The pivotal role of PFO in paradoxical embolism following venous sclerotherapy: a unique case report with pathological correlations.

BACKGROUND: Vein sclerosing therapy for varicose veins remains an extremely popular procedure. Cerebrovascular accidents can be a serious complication. A patent foramen ovale (PFO) can act as a conduit to the arterial circulation, which could explain the adverse neurologic consequence of this procedure. This case provides pathologic evidence of this concept. CASE SUMMARY: A 66-year-old female presented with syncope after undergoing varicose vein sclerotherapy. A computed tomography angiography of the head and neck in the emergency room revealed an occluded right distal M1 middle cerebral artery. Clot retrieval was performed with final pathology revealing amorphous material consistent with an exogenous agent, polidocanol foam, which was used for the patient's vein sclerotherapy. A transthoracic echocardiogram and transoesophageal echocardiogram showed a PFO, which was ultimately closed percutaneously. DISCUSSION: In a quarter of the population, lack of closure of the intrauterine interatrial shunt leads to the existence of a PFO. This direct communication between the atria provides an anatomical conduit for paradoxical emboli and eventually infarction of affected tissues. While a paradoxical embolism is an uncommon cause of acute arterial occlusion, it can have catastrophic sequelae. Historically, the presence of an arterial thrombus from the venous circulation has been difficult to establish unless the thrombus is visualized in transit through a PFO. Complications from vein sclerotherapy have been reported in the literature and include transient ischaemic attacks and strokes, however, this is the first case to provide pathological proof of a paradoxical embolism, which ultimately resulted in percutaneous closure of the PFO.

Balloon Aortic Valvuloplasty Followed by Impella®-Assisted Left Main Coronary Artery Percutaneous Coronary Intervention in Patients With Severe Aortic Stenosis as a Bridge to Transcatheter Aortic Valve Replacement.

BACKGROUND: The use of Impella® to provide hemodynamic support during unprotected left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has been shown to be feasible, but severe AS is a relative contraindication for its use. Balloon aortic valvuloplasty (BAV) may facilitate the use of Impella® in these patients. OBJECTIVE: To assess the feasibility of BAV followed by Impella®-assisted LMCA PCI in patients with severe AS as bridge to TAVR. METHODS: Patients with symptomatic severe AS with LMCA stenosis ≥70% requiring PCI prior to TAVR were included. Outcomes were retrospectively collected. RESULTS: Seven patients underwent BAV followed by Impella®-assisted LMCA PCI. Five patients were male; mean age 86 (75-91; SD ± 5.5). Mean STS score was 6.5% (4.3-13.8; SD ± 3.4). Impella® 2.5 L was used in all cases. The procedure was successful in all patients without peri-procedure complications. At 30-day post-BAV/PCI follow up, all patients had experienced improvement in NYHA class (N = 2 NYHA IV to III, N = 5 NYHA III to II). At such interval, mean EF was 54% (30-77; SD ± 17.7). The post BAV change in AVA [0.8 cm2 (0.4-1.5; SD ± 0.3; P = 0.07)], and AV mean gradient [30.8 mmHg (21-45; SD ± 8.9; P = 0.95)] after the procedure were not statistically significant. All patients underwent TAVR after a median PCI-to-TAVR interval of 62 days (33-339; SD ± 96.7). CONCLUSIONS: BAV followed by Impella®-assisted LMCA PCI appears to be a feasible strategy for intermediate and high surgical risk patients with severe AS undergoing LMCA PCI as bridge to TAVR.

Sex-Based Considerations in the Evaluation of Chest Pain and Management of Obstructive Coronary Artery Disease.

PURPOSE OF REVIEW: Coronary artery disease (CAD) is a major cause of morbidity and mortality globally and poses a threat to both men and women across their lifespans. There is accumulating evidence to support that CAD may present differently in women and men, ranging from the clinical presentation, diagnosis, and management of the disease to underlying differences in the biological and pathophysiological mechanisms. This has called for an expansion of our conventional tools used in the diagnosis and management of obstructive CAD. Understanding these key sex differences will potentially help tailor our diagnostic and treatment strategies and provide equitable and optimal care to both men and women. RECENT FINDINGS: Numerous studies have consistently shown that women with CAD tend to be older, have a higher burden of co-morbidities, and experience worse outcomes compared to their male counterparts. Women tend to wait longer to seek medical care for cardiovascular symptoms and when they do, they are usually referred late in the disease process and treated less aggressively. Women are significantly underrepresented in most cardiovascular clinical trials, thereby creating an important limitation in the evidence base used for treating cardiovascular disease in women. In this review, we sought to describe the sex-based considerations in evaluation and management of obstructive CAD, underscore the mechanisms behind these considerations, and help develop a more personalized approach according to current paradigms.

Correlation of Sugar-Sweetened Beverage Consumption and School Free and Reduced Lunch Eligibility as a Measure of Socioeconomic Status.

To determine whether a correlation exists between sugar-sweetened beverage consumption (SSB) and school free and reduced lunch (FRL) eligibility as a measure of socioeconomic status (SES). In January 2016, a modified version of the Bev 15 survey was anonymously administered to 5th and 6th grade students in 14 Chicago suburban public elementary schools. Students were asked to recall and record their beverage intake over the last 24 h for five predefined beverage groups [SSB, real fruit juice (RFJ), diet or sugar free beverages, milk, and water]. Concurrently, data regarding FRL eligibility for each of the 14 schools was obtained from the Illinois State Board of Education website. Mean student consumption of the five beverage categories in each school was correlated with the school's respective FRL status. A total of 1389 student surveys were used for analysis. FRL eligibility ranged from 16 to 64% in the 14 schools. There was a significant correlation between school FRL eligibility and consumption of SSB (p = 0.001), RFJ (p = 0.004) and diet or sugar-free beverage (p = 0.04). There was no significant correlation between FRL eligibility and consumption of water (p = 0.5), and milk (p = 0.2). This study shows that consumption of SSB highly correlates with school FRL eligibility, which can be a measure of SES. These findings reinforce the idea that there is a link between lower SES and unhealthy behaviors pertaining to dietary choices. Knowing this relationship between SSB consumption and FRL eligibility, specific schools can be targeted to reduce SSB consumption and its negative health consequences.

Arterial Cutaneous Femoral Fistulous Tract Closure Using Surgiflo Hemostatic Matrix: A Novel Adjunct for Post-TAVR Access-Site Management.

Several options are available to address hemostasis at the end of a cardiac catheterization or percutaneous transfemoral transcatheter aortic valve replacement (TAVR) when conventional options are ineffective. To date, there have been few studies exploring the use of a topical thrombin preparation, as one of its main contraindications is that it cannot be used intravascularly due to risk of embolization. The following case shows safe utilization of Surgiflo hemostatic gel matrix under fluoroscopic guidance against an inflated balloon in order to achieve closure of a fistulous tract from a femoral artery access site during percutaneous TAVR.