Paradoxical cardiac and cerebral arterial gas embolus during percutaneous lead extraction in a patient with a patent foramen ovale.

A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures.

Patent foramen ovale influences the presentation of decompression illness in SCUBA divers.

BACKGROUND: Few have examined the influence of patent foramen ovale (PFO) on the phenotype of decompression illness (DCI) in affected divers. METHODOLOGY: A retrospective review of our database was performed for 75 SCUBA divers over a 10-year period. RESULTS: Overall 4,945 bubble studies were performed at our institution during the study period. Divers with DCI were more likely to have positive bubble studies than other indications (p<0.001). Major DCI was observed significantly more commonly in divers with PFO than those without (18/1,000 v.s. 3/1,000, p=0.02). Divers affected by DCI were also more likely to require a longer course of hyperbaric oxygen therapy (HBOT) if PFO was present (p=0.038). If the patient experienced one or more major DCI symptoms, the odds ratio of PFO being present on a transoesophageal echocardiogram was 3.2 (p=0.02) compared to those who reported no major DCI symptoms. CONCLUSION: PFO is highly prevalent in selected SCUBA divers with DCI, and is associated with a more severe DCI phenotype and longer duration of HBOT. Patients with unexpected DCI with one or more major DCI symptoms should be offered PFO screening if they choose to continue diving, as it may have considerable prognostic and therapeutic implications.

Scuba divers' pulmonary oedema: recurrences and fatalities.

Scuba divers' pulmonary oedema (SDPE) is an increasingly recognised disorder in divers. We report three fatal cases of SDPE, demonstrating its potential serious nature even in the absence of underlying cardiac disease demonstrable clinically or at autopsy. This, together with the frequency of recurrences, has implications on assessing fitness for subsequent diving, snorkelling and swimming. The differential diagnosis of this disorder is also considered, as is its possible inducement by salt water aspiration and its relationship to drowning.