Temporary atrial septal defect balloon occlusion test as a must in the elderly.

BACKGROUND: Atrial septal defect (ASD) can often remain asymptomatic until adulthood. It still remains unclear whether large ASD closure in senior people should be performed or not. Temporary ASD balloon occlusion test has been suggested as a tool to assess the risk of acute left ventricular heart failure post-ASD closure, and it allows to better distinguish responders from non-responders. CASE PRESENTATION: An 83-year-old man with a long-standing uncorrected secundum ASD was admitted for recently decompensated right-sided heart failure. During hospitalization, this patient was studied with trans-esophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization, showing high Qp:Qs ratio and favorable anatomical conditions for percutaneous closure. Because of patient's increasing need for intravenous diuretics and worsening renal function, it was considered that transcatheter ASD closure could improve symptoms, hence it was performed an attempt of percutaneous closure of the ASD with a fenestrated device. Unfortunately, irrespective of ASD being hemodynamically significant, it was found a very significant increase in pulmonary capillary wedge pressure during the temporary balloon occlusion test, supporting the existence of concealed left ventricular diastolic dysfunction. As a result, it was decided to abandon the procedure and not to close the ASD. CONCLUSION: This clinical case illustrates the value of temporary balloon occlusion test before permanent percutaneous closure of ASD in elderly patients, regardless of left ventricular (systolic or diastolic) dysfunction.

Platypnoea Orthodeoxia Syndrome and Patent Foramen Ovale Closure: Single-Centre Experience and Long-Term Follow-Up.

INTRODUCTION: Platypnoea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS. METHODS: Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO2) improved to >94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO2 improved from baseline but still required oxygen to achieve >94%. Secondary outcomes were an absolute improvement in SpO2 and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up. RESULTS: Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO2 ratio increased from 155.9±50.6 to 318.3±73.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO2 and complete resolution of dyspnoea, which was maintained at follow-up (37±20 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up. CONCLUSION: The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.

Mitral valve aneurysm: A serious complication of aortic valve endocarditis.

Mitral valve aneurysms are rare and occur most commonly in association with aortic valve endocarditis. Transesophageal echocardiography is the most sensitive imaging modality for the diagnosis of this entity and its potential complications, such as leaflet rupture and mitral regurgitation, which mandate prompt surgical intervention. We present the case of a 70-year-old male patient with aortic valve endocarditis complicated with a ruptured aneurysm of the anterior mitral valve leaflet and associated severe mitral regurgitation, diagnosed by transesophageal echocardiography, with impressive images. We hypothesized that the aneurysm developed through direct extension of infection from the aortic valve or from a prolapsing aortic vegetation, with abscess formation and subsequent rupture and drainage. This case highlights the importance of appropriate imaging for early detection and timely surgical intervention (repair or replacement) to prevent fatal outcomes.

Lack of Benefit of Ischemic Postconditioning After Routine Thrombus Aspiration During Reperfusion: Immediate and Midterm Results.

OBJECTIVES: The underutilization of manual thrombus aspiration (MTA) may have reduced the benefits of ischemic postconditioning (PostCon), as it reduces thrombus embolization. We aimed to assess the benefits of PostCon in patients with ST-segment elevation myocardial infarction (STEMI) after the systematic utilization of MTA. METHODS: A total of 87 patients were enrolled in a prospective, randomized trial (43 PostCon and 44 controls). After MTA, PostCon was performed on the treatment group by applying 4 cycles of alternate reperfusion and reocclusion (60 seconds each) using the angioplasty balloon. The primary end point was infarct size assessed by the area under the curve (AUC) of troponin T (TnT) activity. The secondary end points were left ventricle ejection fraction (LVEF) and major cardiac events (new myocardial infarction or cardiac death) both at discharge and at follow-up. RESULTS: The AUC for TnT was no different with respect to study arms (median [interquartile range]): PostCon = 8.9 (10.6) versus control = 8.2 (10.6), P = .68. Left ventricle ejection fraction improved from in-hospital to follow-up (9 ± 3 months) for the entire cohort (46.3% ± 7.3% vs 52.2% ± 10.7%, P < .001), with no differences between PostCon and controls (51.6% ± 9.5% vs 52.7% ± 11.9%, P = .89); major cardiac events at 14 ± 4 months of follow-up were also no different (PostCon = 1.0 (2.3%) vs control = 0, P = .49). CONCLUSION: In patients with STEMI treated with MTA, PostCon offered no benefits to infarct size, LVEF, or major cardiac events.

Body position and oxygenation: An intriguing relationship.

Dyspnea and hypoxemia are among the most common symptoms and signs that need to be assessed in clinical practice. This case illustrates how simple steps in history taking and physical examination can be crucial for diagnosis. We present a patient with intermittent hypoxemia, initially attributed to a pulmonary infection. However, the hypoxemia persisted even after successful treatment of the infection. Computed tomography angiography of the chest and ventilation/perfusion lung scan excluded pulmonary embolism. We then observed that the hypoxemia and dyspnea were triggered by orthostatism. An echocardiogram with a bubble test showed a patent foramen ovale, with a right-to-left shunt, without pulmonary hypertension. After percutaneous closure of the foramen ovale, the symptoms completely resolved. This is a case of platypnea-orthodeoxia syndrome, which is usually associated with patent foramen ovale or atrial septal defect and is typically observed in the elderly. The features and causes of this curious syndrome are discussed.

[Guidelines for the management of pulmonary hypertension patients]. / Recomendações para a abordagem clínica do doente com hipertensão pulmonar.

INTRODUCTION: Pulmonary hypertension (PH) was until recently an obscure pathology which frequently went unidentified as it lacked a precise diagnostic strategy. Recent years have seen advances in the knowledge of the pathogenesis and mechanisms of vascular lesion of PH. This has led to the scientific community's growing interest in this area, an interest manifested in appreciable progress in the pathology's clinical characterisation, diagnostic strategies and the development of effective drugs. All of this together has been fundamental in changing the previously unfavourable prognosis of this disease. This evolution implies the need to rationalise the use of available resources through organisation of healthcare services, defining the role of each level of care, and developing norms for good clinical management practices in keeping with best medical practice guidelines. These twin aspects have attracted the interest of the scientific community, as shown by the wealth of literature, and have led healthcare authorities to introduce regulatory mechanisms. In order to improve clinical practice, the Pulmonary Vascular Disease Study Group (NEDVP) of the Portuguese Society of Internal Medicine (SPMI), the Pulmonary Hypertension Study Group (GEHTP) of the Portuguese Society of Cardiology and the boards of the Portuguese Societies of Pulmonology and Paediatric Cardiology created an interdisciplinary working group. The group's remit was to draft this document, "Guidelines for the management of pulmonary hypertension patients", based on a review of the literature and the authors' clinical expertise. These guidelines aim to present all the relevant evidence on the diagnostic and treatment strategy of PH and the definition of requirements for referral centres. The organisation of care is fundamental for an appropriate and rational use of the available resources and for the better care of the patient.

Recurrent orthodeoxia and patent foramen ovale.

BACKGROUND: Patent foramen ovale (PFO) occurs in 25% of healthy adults. It can lead to paradoxical embolization, migraine and respiratory failure (RF). The authors present a case of RF and orthodeoxia due to a right-to-left shunt via a PFO without previous elevation of right atrial pressure. Closure of the PFO effectively resolved the RF. CASE REPORT: A 52-year-old man, with IgA-k multiple myeloma diagnosed one year before, was admitted for severe hypoxemic RF, with orthodeoxia and poor response to oxygen supplementation, after placement of a central venous catheter (CVC) in the right subclavian vein. The patient reported paresthesia and nonspecific visual changes after manipulation of the CVC. The RF suggested a shunt between the pulmonary and systemic circulations. There was no clinical or radiological evidence of an intrapulmonary shunt. Contrast echocardiography showed a right-to-left shunt and transesophageal echocardiography revealed a PFO. Cardiac catheterization, after spontaneous resolution of the RF, showed no shunt. A week later, severe RF recurred. Complete resolution of respiratory dysfunction and neurological symptoms was seen after PFO closure. DISCUSSION: RF due to an intracardiac shunt without increased right-sided pressure is hemodynamically difficult to interpret. A few reports (in adults) relate this entity to anatomical anomalies, which can lead to a shunt by directing blood flow preferentially to the PFO. Examples include right diaphragmatic paresis and ectasia of the ascending aorta, which were observed in this patient. The role of the CVC, which was placed immediately before the RF, is uncertain. Complete therapeutic success after closure of the PFO supports the diagnosis. CONCLUSION: Correct evaluation of RF (by investigating orthodeoxia and response to oxygen therapy) enables the suspicion of a shunt, which can be confirmed through simple, safe and cost-effective exams. Intracardiac shunt without increased right-sided pressure should be considered because it can be successfully treatment.

Intramyocardial dissecting haematoma: a rare complication of acute myocardial infarction.

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patient's bedside.

[Right heart thrombus in a patient with pulmonary embolism. Clinical report]. / Trombo móvel nas cavidades cardíacas direitas em doente com embolia pulmonar.

Right heart thrombi are an uncommon finding in pulmonary embolism. The authors report a case of pulmonary embolism in an elderly male, describing its atypical presentation as well as the workup and therapy, followed by a brief thematic review.

Noncompaction of ventricular myocardium.

Noncompaction of ventricular myocardium is a rare cardiomyopathy thought to be caused by arrest of normal embryogenesis of the endocardium and myocardium; its true prevalence is still uncertain. A strong association between noncompaction and neuromuscular disorders has been described. Its major clinical manifestations are heart failure, arrhythmias and systemic embolic events. Diagnosis of noncompaction of ventricular myocardium can be made by conventional two-dimensional and color Doppler echocardiography. Recently contrast echocardiography has been used to provide a definitive diagnosis in most cases in which conventional echocardiography could not do so. We describe the case of a patient with clinical suspicion of noncompaction of ventricular myocardium established by conventional two-dimensional and color Doppler echocardiography and definitive diagnosis, as well as additional information, obtained by cardiac magnetic resonance imaging. We also discuss the difficulties in defining the therapeutic approach.

Familial apical hypertrophic cardiomyopathy with aneurysmal evolution--an unusual form.

The authors present the case of a 76-year-old patient with multiple vascular risk factors, admitted with acute coronary syndrome. The initial electrocardiogram was compatible with evolving anterior wall myocardial infarction and the echocardiogram showed an image interpreted in this context as left apical pseudoaneurysm. Complementary echocardiographic findings of atypical apical hypertrophy and echocardiographic screening performed on close relatives suggested apical hypertrophic cardiomyopathy as the most likely diagnosis, later confirmed by genetic study. This unusual presentation with evolution to ventricular aneurysm is probably due to progressive left ventricular apical remodeling and an echocardiographic image similar to that described points to the diagnosis of this entity. We emphasize the rarity of this phenotypic expression of apical hypertrophic cardiomyopathy, in particular with familial association.