , Thrombophilia/complications
8.
BMC Pulm Med ; 21(1): 126, 2021 Apr 19.
Article in English | MEDLINE | ID: covidwho-1191325

ABSTRACT

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare condition characterized by dyspnoea (platypnea) and arterial desaturation in the upright position resolved in the supine position (orthodeoxia). Intracardiac shunt, pulmonary ventilation-perfusion mismatch and others intrapulmonary abnormalities are involved. CASE PRESENTATION: We report a case of POS associated with two pathophysiological issues: one, cardiac POS caused by a patent foramen ovale (PFO) and second, pulmonary POS due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interstitial pneumonia. POS has resolved after recovery of coronavirus disease 2019 (COVID-19) pneumonia. CONCLUSIONS: Right-to-left interatrial shunt and intrapulmonary shunt caused by SARS-CoV-2 pneumonia contributed to refractory hypoxemia and POS. Therefore, in case of COVID-19 patient with unexplained POS, the existence of PFO must be investigated.


Subject(s)
COVID-19 , Dyspnea , Foramen Ovale, Patent , Hypoxia , Lung/diagnostic imaging , Pneumonia, Viral , COVID-19/diagnosis , COVID-19/physiopathology , Dyspnea/diagnosis , Dyspnea/etiology , Dyspnea/physiopathology , Echocardiography/methods , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/physiopathology , Hemodynamics , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Hypoxia/physiopathology , Lung Diseases, Interstitial/complications , Lung Diseases, Interstitial/physiopathology , Lung Diseases, Interstitial/virology , Male , Middle Aged , Oxygen/analysis , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/physiopathology , Posture/physiology , SARS-CoV-2/isolation & purification , Syndrome , Treatment Outcome
10.
J Thromb Thrombolysis ; 52(3): 889-897, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1103504

ABSTRACT

Sickle cell disease (SCD) is an inherited monogenic hemoglobinopathy characterized by formation of sickle erythrocytes under conditions of deoxygenation. Sickle erythrocytes can lead to thrombus formation and vaso-occlusive episodes that may result in hemolytic anemia, pain crisis and multiple organ damage. Moreover, SCD is characterized by endothelial damage, increased inflammatory response, platelet activation and aggravation, and activation of both the intrinsic and the extrinsic coagulation pathways. Cerebrovascular events constitute an important clinical complication of SCD. Children with SCD have a 300-fold higher risk of acute stroke and by the age of 45 about 25% of patients have suffered an overt stoke. Management and prevention of stroke in patients with SCD is not well defined. Moreover, the presence of patent foramen ovale (PFO) increases the risk of the occurrence of an embolic cerebrovascular event. The role of PFO closure and antiplatelet or anticoagulation therapy has not been well investigated. Moreover, during COVID-19 pandemic and taking into account the increased rates of thrombotic events and the difficulties in blood transfusion, management of SCD patients is even more challenging and difficult, since data are scarce regarding stroke occurrence and management in this specific population in the COVID-19 era. This review focuses on pathophysiology of stroke in patients with SCD and possible treatment strategies in the presence of PFO.


Subject(s)
Anemia, Sickle Cell/complications , Foramen Ovale, Patent/complications , Stroke/etiology , Anemia, Sickle Cell/diagnosis , Anemia, Sickle Cell/physiopathology , Anemia, Sickle Cell/therapy , COVID-19/complications , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/physiopathology , Foramen Ovale, Patent/therapy , Humans , Primary Prevention , Prognosis , Recurrence , Risk Assessment , Risk Factors , Secondary Prevention , Stroke/diagnosis , Stroke/physiopathology , Stroke/prevention & control
11.
Neurol Sci ; 42(1): 21-23, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-893286

ABSTRACT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic-associated quarantine has led to a more sedentary lifestyle in teenagers. This may increase the risk for venous thromboembolism and a subsequent source of an ischemic stroke through a patent foramen ovale (PFO). Here, we report a pediatric stroke case likely due to these factors.


Subject(s)
COVID-19 , Foramen Ovale, Patent/complications , Ischemic Stroke/etiology , Physical Distancing , Sedentary Behavior , Adolescent , COVID-19/prevention & control , Humans , Ischemic Stroke/diagnosis , Male
12.
Thromb Res ; 196: 206-208, 2020 12.
Article in English | MEDLINE | ID: covidwho-738764

ABSTRACT

There is increasing evidence that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection causes an unusual pneumonia and a pro-coagulant state that significantly increases the risk of arterial and venous thromboembolism. We hypothesize that, in select patients, some complications of COVID-19 may be due to right-to-left (RTL) shunt. Shunt may be intra-pulmonary, or extra-pulmonary, and can cause paradoxical embolization, hypoxia and platypnoea orthodeoxia. Saline microbubble contrast echocardiography is a minimally invasive, inexpensive, bedside test that can detect, quantify, and define the anatomical substrate of intra-pulmonary and intra-cardiac shunts. The prevalence of patent foramen ovale (PFO) in the general population is high (20-30%) but is even higher in patients who have a stroke (50%). Thus, the striking absence of data on patients with PFO who develop COVID-19 suggests that this is being under-diagnosed. This may be because physicians and sonographers currently feel that screening for shunt is unnecessary. This could be an unintended consequence of guidance from several specialist societies to defer procedures to close PFO until after the pandemic. This may be counterproductive. Patients with shunt may be at particularly high risk of complications from COVID-19 and interventions to minimise RTL shunt could prevent paradoxical embolization and improve hypoxia in select high risk patients with COVID-19.


Subject(s)
COVID-19 , Foramen Ovale, Patent , Thrombosis , Foramen Ovale, Patent/complications , Humans , Pandemics , Patients , SARS-CoV-2
13.
Med Hypotheses ; 143: 110022, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-610332

ABSTRACT

The current SARS-Cov-2 virus pandemic challenges critical care physicians and other caregivers to find effective treatment for desperately ill patients - especially those with sudden and extreme hypoxemia. Unlike patients with other forms of Acute Respiratory Distress Syndrome, these patients do not exhibit increased lung stiffness or dramatic dyspnea., even in the presence of arterial blood oxygen levels lower than that seen normally in mixed venous blood. Urgent intubation and mechanical ventilation with high inflation pressures and raised inhaled oxygen concentration have proved unhelpful or worse, but why? Our Hypothesis is that sudden opening of a previously undetected probe-patent foramen ovale (PPFO) may explain this mystery. As hypoxemia without acidosis is a rather weak stimulus of dyspnea or increased ventilation, and opening of such an intracardiac shunt would not worsen lung mechanical properties, the absence of dramatic symptom changes would not be surprising. We point out the high frequency of PFO both in life and at autopsy, and the physiological evidence of large shunt fractions found in Covid-19 patients. Published evidence of hypercoagulability and abundant evidence of pulmonary emboli found at autopsy are in accord with our hypothesis, as they would contribute to raised pressure in the pulmonary arteries and right heart chambers, potentially causing a shunt to open. We review the interaction between viral corona spike protein and ACE-2 receptors present on the surface of alveolar lining cells, and contribution to hypercoagulabilty caused by the spike protein. Search for an open PFO after a large drop in arterial oxygen saturation can be performed at the bedside with a variety of well-established techniques including bedside echocardiography, nitrogen washout test, and imaging studies. Potential treatments might include balloon or patch closure of the shunt, and various drug treatments to lower pulmonary vascular resistance.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Foramen Ovale, Patent/complications , Hypoxia/etiology , Pneumonia, Viral/complications , Angiotensin-Converting Enzyme 2 , Betacoronavirus/pathogenicity , Betacoronavirus/physiology , COVID-19 , Coronavirus Infections/blood , Coronavirus Infections/physiopathology , Foramen Ovale, Patent/blood , Foramen Ovale, Patent/physiopathology , Humans , Hypoxia/blood , Hypoxia/physiopathology , Models, Biological , Pandemics , Peptidyl-Dipeptidase A/physiology , Pneumonia, Viral/blood , Pneumonia, Viral/physiopathology , Pulmonary Circulation , Receptors, Virus/physiology , Respiratory Mechanics , SARS-CoV-2 , Spike Glycoprotein, Coronavirus/physiology , Thrombophilia/etiology
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