Right-to-left shunt across atrial septal defect related to tricuspid regurgitation: assessment by transesophageal Doppler echocardiography

Prevalence and Hemodynamic Consequences of Mitral Valve Abnormalities in Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common congenital heart disease in adults. Concomitant mitral valve disease in patients with ASD could have significant hemodynamic effects whit a great impact on managing this congenital defect. Objectives: This study evaluated the prevalence of mitral valve abnormalities and the hemodynamic burden associated with different types of ASD. Methods: This retrospective study reanalyzed 1,006 consecutive patients referred to Rajaie Heart Center in Tehran from March 2019 to February 2022. We evaluated adult patients with the diagnosis of a shunt at the atrial level. Diagnoses were made with 2D and 3D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). 3D analysis was performed with 3D zoom, mitral valve navigation (MVN), and full-volume and multi-planar reconstruction (MPR) modalities. We performed statistical analysis by SPSS version 22.0. The qualitative data were expressed as frequency and percentage. Data were compared between subgroups via Mann-Whitney U/Kruskal-Wallis tests for the interval variables, Pearson's chi-square test for nominal variables, and chi-square for trends test for ordinal variables. Results: The distribution of different ASD types was ostium secundum in 88.8% of cases, primum ASD in 0.9%, SVC-type sinus venosus ASD in 9%, IVC-type sinus venosus in 0.4%, and unroofed coronary sinus in 0.9%. We found mitral valve abnormalities in 21.1% of cases, and the most common mitral valve abnormality were prolaptic lesions (17.4%). Conclusions: Age, ASD size, estimated Systolic Pulmonary Artery Pressure (SPAP), and severity of mitral regurgitation (MR) were markedly higher were markedly higher among patients with MV anomalies, more over left ventricular ejection fraction (LVEF) was significantly lower among this group (P-value < 0.05).

A case report of a triad causing platypnoea–orthodeoxia syndrome

Background

Platypnoea–orthodeoxia syndrome (POS) is a rare condition characterized by hypoxaemia and dyspnoea when changing from a recumbent to an upright position. Diagnosis requires a high clinical suspicion and is often underdiagnosed.

Case summary

We report a case of POS in a 50-year-old woman with dyspnoea and new-onset atrial fibrillation. Oxygen saturation and dyspnoea worsened as she changed from a supine to a sitting position (96 vs. 86%, respectively). Transoesophageal echocardiography demonstrated enlargement of both atria and right ventricle with reduced systolic function and a large Chiari network (CN). Colour Doppler discovered severe tricuspid regurgitation with tenting and tethering of the valve leaflets. Finally, a bubble test revealed the cause of POS to be a patent foramen ovale along with the severe tricuspid regurgitant jet moving into the left atrium and favoured by the CN. Surgical closure of the foramen ovale resulted in the resolution of symptoms.

Discussion

Platypnoea–orthodeoxia syndrome is most commonly caused by a right-to-left shunt through an anatomical defect of the interatrial septum, typically a patent foramen ovale, combined with elevated right atrium pressure. This case illustrates an uncommon cause of POS in the absence of elevated atrium pressure due to the interplay of three key elements: a patent foramen ovale, tricuspid regurgitation, and the CN. Our aim is to alert physicians to the possibility of an intracardiac shunt as the cause of unexplained and/or refractory hypoxaemia related to position changes. Early recognition of this syndrome promotes timely treatment, greatly improving patient outcomes.

Early onset of cyanosis in a patient with atrial septal defect: Transesophageal echocardiography reveals the underlying mechanism

Cyanosis due to right to left shunt across an atrial septal defect (ASD) brings up lots of questions in an inquisitive mind! Systemic desaturation at rest or during exercise can limit physical ability and impair the quality of life of patients with congenital heart defect (CHD). Traditionally, ASD is taught as an acyanotic CHD, but we encountered a child with a different clinical presentation. Understanding the mechanism of early onset systemic desaturation in the presence of an ASD is vital for surgical planning and decision-making. A comprehensive TEE examination always compliments clinical and haemodynamic data for an aetiology based patient management. This brief clinical communication attempts to discuss the role of perioperative TEE examinations in a case of ASD with central cyanosis.

Influence of transcatheter closure of atrial communication on migraine headache in patients with ischemic stroke

Some types of migraine are associated with ischemic stroke. Although a right-to-left communication is linked with ischemic stroke, a causal relationship between migraine and right-to-left communication remains unclear. Furthermore, the efficacy of transcatheter closure of atrial communication on migraine is controversial. We aimed to evaluate the influence of transcatheter closure of atrial communication on migraine in patients with ischemic stroke. Thirty-eight consecutive patients with ischemic stroke who underwent transcatheter closure of atrial communication were enrolled. The prevalence, frequency, and severity of migraine were prospectively evaluated at baseline, 3 months, and >6 months after the procedure. Changes in migraine after the procedure were classified according to the frequency and severity of migraine: disappeared, improved, no-change, and worsening. Nineteen (50 %) of 38 patients suffered from migraine at baseline. No significant differences were observed in age, comorbidities, defect diameter, and atrial septal aneurysm between patients with migraine and patients without migraine. Among the 19 patients with migraine, migraine disappeared in 10 (53 %) patients and improved in 8 (42 %) patients at 3 months after transcatheter closure of atrial communication. At mean follow-up of 38 ± 28 months after the procedure, migraine disappeared in 12 (63 %) patients and improved in five (26 %) patients. No patients experienced worsening of migraine during the follow-up period. New-onset migraine was not observed in patients without migraine. Migraine is complicated in a half of patients with ischemic stroke related to atrial communication. Such migraine may disappear or improve after transcatheter closure of atrial communication.

Migraine prevalence in patients with atrial septal defect

Background

Patients with a patent foramen ovale have a high prevalence of migraine with aura (MA). However, whether patients with an atrial septal defect (ASD) have a high prevalence of migraine remains unclear. The present study aimed to determine the prevalence of migraine and its clinical characteristics in patients with ASD.

Findings

Ninety-five patients (age ≥ 20 years) who had undergone percutaneous ASD closure responded to a questionnaire used by neurologists to diagnose migraine either with or without aura. We diagnosed migraine before ASD closure according to the criteria of the International Headache Society. The overall prevalence of migraine seemed to be higher in the present study than in the Japanese general population (24.2% vs. 9.4%, respectively). All patients with MA were female and significantly younger than those without migraine (p < 0.01).

Conclusions

Our findings suggested that the susceptibility to the development of MA differs according to sex and age in patients with cardiac shunt.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

Atrial Septal Rupture, Flail Tricuspid Valve, and Complete Heart Block Due to Nonpenetrating Chest Trauma

This is a report of a patient with an atrial septal defect with right-to-left shunting, flail tricuspid valve, and complete heart block secondary to blunt chest trauma after a motor vehicle accident. The patient surgically repaired with pericardial recreation of atrial septum, bioprosthetic tricuspid valve replacement, and pacemaker insertion. The patient had minimal problems during the hospital course and subsequently made a full postsurgical recovery.

Tricuspid Regurgitation Causing a Right to Left Interatrial Shunt with Normal Pulmonary Pressures

We describe a patient who presented with asymptomatic hypoxia refractory to supplemental oxygen. Transthoracic echocardiography and angiography demonstrated a tricuspid valve with a large regurgitant jet oriented directly at a patent foramen ovale, producing a right to left shunt with systemic hypoxia. The patient was found to have normal right-sided cardiac pressures as well as normal pulmonary arterial pressures, demonstrating the shunt was secondary to the tricuspid regurgitant jet and not a result of a pressure gradient between atria. Surgical correction of the tricuspid valve and closure of the patent foramen ovale resulted in resolution of the patient's hypoxemia.

Partial pressure of oxygen is lower in the left upper pulmonary vein than in the right in adults with atrial septal defect: difference in P(O2) between the right and left pulmonary veins

BACKGROUND

The right-to-left shunt at the atrial level is responsible for arterial hypoxemia in patients with atrial septal defect.

OBJECTIVES

This study investigated the mechanism of arterial hypoxemia in patients with atrial septal defect by measuring the P(O2) in both the right and left upper pulmonary veins.

SUBJECTS AND METHOD

We prospectively measured the P(O2) in the femoral artery and the right and left upper pulmonary veins during cardiac catheterization in 13 adults (median age, 53 years) and 7 children (median age, 7 years) with secundum atrial septal defect. The adults and children were studied consecutively. Contrast echocardiography was performed to evaluate right-to-left shunt in all adults.

RESULTS

Among the children, there were no patients showing arterial hypoxemia, and there was no difference in the P(O2) (+/-SD) between the right and left upper pulmonary veins (right, 100+/-3.8 mm Hg vs left, 100+/-7.8 mm Hg; p = 0.92). However, arterial hypoxemia was present in 11 of the 13 adult patients, although contrast echocardiography showed more than a moderate degree of right-to-left shunt in only four adults. The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in all adult patients (right, 91.6+/-13.8 mm Hg vs left, 73.0+/-11.5 mm Hg; p < 0.0001).

CONCLUSION

The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in adults with atrial septal defect. Care must be taken in measuring pulmonary blood flow if the P(O2) in the left upper pulmonary vein is low enough to influence oxygen content. The decreased P(O2) in the left upper pulmonary vein may contribute to arterial hypoxemia in addition to right-to-left shunt at the atrial level in adults with atrial septal defect.

Effects of balloon pulmonary valvuloplasty on atrial shunting--a patient with pulmonary valve stenosis and a large secundum atrial septal defect

Percutaneous balloon valvuloplasty has been established as an effective treatment for pulmonary valve stenosis (PS) in children and adults. However, there are few reports of the use of this technique in patients with other cardiac anomalies. We report the performance of balloon pulmonary valvuloplasty in a 72-year-old woman with a large atrial septal defect (ASD). This patient had a PS with a right ventricular pressure of 108/18 mmHg and a pulmonary arterial pressure of 42/21 mmHg, corresponding to a 66 mmHg pressure gradient. The ASD measured 32 x 27 mm. Balloon pulmonary valvuloplasty reduced the pressure gradient to 5 mmHg immediately after the procedure and to 2 mmHg 40 days after the procedure. The left-to-right shunt ratio was reduced from 17% before to 12% immediately after and to 36% 40 days after the procedure. In contrast, the right-to-left shunt ratio showed a transient increase from 16% before to 28% immediately after the procedure before decreasing to 11% 40 days after the procedure. The arterial blood oxygen tension was 53 Torr before, 46 Torr immediately after and 55 Torr 40 days after the procedure. The grade of heart failure decreased from New York Heart Association class IV before to class II in the chronic stage. These findings indicated that balloon pulmonary valvuloplasty in a patient with ASD transiently increased the right-to-left shunting associated with a decrease in oxygen tension, but that the change in the chronic stage was slight. In our patient with ASD valvuloplasty was useful in relieving the symptoms associated with elevated right ventricular pressure but could not reduce the hypoxemia caused by right-to-left shunting. In conclusion, valvuloplasty in patients with ASD should be considered as a preoperative treatment with the aim of reducing the risk of surgery and to treat symptoms in patients who refuse to undergo surgery.

Intracardiac shunts

Unsuspected intracardiac shunts can be a cause of acute deterioration in critically ill patients. Shunts can be acquired or congenital conditions that become symptomatic only with changed physiologic conditions. Transesophageal echocardiography is an excellent tool for the diagnosis of intracardiac shunts.