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Shehata A, Nasser A, Mohsen A, Anwar Samaan A, Mostafa A, Hassan M. Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study. Egypt Heart J 2024; 76:73. [PMID: 38856789 PMCID: PMC11164847 DOI: 10.1186/s43044-024-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. RESULTS This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). CONCLUSION The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.
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Affiliation(s)
- Ahmed Shehata
- Cardiology Department, Cairo University, Giza, Egypt
| | | | - Ahmed Mohsen
- Cardiology Department, Cairo University, Giza, Egypt
| | - Amir Anwar Samaan
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Amir Mostafa
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Mohamed Hassan
- Cardiology Department, Cairo University, Giza, Egypt.
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt.
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Quatre R, Delafosse B, Schmerber S, Soriano E. Decompression sickness of the inner ear and relationship with a patent oval foramen: a study of 61 cases. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08544-w. [PMID: 38470517 DOI: 10.1007/s00405-024-08544-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To discuss the link between inner ear decompression sickness and patent foramen ovale. MATERIALS AND METHODS Monocentric and retrospective study on decompression sickness of the inner ear requiring hyperbaric chamber treatment, from 2014 to 2021. RESULTS Sixty-one patients of inner ear decompression sickness were included in this study. Twenty-four patients had vestibular injuries, 28 cochlear injuries and 9 cochleo-vestibular injuries. Compression chamber treatment was given, using an oxygen-helium mixture with oxygen partial pressure (PIO2) limited to 2.8 atmosphere absolute (ATA). All vestibular accidents completely recovered without clinical sequelae. For cochlear accident only 10 out of 37 patients (27%) recovered completely. A right-left shunt (patent foramen oval or intra-pulmonary shunt) was found in 31.1% of patients with inner ear decompression sickness (p > 0.05). CONCLUSION The presence of patent foramen oval in patients with inner ear decompression was not statistically significant in our study. Understanding of the pathophysiology of decompression illness and the physiology and anatomy of the labyrinth would suggest a mechanism of supersaturation with degassing in intra-labyrinthine liquids.
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Affiliation(s)
- Raphaële Quatre
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France.
- GeodAIsics, Grenoble, France.
- BrainTech Lab INSERM UMR 2015, Grenoble, France.
| | - Bertrand Delafosse
- Service de Médecine Hyperbare, CHU de Lyon, University of Lyon, Lyon, France
| | - Sébastien Schmerber
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France
- BrainTech Lab INSERM UMR 2015, Grenoble, France
| | - Edouard Soriano
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Grenoble-Alpes, BP 217, 38043, Grenoble Cedex 09, France
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3
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Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
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Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
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Abstract
Pulmonary physiology is significantly altered during underwater exposure, as immersion of the body and increased ambient pressure elicit profound effects on both the cardiovascular and respiratory systems. Thoracic blood pooling, increased breathing gas pressures, and variations in gas volumes alongside ambient pressure changes put the heart and lungs under stress. Normal physiologic function and fitness of the cardiovascular and respiratory systems are prerequisites to safely cope with the challenges of the underwater environment when freediving, or diving with underwater breathing apparatus. Few physicians are trained to understand the physiology and medicine of diving and how to recognize or manage diving injuries. This article provides an overview of the physiologic challenges to the respiratory system during diving, with or without breathing apparatus, and outlines possible health risks and hazards unique to the underwater environment. The underlying pathologic mechanisms of dive-related injuries are reviewed, with an emphasis on pulmonary physiology and pathophysiology.
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Affiliation(s)
- Kay Tetzlaff
- Department of Sports Medicine, University Hospital of Tuebingen, Tuebingen, Germany
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Lee HJ, Lim DS, Lee J, Lee DG, Oh MY, Park J, Kim CH, Jung JH, Choi RK, Kang YC. Decompression Illness in Divers With or Without Patent Foramen Ovale : A Cohort Study. Ann Intern Med 2023. [PMID: 37429031 DOI: 10.7326/m23-0260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND In previous studies, the prevalence of patent foramen ovale (PFO) has been reported to be higher in scuba divers who experienced decompression illness (DCI) than in those who did not. OBJECTIVE To assess the association between PFO and DCI in scuba divers. DESIGN Prospective cohort study. SETTING Tertiary cardiac center in South Korea. PARTICIPANTS One hundred experienced divers from 13 diving organizations who did more than 50 dives per year. MEASUREMENTS Participants had transesophageal echocardiography with a saline bubble test to determine the presence of a PFO and were subsequently divided into high- and low-risk groups. They were followed using a self-reported questionnaire while blinded to their PFO status. All of the reported symptoms were adjudicated in a blinded manner. The primary end point of this study was PFO-related DCI. Logistic regression analysis was done to determine the odds ratio of PFO-related DCI. RESULTS Patent foramen ovale was seen in 68 divers (37 at high risk and 31 at low risk). Patent foramen ovale-related DCI occurred in 12 divers in the PFO group (non-PFO vs. high-risk PFO vs. low-risk PFO: 0 vs. 8.4 vs. 2.0 incidences per 10 000 person-dives; P = 0.001) during a mean follow-up of 28.7 months. Multivariable analysis showed that high-risk PFO was independently associated with an increased risk for PFO-related DCI (odds ratio, 9.34 [95% CI, 1.95 to 44.88]). LIMITATION The sample size was insufficient to assess the association between low-risk PFO and DCI. CONCLUSION High-risk PFO was associated with an increased risk for DCI in scuba divers. This finding indicates that divers with high-risk PFO are more susceptible to DCI than what has been previously reported and should consider either refraining from diving or adhering to a conservative diving protocol. PRIMARY FUNDING SOURCE Sejong Medical Research Institute.
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Affiliation(s)
- Hyun-Jong Lee
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, South Korea (H.L., D.S.L., J.P., C.K., J.J.)
| | - Dal Soo Lim
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, South Korea (H.L., D.S.L., J.P., C.K., J.J.)
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul, South Korea (J.L.)
| | - Dong-Geun Lee
- Department of Neurology, Pyeongtaek St. Mary's Hospital, Pyeongtaek, South Korea (D.L.)
| | - Mi-Young Oh
- Department of Neurology, Bucheon Sejong Hospital, Bucheon, South Korea (M.O.)
| | - Jinsik Park
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, South Korea (H.L., D.S.L., J.P., C.K., J.J.)
| | - Chi-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, South Korea (H.L., D.S.L., J.P., C.K., J.J.)
| | - Ji-Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, South Korea (H.L., D.S.L., J.P., C.K., J.J.)
| | - Rak Kyeong Choi
- Division of Cardiology, Department of Internal Medicine, Incheon Sejong Hospital, Incheon, South Korea (R.K.C.)
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Peppas S, Palaiodimos L, Nagraj S, Kokkinidis DG, Tiwari N, Kharawala A, Mojadidi MK, Mojaddedi S, Ntaios G, Faillace RT, Tobis JM. Right-to-Left Shunt in Divers with Neurological Decompression Sickness: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2023; 11:healthcare11101407. [PMID: 37239692 DOI: 10.3390/healthcare11101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers. BACKGROUND Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS. METHODS We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios. RESULTS Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79-5.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86-8.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10-18.17) compared to cerebral (OR: 4.96; 95% CI: 2.43-10.12) and spinal cord (OR: 2.47; 95% CI: 2.74-7.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80-2.91). CONCLUSIONS RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.
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Affiliation(s)
- Spyros Peppas
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT 06520, USA
| | - Nidhish Tiwari
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Amrin Kharawala
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Sanauallah Mojaddedi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 382 21 Larissa, Greece
| | - Robert T Faillace
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jonathan M Tobis
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
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Miki T, Nakagawa K, Ichikawa K, Mizuno T, Nakayama R, Ejiri K, Kawada S, Takaya Y, Miyamoto M, Miyoshi T, Akagi T, Ito H. Diagnostic Performance of Cardiac Computed Tomography for Detecting Patent Foramen Ovale: Evaluation Using Transesophageal Echocardiography and Catheterization as Reference Standards. J Cardiovasc Dev Dis 2023; 10:jcdd10050193. [PMID: 37233160 DOI: 10.3390/jcdd10050193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is associated with various diseases such as cryptogenic stroke, migraine, and platypnea-orthodeoxia syndrome. This study aimed to evaluate the diagnostic performance of cardiac computed tomography (CT) for PFO detection. MATERIALS AND METHODS Consecutive patients diagnosed with atrial fibrillation and who underwent catheter ablation with pre-procedural cardiac CT and transesophageal echocardiography (TEE) were enrolled in this study. The presence of PFO was defined as (1) the confirmation of PFO using TEE and/or (2) the catheter crossing the interatrial septum (IAS) into the left atrium during ablation. CT findings indicative of PFO included (1) the presence of a channel-like appearance (CLA) on the IAS and (2) a CLA with a contrast jet flow from the left atrium to the right atrium. The diagnostic performance of both a CLA alone and a CLA with a jet flow was evaluated for PFO detection. RESULTS Altogether, 151 patients were analyzed in the study (mean age, 68 years; men, 62%). Twenty-nine patients (19%) had PFO confirmed by TEE and/or catheterization. The diagnostic performance of a CLA alone was as follows: sensitivity, 72.4%; specificity, 79.5%; positive predictive value (PPV), 45.7%; negative predictive value (NPV), 92.4%. The diagnostic performance of a CLA with a jet flow was as follows: sensitivity, 65.5%; specificity, 98.4%; PPV, 90.5%; NPV, 92.3%. The diagnostic performance of a CLA with a jet flow was statistically superior to that of a CLA alone (p = 0.045), and the C-statistics were 0.76 and 0.82, respectively. CONCLUSION A CLA with a contrast jet flow in cardiac CT has a high PPV for PFO detection, and its diagnostic performance is superior to that of a CLA alone.
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Affiliation(s)
- Takashi Miki
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Keishi Ichikawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Tomofumi Mizuno
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Hiroshi Ito
- Department of General Internal Medicine 3, Kawasaki Medical School, Okayama 700-8505, Japan
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SCUBA Diving in Adult Congenital Heart Disease. J Cardiovasc Dev Dis 2023; 10:jcdd10010020. [PMID: 36661915 PMCID: PMC9863475 DOI: 10.3390/jcdd10010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023] Open
Abstract
Conventionally, scuba diving has been discouraged for adult patients with congenital heart disease (ACHD). This restrictive sports advice is based on expert opinion in the absence of high-quality diving-specific studies. However, as survival and quality of life in congenital heart disease (CHD) patients have dramatically improved in the last decades, a critical appraisal whether such restrictive sports advice is still applicable is warranted. In this review, the cardiovascular effects of diving are described and a framework for the work-up for ACHD patients wishing to engage in scuba diving is provided. In addition, diving recommendations for specific CHD diagnostic groups are proposed.
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Lee HJ, Lim DS, Kang YC. Recurrent Decompression Illness Even After the Closure of Patent Foramen Ovale in a Diver. JACC Case Rep 2022; 5:101687. [PMID: 36636504 PMCID: PMC9830462 DOI: 10.1016/j.jaccas.2022.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/26/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022]
Abstract
Patent foramen ovale (PFO) is a risk factor for the development of decompression illness (DCI) and a therapeutic target for preventing the recurrence of DCI because nitrogen bubbles generated during diving can be paradoxically embolized through the PFO. Here, we report the case of a diver who experienced recurrent DCI even after a successful PFO closure. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Hyun-Jong Lee
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea,Address for correspondence: Dr. Hyun-Jong Lee, Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, 91-121 Sosa 2-Dong, Sosa-Gu, Bucheon 14574, Republic of Korea.
| | - Dal Soo Lim
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
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Application of Transesophageal Echocardiography in Amplatzer Atrial Septal Defect Occluder for Percutaneous Closure of Large Patent Foramen Ovale. Cardiovasc Ther 2022; 2022:3226080. [PMID: 35936794 PMCID: PMC9337921 DOI: 10.1155/2022/3226080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Objective. The Amplatzer patent foramen ovale (PFO) occluder is the most commonly used device for percutaneous closure of a large PFO. However, its use may predispose the patient to postoperative residual shunting. To reduce the incidence of residual shunting, we investigated the safety and effectiveness of the Amplatzer atrial septal defect (ASD) occluder for percutaneous closure of a large PFO measured by transesophageal echocardiography (TEE) and evaluated the value of TEE in this procedure. Methods. Overall, 118 patients who were diagnosed with a large PFO (all with
mm left atrial side height after the Valsalva maneuver (VM) excluding those with a small ASD) using contrast transthoracic echocardiography (c-TTE) and TEE underwent closure under TEE guidance at The First Affiliated Hospital of Xi’an Jiaotong University. An ASD device was used in 48 patients (group I) and a PFO device in 70 (group II). After the procedure, we verified the safety and efficacy of different devices using c-TTE, TTE, and TEE. Results. In both groups, the preoperative TEE results showed a significantly increased left height of the PFO after VM compared with that at rest (all
). Compared with the left height of the PFO measured using TEE after VM, the PFO-stretch diameter (SD) measured by TEE after the delivery sheath passed the PFO was higher (all
). We selected the ASD occluder size according to this PFO-SD. In group II, most patients underwent the implantation of the larger PFO devices. Interventional treatment was successfully performed on all patients. The effective occlusion rate in group I at 12 months after the procedure was significantly higher than that in group II (93.7% vs. 78.6%,
). The TEE results showed that 18 patients with a medium and large residual shunt at 12 months after the procedure exhibited an intradisc tunnel-like shunt. Conclusion. The Amplatzer ASD device and Amplatzer PFO device are safe for large PFO closure, but the Amplatzer ASD device has a higher effective occlusion rate. TEE plays a crucial role in the use of the Amplatzer ASD occluder for percutaneous closure of a large PFO.
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Apostolos A, Drakopoulou M, Trantalis G, Synetos Α, Oikonomou G, Karapanayiotides T, Tsioufis C, Toutouzas K. The management of patent foramen ovale in divers: where do we stand? Ther Adv Neurol Disord 2022; 15:17562864221103459. [PMID: 35837370 PMCID: PMC9274415 DOI: 10.1177/17562864221103459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Diving is a fascinating activity, but it does not come without any cost; decompression illness (DCI) is one of the most frequent diseases occurring in divers. Rapid surfacing after diving causes alveolar rupture and bubbles release, which enter in the systemic circulation and could embolize numerous organs and tissues. The presence of patent foramen ovale (PFO) contributes to the passage of venous gas bubbles into the arterial circulation, increasing the risk of complications related to DCI. The diagnosis is established with a detailed medical history, a comprehensive clinical evaluation, and a multimodal imaging approach. Although the percutaneous closure of PFO is ambiguous for divers, as a primary prevention strategy, transcatheter management is considered as beneficial for DCI recurrence prevention. The aim of this study is to introduce the basic principles of DCI, to review the pathophysiological connection between DCI and PFO, to highlight the risk factors and the optimal treatment, and, last but not least, to shed light on the role of closure as primary and secondary prevention.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Maria Drakopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - George Trantalis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Αndreas Synetos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - George Oikonomou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Costas Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- Professor of Cardiology, First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, 114 Vasilissis Sophias Avenue, Athens 115 27, Greece
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Germonpré P, Lafère P, Portier W, Germonpré FL, Marroni A, Balestra C. Increased Risk of Decompression Sickness When Diving With a Right-to-Left Shunt: Results of a Prospective Single-Blinded Observational Study (The "Carotid Doppler" Study). Front Physiol 2021; 12:763408. [PMID: 34777020 PMCID: PMC8586212 DOI: 10.3389/fphys.2021.763408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/07/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Divers with a patent Foramen Ovale (PFO) have an increased risk for decompression sickness (DCS) when diving with compressed breathing gas. The relative risk increase, however, is difficult to establish as the PFO status of divers is usually only determined after a DCS occurrence. Methods: This prospective, single-blinded, observational study was designed to collect DCS data from volunteer divers after screening for right-to-left shunt (RLS) using a Carotid Doppler test. Divers were blinded to the result of the test, but all received a standardized briefing on current scientific knowledge of diving physiology and “low-bubble” diving techniques; they were then allowed to dive without restrictions. After a mean interval of 8 years, a questionnaire was sent collecting data on their dives and cases of DCS (if any occurred). Results: Data was collected on 148 divers totaling 66,859 dives. There was no significant difference in diving data between divers with or without RLS. Divers with RLS had a 3.02 times higher incidence of (confirmed) DCS than divers without RLS (p = 0.04). When all cases of (confirmed or possible DCS) were considered, the Relative Risk was 1.42 (p = 0.46). DCS occurred mainly in divers who did not dive according to “low-bubble” diving techniques, in both groups. Conclusion: This prospective study confirms that DCS is more frequent in divers with RLS (such as a PFO), with a Relative Risk of 1.42 (all DCS) to 3.02 (confirmed DCS). It appears this risk is linked to diving behavior, more specifically diving to the limits of the adopted decompression procedures.
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Affiliation(s)
- Peter Germonpré
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium.,Divers Alert Network (DAN) Europe Research Division, Roseto, Italy
| | - Pierre Lafère
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium.,Divers Alert Network (DAN) Europe Research Division, Roseto, Italy.,Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium
| | - William Portier
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium
| | | | - Alessandro Marroni
- Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium
| | - Costantino Balestra
- Divers Alert Network (DAN) Europe Research Division, Roseto, Italy.,Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium.,Physical Activity Teaching Unit, Motor Sciences Department, Université Libre de Bruxelles (ULB), Brussels, Belgium
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13
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Tso JV, Powers JM, Kim JH. Cardiovascular considerations for scuba divers. Heart 2021; 108:1084-1089. [PMID: 34670825 DOI: 10.1136/heartjnl-2021-319601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022] Open
Abstract
As the popularity of scuba diving increases internationally, physicians interacting with divers in the clinical setting must be familiar with the cardiovascular stresses and risks inherent to this activity. Scuba presents a formidable cardiovascular challenge by combining unique environmental conditions with the physiologic demands of underwater exercise. Haemodynamic stresses encountered at depth include increased hydrostatic pressure leading to central shifts in plasma volume coupled with cold water stimuli leading to simultaneous parasympathetic and sympathetic autonomic responses. Among older divers and those with underlying cardiovascular risk factors, these physiologic changes increase acute cardiac risks while diving. Additional scuba risks, as a consequence of physical gas laws, include arterial gas emboli and decompression sickness. These pathologies are particularly dangerous with altered sensorium in hostile dive conditions. When present, the appropriate management of patent foramen ovale (PFO) is uncertain, but closure of PFO may reduce the risk of paradoxical gas embolism in divers with a prior history of decompression sickness. Finally, similar to other Masters-level athletes, divers with underlying traditional cardiovascular risk should undergo complete cardiac risk stratification to determine 'fitness-to-dive'. The presence of undertreated coronary artery disease, occult cardiomyopathy, channelopathy and arrhythmias must all be investigated and appropriately treated in order to ensure diver safety. A patient-centred approach facilitating shared decision-making between divers and experienced practitioners should be utilised in the management of prospective scuba divers.
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Affiliation(s)
- Jason V Tso
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joshua M Powers
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan H Kim
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Orsinelli DA, Rajpal S. Doing a Deep Dive on Patent Foramen Ovale: Stay Tuned in the PFO World. JACC Cardiovasc Imaging 2021; 15:190-192. [PMID: 34656484 DOI: 10.1016/j.jcmg.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/24/2021] [Accepted: 09/09/2021] [Indexed: 11/24/2022]
Affiliation(s)
- David A Orsinelli
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Nationwide Children's Hospital, Columbus, Ohio, USA.
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15
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Importance of saline contrast transthoracic echocardiography for evaluating large right-to-left shunt in patent foramen ovale associated with cryptogenic stroke. Int J Cardiovasc Imaging 2021; 38:515-520. [PMID: 34546456 PMCID: PMC8926986 DOI: 10.1007/s10554-021-02418-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Transcatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing recurrent stroke in very specific patient cohorts, such as cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of saline contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. We enrolled 119 patients with or without CS who were confirmed to have PFO by transesophageal echocardiography (TEE) or catheterization. The severity of RL shunt evaluated by TTE and TEE was classified as follows: small (< 10 microbubbles), moderate (10–20 microbubbles), and large (> 20 microbubbles). With TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With TEE, large RL shunt was observed in 33 (28 %) patients, including 26 with CS and 7 without CS. TTE showed large RL shunt more frequently than TEE (p < 0.01). Large RL shunt evaluated by TTE had a sensitivity of 89 % and an accuracy of 70 % for the association with CS, whereas large RL shunt evaluated by TEE had a sensitivity of 35% and an accuracy of 56 %. Accuracy was significantly greater in TTE than in TEE (p = 0.02). In conclusion, TTE identified large RL shunt associated with CS with higher sensitivity and accuracy compared to TEE. Our findings suggest that the decision for device closure should be made based on the severity of RL shunt by TTE.
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16
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Screening and Risk Stratification Strategy Reduced Decompression Sickness Occurrence in Divers With Patent Foramen Ovale. JACC Cardiovasc Imaging 2021; 15:181-189. [PMID: 34419390 DOI: 10.1016/j.jcmg.2021.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This paper sought to evaluate the occurrence of decompression sickness (DCS) after the application of a patent foramen ovale (PFO) screening and risk stratification strategy. BACKGROUND PFO is associated with an increased risk of DCS. Recently, transcatheter closure was reported to reduce DCS occurrence in divers with a high-grade shunt. However, to date, there are no data regarding the effectiveness of any PFO screening and risk stratification strategy for divers. METHODS A total of 829 consecutive divers (35.4 ± 10.0 years, 81.5% men) were screened for PFO by means of transcranial color-coded sonography in the DIVE-PFO (Decompression Illness Prevention in Divers with a Patent Foramen Ovale) registry. Divers with a high-grade PFO were offered either catheter-based PFO closure (the closure group) or advised conservative diving (high grades). Divers with a low-grade shunt were advised conservative diving (low grades), whereas those with no PFO continued unrestricted diving (controls). A telephone follow-up was performed. To study the effect of the screening and risk stratification strategy, DCS occurrence before enrollment and during the follow-up was compared. RESULTS Follow-up was available for 748 (90%) divers. Seven hundred and 2 divers continued diving and were included in the analysis (mean follow-up 6.5 ± 3.5 years). The DCS incidence decreased significantly in all groups, except the controls. During follow-up, there were no DCS events in the closure group; DCS incidence was similar to the controls in the low-grade group (HR: 3.965; 95% CI: 0.558-28.18; P = 0.169) but remained higher in the high-grade group (HR: 26.170; 95% CI: 5.797-118.16; P < 0.0001). CONCLUSIONS The screening and risk stratification strategy using transcranial color-coded sonography was associated with a decrease in DCS occurrence in divers with PFO. Catheter-based PFO closure was associated with a DCS occurrence similar to the controls; the conservative strategy had a similar effect in the low-grade group, but in the high-grade group the DCS incidence remained higher than in all other groups.
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17
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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18
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Romano V, Gallinoro CM, Mottola R, Serio A, Di Meglio F, Castaldo C, Sirico F, Nurzynska D. Patent Foramen Ovale-A Not So Innocuous Septal Atrial Defect in Adults. J Cardiovasc Dev Dis 2021; 8:jcdd8060060. [PMID: 34070460 PMCID: PMC8228640 DOI: 10.3390/jcdd8060060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/14/2021] [Accepted: 05/22/2021] [Indexed: 12/11/2022] Open
Abstract
Patent foramen ovale (PFO) is a common congenital atrial septal defect with an incidence of 15–35% in the adult population. The development of the interatrial septum is a process that begins in the fourth gestational week and is completed only after birth. During intrauterine life, the foramen ovale allows the passage of highly oxygenated blood from the right to the left atrium and into the systemic arteries, thus bypassing the pulmonary circulation. In 75% of the general population, the foramen ovale closes after birth, and only an oval depression, called fossa ovalis, remains on the right side of the interatrial septum. Patent foramen ovale can be associated with various clinically important conditions, including migraine and stroke, or decompression illness in divers. The aim of this review is to summarize the PFO developmental and anatomical features and to discuss the clinical risks associated with this atrial septal defect in adults.
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Affiliation(s)
- Veronica Romano
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Carlo Maria Gallinoro
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Rosita Mottola
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Alessandro Serio
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Franca Di Meglio
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Clotilde Castaldo
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
| | - Felice Sirico
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (V.R.); (C.M.G.); (R.M.); (A.S.); (F.D.M.); (C.C.)
- Correspondence: (F.S.); (D.N.)
| | - Daria Nurzynska
- Department of Medicine, Surgery and Dentistry “ScuolaMedicaSalernitana”, University of Salerno, 84081 Baronissi, Italy
- Correspondence: (F.S.); (D.N.)
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19
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Brampton W, Sayer MD. Decompression sickness after a highly conservative dive in a diver with known persistent foramen ovale: Case report. Diving Hyperb Med 2021; 51:111-115. [PMID: 33761552 DOI: 10.28920/dhm51.1.111-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/29/2020] [Indexed: 11/05/2022]
Abstract
A diver returned to diving, 15 months after an episode of neuro-spinal decompression sickness (DCS) with relapse, after which she had been found to have a moderate to large provoked shunt across a persistent (patent) foramen ovale (PFO), which was not closed. She performed a single highly conservative dive in line with the recommendations contained in the 2015 position statement on PFO and diving published jointly by the South Pacific Underwater Medicine Society and the United Kingdom Sports Diving Medical Committee. An accidental Valsalva manoeuvre shortly after surfacing may have provoked initial symptoms which later progressed to DCS. Her symptoms and signs were milder but closely mirrored her previous episode of DCS and she required multiple hyperbaric oxygen treatments over several days, with residua on discharge. Although guidance in the joint statement was mostly followed, the outcome from this case indicates that there may be a subgroup of divers with an unclosed PFO, who have had a previous episode of serious DCS, who may not be safe to dive, even within conservative limits.
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Affiliation(s)
- William Brampton
- Hyperbaric Medicine Unit. Aberdeen Royal Infirmary, Aberdeen, Scotland.,Corresponding author: Dr William Brampton, Hyperbaric Medical Unit, Aberdeen Royal Infi rmary, Foresterhill, Aberdeen, AB25 2ZN, Scotland, UK,
| | - Martin Dj Sayer
- Tritonia Scientific Ltd., Oban, Scotland.,West Scotland Centre for Diving and Hyperbaric Medicine, Oban, Scotland
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20
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Edvinsson B, Thilén U, Nielsen NE, Christersson C, Dellborg M, Eriksson P, Hlebowicz J. Does persistent (patent) foramen ovale closure reduce the risk of recurrent decompression sickness in scuba divers? Diving Hyperb Med 2021; 51:63-67. [PMID: 33761542 DOI: 10.28920/dhm51.1.63-67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/20/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Interatrial communication is associated with an increased risk of decompression sickness (DCS) in scuba diving. It has been proposed that there would be a decreased risk of DCS after closure of the interatrial communication, i.e., persistent (patent) foramen ovale (PFO). However, the clinical evidence supporting this is limited. METHODS Medical records were reviewed to identify Swedish scuba divers with a history of DCS and catheter closure of an interatrial communication. Thereafter, phone interviews were conducted with questions regarding diving and DCS. All Swedish divers who had had catheter-based PFO-closure because of DCS were followed up, assessing post-closure diving habits and recurrent DCS. RESULTS Nine divers, all with a PFO, were included. Eight were diving post-closure. These divers had performed 6,835 dives (median 410, range 140-2,200) before closure, and 4,708 dives (median 413, range 11-2,000) after closure. Seven cases with mild and 10 with serious DCS symptoms were reported before the PFO closure. One diver with a small residual shunt suffered serious DCS post-closure; however, that dive was performed with a provocative diving profile. CONCLUSION Divers with PFO and DCS continue to dive after PFO closure and this seems to be fairly safe. Our study suggests a conservative diving profile when there is a residual shunt after PFO closure, to prevent recurrent DCS events.
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Affiliation(s)
- Björn Edvinsson
- Department of Cardiology, Department of Clinical Science, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ulf Thilén
- Department of Cardiology, Department of Clinical Science, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niels Erik Nielsen
- Department of Cardiology, Department of Clinical Science, University Hospital Linköping, Linköping University, Linköping, Sweden
| | | | - Mikael Dellborg
- Department of Cardiology, Department of Clinical Science, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Peter Eriksson
- Department of Cardiology, Department of Clinical Science, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Joanna Hlebowicz
- Department of Cardiology, Department of Clinical Science, Skåne University Hospital, Lund University, Lund, Sweden.,Corresponding author: Dr Joanna Hlebowicz, Department of Cardiology, Skåne University Hospital, Lund University, SE-221, 85 Lund, Sweden,
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21
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Filomena D, Cimino S, Maestrini V, Monosilio S, Birtolo LI, Vicenzini E, Mancone M, Fedele F, Agati L. The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism. Echocardiography 2021; 38:657-675. [PMID: 33740289 DOI: 10.1111/echo.15018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.
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Affiliation(s)
- Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Monosilio
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Edoardo Vicenzini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Luciano Agati
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
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22
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Kheiwa A, Hari P, Madabhushi P, Varadarajan P. Patent foramen ovale and atrial septal defect. Echocardiography 2020; 37:2172-2184. [PMID: 33368546 DOI: 10.1111/echo.14646] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/07/2020] [Indexed: 11/30/2022] Open
Abstract
Atrial septal defects (ASD) are among the most common congenital heart diseases encountered in adulthood. Patent foramen ovale (PFO) is present in up to 25% of the population. ASD could present as isolated lesion or in association with more complex congenital heart disease form as tetralogy of Fallot, or Ebstein's anomaly of tricuspid valve. There is a wide range of clinical presentation ranging from asymptomatic subjects surviving to adulthood undiagnosed to subjects presenting with right heart failure and severe pulmonary vascular disease (Eisenmenger syndrome). This manuscript is an in depth review of the complex atrial septation, the variable clinical presentation of ASD and PFO, and its clinical and therapeutic implications.
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Affiliation(s)
- Ahmed Kheiwa
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pawan Hari
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pranav Madabhushi
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Padmini Varadarajan
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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23
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Scarff CW, Lippmann J, Fock A. A review of diving practices and outcomes following the diagnosis of a persistent (patent) foramen ovale in compressed air divers with a documented episode of decompression sickness. Diving Hyperb Med 2020; 50:363-369. [PMID: 33325017 DOI: 10.28920/dhm50.4.363-369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/01/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The presence of a persistent (patent) foramen ovale (PFO) increases the risk of decompression sickness (DCS) whilst diving with pressurised air. After the diagnosis of a PFO, divers will be offered a number of options for risk mitigation. The aim of this study was to review the management choices and modifications to diving practices following PFO diagnosis in the era preceding the 2015 joint position statement (JPS) on PFO and diving. METHODS A retrospective study was conducted of divers sourced from both the Alfred Hospital, Melbourne and the Divers Alert Network Asia-Pacific during the period 2005-2015. Divers were contacted via a combination of phone, text, mail and email. Data collected included: diving habits (years, style and depths); DCS symptoms, signs and treatment; return to diving and modifications of dive practices; history of migraine and echocardiography (ECHO) pre- and post-intervention; ECHO technique(s) used, and success or failure of PFO closure (PFOC). Analyses were performed to compare the incidence of DCS pre- and post-PFO diagnosis. RESULTS Seventy-three divers were interviewed. Sixty-eight of these returned to diving following the diagnosis of PFO. Thirty-eight underwent PFOC and chose to adopt conservative diving practices (CDPs); 15 chose PFOC with no modification to practices; 15 adopted CDPs alone; and five have discontinued diving. The incidence of DCS decreased significantly following PFOC and/or adoption of conservative diving practices. Of interest, migraine with aura resolved in almost all those who underwent PFOC. CONCLUSIONS Many divers had already adopted practices consistent with the 2015 JPS permitting the resumption of scuba diving with a lowering of the incidence of DCS to that of the general diving population. These results support the recommendations of the JPS.
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Affiliation(s)
- Christopher W Scarff
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia.,Corresponding author: Dr Christopher W Scarff, The Alfred, PO Box 315, Prahran 3181, VIC, Australia,
| | - John Lippmann
- Australasian Diving Safety Foundation, Melbourne, Australia.,Department of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Fock
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia.,Department of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Giblett JP, Williams LK, Kyranis S, Shapiro LM, Calvert PA. Patent Foramen Ovale Closure: State of the Art. Interv Cardiol 2020; 15:e15. [PMID: 33318751 PMCID: PMC7726850 DOI: 10.15420/icr.2019.27] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 09/22/2020] [Indexed: 12/29/2022] Open
Abstract
Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea–orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.
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Affiliation(s)
- Joel P Giblett
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital Liverpool, UK
| | - Lynne K Williams
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Stephen Kyranis
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Leonard M Shapiro
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
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Sievert K, Yu J, Bertog S, Hornung M, von Bardeleben RS, Gafoor S, Reinartz M, Matic P, Hofmann I, Grunwald I, Schnelle N, Sievert H. Post-Market Clinical Follow-Up With the Patent Foramen Ovale Closure Device IrisFIT (Lifetech) in Patients With Stroke, Transient Ischemic Attack, or Other Thromboembolic Events. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 30:72-75. [PMID: 33097460 DOI: 10.1016/j.carrev.2020.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A patent foramen ovale (PFO) has been associated with embolic strokes and transient ischemic attacks (TIAs). Catheter closure of PFO is effective in preventing recurrent events. Residual shunts and procedure or device related complications can occur, including atrial fibrillation and thrombus formation. This study examines the initial experience with a new PFO closure device, the IrisFIT PFO-Occluder (Lifetech Scientific, Shenzhen, China). METHODS 95 patients with indications for PFO closure underwent percutaneous closure with the IrisFIT PFO-Occluder. The primary endpoint was the rate of accurate device placement with no/small residual shunt at 3 or 6 months follow-up. All patients underwent transoesophageal echocardiography (TEE) after 1 to 6 months. In case of a residual shunt, an additional TEE was performed after 12 months. Clinical follow-up was performed up to a mean of 33.1 ± 3.6 months. RESULTS The device was successfully implanted in 95 (100%) patients with no relevant procedural complications. At final TEE follow-up (7.6 ± 3.9 months) the effective closure rate was 96.8% with 1 moderate and 2 large residual shunts. There were 8 cases of new onset atrial fibrillation and 2 TIAs. There were no cases of device embolization or erosion. CONCLUSION The IrisFIT occluder is a new PFO closure device with several advantages compared to other devices. In this small study cohort, technical success rate, closure rate and adverse event rate were comparable to other devices. The rate of new onset atrial fibrillation was higher in comparison to other studies and warrants further investigation.
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Affiliation(s)
| | - Jiangtao Yu
- Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | | | | | - Ralph Stephan von Bardeleben
- Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | | | | | | | | | - Iris Grunwald
- CardioVascular Center Frankfurt, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom
| | - Nalan Schnelle
- CardioVascular Center Frankfurt, Frankfurt, Germany; Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom.
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Hernigou P. Bone marrow in orthopaedics (part II): a three hundred and seventy million-year saga from the Devonian to the coronavirus disease 2019 pandemic-osteonecrosis; transplantation; "human chimera"; stem cells, bioreactors, and coronavirus disease. INTERNATIONAL ORTHOPAEDICS 2020; 44:2787-2805. [PMID: 33037446 PMCID: PMC7546933 DOI: 10.1007/s00264-020-04843-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Three hundred seventy million years ago, bone marrow appeared in skeleton of a fish. More than one hundred years ago, the concept of bone marrow transplantation was proposed to treat human diseases. During the last five decades, this concept became a reality first in hematology and later for orthopaedic diseases. MATERIAL AND METHODS These advances were possible due to the comprehension of the three major components of bone marrow: the fat part, the haematologic part, and the stroma part. Each part has a different history, but the three parts are linked in physiology as in history. RESULTS During many centuries, bone marrow was considered just as food; however, one hundred years ago, the concept of bone marrow transplantation to treat humans was proposed by the French physician Brown-Séquard. During the last five decades, this concept became a reality first in haematology and later for orthopaedic diseases. Transferring what was known from experimental animal models to humans was met with many challenges, the atomic bomb research, and many deaths. Yet through the recognition and subsequent understanding of fundamental processes, medical resiliency, and the determination of a few pioneers, local bone marrow transplantation in orthopaedic surgery became a therapeutic option first for a limited number of diseases and patients. Over the last two decades, mesenchymal stromal cells (MSCs) have been the focus of intense research by acadaemia and industry due to their unique features. MSCs can be easily isolated and expanded through in vitro culture by taking full advantage of their self-renewing capacity. In addition, MSCs exert immunomodulatory effects and can be differentiated into various lineages, which makes them highly attractive for clinical applications in cell-based therapies. CONCLUSION In this review, we attempted to provide a historical overview of bone marrow history, MSC discovery, characterization, and the first clinical studies conducted.
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Affiliation(s)
- Philippe Hernigou
- Orthopedic Department Henri Mondor Hospital, University Paris East, Paris, France.
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Hernigou P, Hernigou J, Scarlat M. Shoulder Osteonecrosis: Pathogenesis, Causes, Clinical Evaluation, Imaging, and Classification. Orthop Surg 2020; 12:1340-1349. [PMID: 33015963 PMCID: PMC7670135 DOI: 10.1111/os.12788] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 11/29/2022] Open
Abstract
The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as traumatism, corticosteroid use, sickle cell disease, alcoholism, dysbarism (or caisson disease), and Gaucher's disease. The diagnosis is clinical and radiographic with MRI, with radiographs being the basis for staging. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis, but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of fractures, steroid usage, or sickle cell disease, and in divers. This report reviews osteonecrosis of the humeral head, with an emphasis on causes, clinical evaluation, imaging, and classification.
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Hartig F, Reider N, Sojer M, Hammer A, Ploner T, Muth CM, Tilg H, Köhler A. Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt. Front Physiol 2020; 11:994. [PMID: 33013436 PMCID: PMC7497564 DOI: 10.3389/fphys.2020.00994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.
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Affiliation(s)
- Frank Hartig
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Norbert Reider
- Department of Dermatology, University Clinic Innsbruck, Innsbruck, Austria
| | - Martin Sojer
- Department of Neurology, University Clinic Innsbruck, Innsbruck, Austria
| | - Alexander Hammer
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Thomas Ploner
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | | | - Herbert Tilg
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Andrea Köhler
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
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Role of transthoracic echocardiography in the detection of atrial septal aneurysm and intracardial shunts of PFO type in ambulatory practice. COR ET VASA 2020. [DOI: 10.33678/cor.2020.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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30
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Alakbarzade V, Keteepe-Arachi T, Karsan N, Ray R, Pereira AC. Patent foramen ovale. Pract Neurol 2020; 20:225-233. [DOI: 10.1136/practneurol-2019-002450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2020] [Indexed: 11/03/2022]
Abstract
Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.
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31
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Takaya Y, Watanabe N, Ikeda M, Akagi T, Nakayama R, Nakagawa K, Toh N, Ito H. Importance of Abdominal Compression Valsalva Maneuver and Microbubble Grading in Contrast Transthoracic Echocardiography for Detecting Patent Foramen Ovale. J Am Soc Echocardiogr 2020; 33:201-206. [DOI: 10.1016/j.echo.2019.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 11/24/2022]
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32
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Blokland D, Lentjes GW, Velthuis BK, Chamuleau SAJ, Rienks R. Persistent left superior vena cava draining into the left superior pulmonary vein in a scuba diver: A case report and literature study. Scand J Med Sci Sports 2019; 29:1265-1269. [PMID: 31111567 DOI: 10.1111/sms.13471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/03/2019] [Accepted: 05/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Donna Blokland
- Department of Rehabilitation, Physical Therapy Science and Sports, Rudolf Magnus Institute of Neurosciences, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Cardiology, Central Military Hospital, Utrecht, The Netherlands
| | - Gijs W Lentjes
- Department of Rehabilitation, Physical Therapy Science and Sports, Rudolf Magnus Institute of Neurosciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rienk Rienks
- Department of Cardiology, Central Military Hospital, Utrecht, The Netherlands.,Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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33
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Detection of Patent foramen Ovale with Contrast Enhanced Transcranial Doppler at Divers. POLISH HYPERBARIC RESEARCH 2019. [DOI: 10.2478/phr-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Patent foramen ovale (PFO) is a condition present in 25% of the adult population. It is a remnant of fetal foramen ovale which allows blood to pass from the right to the left atrium, bypassing the fetal lungs. In majority adults it does not have any clinical significance, but in some people it may allow shunting of venous blood into the left atrium (right – left – shunt or RLS), circumventing the lung filter, especially during sneezing, cough, lifting heavy equipment. Is such case, PFO may be a route for venous emboli or gas bubbles from veins to the arterial system. It is known as a paradoxical embolism and may be cause of ischaemic stroke or neurologic decompression sickness (DCI), inner-ear DCI and cutis marmorata. Transesophageal echocardiography is considered as a reference standard in detection of intracardial shunts. Its sensitivity and specificity ranges between 94%-100%. However, TEE is an invasive examination with potentially serious side effects. An alternative examination in RLS detection is contrast enhanced Transcranial Doppler (the bubble study or c-TCD). In comparison to TEE, Transcranial Doppler is not invasive, relatively not expensive and save technique. With its high sensitivity and specificity in detection of PFO, 97% and 93% respectively, it may improve detection of RLS and allow to conduct screening examination for PFO in divers.
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34
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Mitchell SJ. DCS or DCI? The difference and why it matters. Diving Hyperb Med 2019; 49:152-153. [PMID: 31523788 DOI: 10.28920/dhm49.3.152-153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 11/05/2022]
Abstract
There are few issues that generate as much confusion in diving medicine as the nomenclature of bubble-induced dysbaric disease. Prior to the late 1980s, the diagnosis 'decompression sickness' (DCS) was invoked for symptoms presumed to arise as a consequence of bubble formation from dissolved inert gas during or after decompression. These bubbles were known to form within tissues, and also to appear in the venous blood (presumably after forming in tissue capillaries). A second diagnosis, 'arterial gas embolism' (AGE) was invoked for symptoms presumed to arise when bubbles were introduced directly to the arterial circulation as a consequence of pulmonary barotrauma. This approach was predicated on an assumption that the underlying pathophysiology could usually be inferred from the nature and tempo of resulting symptoms. DCS was considered to exhibit a slower more progressive onset, symptoms were protean (including pain, rash, paraesthesias, subcutaneous swelling, and neurological symptoms), and the neurological manifestations were mainly attributable to spinal cord or inner ear involvement. In contrast, AGE was considered to exhibit a more precipitous onset (often immediately on surfacing), and the principal manifestation was stroke-like focal neurological impairment suggestive of cerebral involvement. In 1989 an association between a large persistent ('patent') foramen ovale (PFO) and serious neurological DCS was independently reported by two groups, and subsequently corroborated for neurological, inner ear, and cutaneous DCS by multiple studies. The assumed pathophysiological role of a PFO in this setting was to allow bubbles formed from inert gas in the venous blood to avoid removal in the pulmonary circulation and to enter the arterial circulation. These bubbles could then pass to the microcirculation of vulnerable target tissues where inward diffusion of supersaturated inert gas from the surrounding tissue could cause them to grow. This emergence of 'arterialisation' of venous bubbles as an important vector of harm in some forms of DCS resulted in a challenge to the use of traditional 'DCS/AGE' terminology. It was suggested that very early onset of cerebral symptoms after diving could be explained not only by arterial bubbles introduced by pulmonary barotrauma, but also by venous bubbles crossing a PFO into the arterial circulation. Moreover, once venous bubbles had entered the arterial circulation they were then technically 'arterial gas emboli'; thus creating confusion with arterial gas emboli from pulmonary barotrauma. To many commentators, it made little sense to use diagnostic labels (DCS and AGE) that implied a particular pathophysiology when the two disorders might be difficult to tell apart, and had mechanistic processes in common. An alternative approach derived at a UHMS workshop in 1991 was to shift from nomenclature that implied a particular pathophysiology, to a descriptive system that lumped both DCS and AGE together under the label "decompression illness" (DCI). Using this system, terms to describe the organ system(s) involved and the progression of symptoms were applied. For example, a diver with worsening upper arm pain after a dive could be suffering 'progressive musculoskeletal DCI'; and a diver who lost consciousness immediately on surfacing but regained consciousness minutes later would be considered to be suffering 'remitting cerebral DCI'. Classifying cases in this manner made considerable sense at a clinical level, particularly given that there was an emerging consensus that manifestations of DCS and AGE that potentially overlapped did not require different approaches to recompression treatment. This descriptive classification of bubble-induced dysbaric disease gained substantial traction in the community, though not always with a full appreciation by users of the intended nuances of its application. Indeed, it became increasingly common over time to see the terms DCS and DCI used interchangeably; for example, authors using the term DCI to specifically infer the consequences of bubble formation from dissolved gas. This highlights one of the shortcomings of the DCI terminology: it becomes confusing when discussing dysbaric disease at a theoretical or experimental level when the nature of the insult is known or there is a specific intent to discuss bubble formation either from dissolved gas or from pulmonary barotrauma. The potential for confusion between mechanisms and manifestations of DCS and AGE as one of the principle drivers for adopting the DCI terminology deserves further discussion. It is tempting to suggest that if venous bubbles cross a PFO into the arterial blood then any resulting symptoms should be considered a manifestation of 'AGE'. However, there seems little sense in re-naming the primary pathophysiological event (DCS caused by bubble formation from inert gas) just because the bubbles have distributed elsewhere; especially using a name that commonly infers a completely different primary event (bubble formation from pulmonary barotrauma). Moreover, there are grounds for suggesting that these two processes may not be as difficult to distinguish as previously believed. Venous inert gas bubbles are small, and of a similar size distribution to those used as bubble contrast during PFO testing. Decades of experience in testing thousands of divers (and other patients) for PFO using bubble-contrast echocardiograpy have shown that even when strongly positive (that is, large showers of bubbles enter the arterial circulation), symptoms of any sort are very rare. There are sporadic reports of evanescent visual or cerebral symptoms, but (to this author's knowledge) reports of the focal or multifocal cerebral infarctions that can be caused by large arterial bubbles introduced iatrogenically or by pulmonary barotrauma are lacking. One could argue that in the context of PFO testing the brain is not supersaturated with inert gas (which might cause small arterial bubbles to grow), but being such a 'fast tissue' nor is it likely to be after diving. Thus, while sustained showers of small inert gas bubbles crossing a PFO after diving appeal as a plausible cause of transient visual symptoms or dysexecutive syndromes after diving, they are less likely to be the cause of dramatic stroke-like events occurring early after surfacing. In the final edition of Bennett and Elliott it was suggested that one editorial approach to the terminology conundrum would be to utilise the traditional terminology (DCS and AGE) when referring specifically to the pathophysiology and manifestations of bubble formation from dissolved inert gas or pulmonary barotrauma respectively, and to utilise the descriptive (DCI) terminology in clinical discussions when a collective term is useful, or when discussing individual patients where there is either ambiguity about pathophysiology or no need to attempt a distinction. Diving and Hyperbaric Medicine recommends a similar approach. The journal is reluctant to attempt to generate or apply hard 'rules' in relation to terminology of bubble-induced dysbaric disease, but we strongly discourage use of the term 'arterial gas emboli(ism)' to characterise venous inert gas bubbles that cross a right-to-left shunt such as a PFO. The pathophysiological consequences of bubble formation from dissolved inert gas should be regarded as decompression sickness (DCS). There is an expectation that authors are cognisant of the above issues and attempt to adopt terminology that reflects these considerations and best suits the circumstances of their manuscript.
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Affiliation(s)
- Simon J Mitchell
- Editor, Diving and Hyperbaric Medicine Journal.,Department of Anesthesiology, University of Auckland. Private Bag 92019, Auckland 1142, New Zealand,
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35
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Serrano CV, Soeiro ADM, Leal TCAT, Godoy LC, Biselli B, Hata LA, Martins EB, Abud-Manta ICK, Tavares CAM, Cardozo FAM, Oliveira MTD. Statement on Antiplatelet Agents and Anticoagulants in Cardiology - 2019. Arq Bras Cardiol 2019; 113:111-134. [PMID: 31411300 PMCID: PMC6684187 DOI: 10.5935/abc.20190128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Carlos V Serrano
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brazil.,Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
| | - Alexandre de M Soeiro
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil.,Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
| | - Tatiana C A Torres Leal
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Lucas C Godoy
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Bruno Biselli
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Luiz Akira Hata
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Eduardo B Martins
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Isabela C K Abud-Manta
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brazil
| | - Caio A M Tavares
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil.,Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
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36
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Honěk J, Šrámek M, Šefc L, Januška J, Fiedler J, Horváth M, Tomek A, Novotný Š, Honěk T, Veselka J. High-grade patent foramen ovale is a risk factor of unprovoked decompression sickness in recreational divers. J Cardiol 2019; 74:519-523. [PMID: 31255461 DOI: 10.1016/j.jjcc.2019.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/20/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patent foramen ovale (PFO), male sex, age, and body mass index (BMI) were all identified as potential risk factors of decompression sickness (DCS). It has been debated whether PFO might cause unprovoked DCS (i.e. without violation of decompression procedure) due to paradoxical embolization of venous gas emboli. To date, there are no data on the incidence or risk factors of unprovoked DCS. This study sought to evaluate the risk factors of unprovoked DCS in recreational divers. METHODS A total of 489 consecutive divers were screened for PFO between January 2006 and January 2014 by means of transcranial Doppler. All patients were prospectively included in the study registry. Survival analysis techniques were used to assess for risk factors for unprovoked DCS. Age, sex, BMI, PFO presence, and grade were analyzed. The total sum of dives was used as a measure of time. RESULTS The group performed a total of 169,411 dives (mean 346±636). Thirty-six (7%) of the divers suffered from an unprovoked DCS. The frequency of PFO was 97.2% in divers with a history of unprovoked DCS and 35.5% in controls (p<0.001). There was no difference in sex, age, BMI, or total number of dives between the respective groups. In the adjusted Cox proportional hazards model, PFO grade 3 was a major risk factor for unprovoked DCS; there was a slight protective effect of increasing age. CONCLUSIONS We demonstrated that a high-grade PFO was a major risk factor for unprovoked DCS in recreational scuba divers.
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Affiliation(s)
- Jakub Honěk
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; Center for Advanced Preclinical Imaging, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic.
| | - Martin Šrámek
- Center for Advanced Preclinical Imaging, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic; Department of Neurology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; Comprehensive Stroke Center, Military University Hospital, Prague, Czech Republic
| | - Luděk Šefc
- Center for Advanced Preclinical Imaging, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
| | | | - Jiří Fiedler
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Martin Horváth
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Aleš Tomek
- Department of Neurology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Štěpán Novotný
- Hyperbaric Chamber, Kladno Regional Hospital, Kladno, Czech Republic
| | - Tomáš Honěk
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
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West BH, Fleming RG, Al Hemyari B, Banankhah P, Meyer K, Rozier LH, Murphy LS, Coluzzi AC, Rusheen JL, Kumar P, Elashoff D, Tobis JM. Relation of Patent Foramen Ovale to Acute Mountain Sickness. Am J Cardiol 2019; 123:2022-2025. [PMID: 30979412 DOI: 10.1016/j.amjcard.2019.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/22/2019] [Accepted: 03/05/2019] [Indexed: 01/28/2023]
Abstract
Over 50% of patients who rapidly ascend to extreme altitudes develop various symptoms known as acute mountain sickness (AMS), which rarely can be life threatening. It is unclear why some patients are more susceptible to AMS than others. Our objective was to determine whether patent foramen ovale (PFO) is a risk factor for AMS. Subjects who had hiked to altitudes above 10,000' (∼3,000 meters) on the John Muir Trail in California were recruited. Participants completed a questionnaire and 2-physician adjudication was performed in regard to AMS status. A transcranial Doppler with agitated saline contrast injection was performed to evaluate the presence or absence of PFO. The primary outcome was the development of AMS. From 2016 to 2018, 137 hikers were recruited into the study. There was a higher prevalence of PFO in hikers with AMS 15 of 24 (63%) compared with hikers without AMS 44 of 113 (39%); p = 0.034. In the multivariate model, the presence of a PFO significantly increased the risk for developing AMS: odds ratio 4.15, 95% confidence intervals 1.14 to 15.05; p = 0.030. In conclusion, hikers with a PFO had significantly higher risk of developing AMS relative to hikers without a PFO. Clinicians should consider PFO a risk factor in patients who plan to hike to high altitudes.
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Nakayama R, Takaya Y, Akagi T, Watanabe N, Ikeda M, Nakagawa K, Toh N, Ito H. Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr 2019; 32:811-816. [PMID: 31130417 DOI: 10.1016/j.echo.2019.03.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) has become an effective therapeutic strategy for cryptogenic stroke (CS). The identification of high-risk PFO is essential, but the data are limited. This study aimed to clarify the factors related to CS and to develop a score for high-risk PFO. METHODS We retrospectively analyzed 57 patients with prior CS and 50 without CS who were scheduled for transcatheter closure. PFO characteristics were evaluated by transesophageal echocardiography. Based on factors related to CS, we estimated the risk score. RESULTS Patients with CS had a greater frequency of large-size PFO (≥2 mm in height), long-tunnel PFO (≥10 mm in length), atrial septal aneurysm, hypermobile interatrial septum, prominent Eustachian valve or Chiari's network, the large right-to-left shunt at rest and during Valsalva maneuver, and low-angle PFO (≤10° of PFO angle from inferior vena cava), compared with patients without CS. Multivariate analysis showed that long-tunnel PFO, the presence of hypermobile interatrial septum, the presence of prominent Eustachian valve or Chiari's network, the large right-to-left shunt during Valsalva maneuver, and low-angle PFO were independently related to CS. When the score was estimated based on 1 point for each factor, the proportion of CS was markedly elevated with a score of ≥2 points. The probability of CS was markedly different between scores of ≤1 or ≥2 points. CONCLUSIONS PFO risk can be assessed with a score based on high-risk features. The presence of two or more high-risk PFO features is associated with CS.
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Affiliation(s)
- Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan.
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Nobuhisa Watanabe
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Madoka Ikeda
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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39
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Anderson W, Murray P, Hertweck K. Dive Medicine: Current Perspectives and Future Directions. Curr Sports Med Rep 2019; 18:129-135. [PMID: 30969238 DOI: 10.1249/jsr.0000000000000583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
As SCUBA diving continues to rapidly grow in the United States and worldwide, physicians should have a fundamental working knowledge to provide care for an injured diver. SCUBA divers are faced with many hazards at depths that are normally well compensated for at sea level. Pressure gradients, changes in the partial pressure of inhaled gases and gas solubility can have disastrous effects to the diver if not managed properly. Many safety measures in SCUBA diving are governed by the laws of physics, but some have come under scrutiny. This has prompted increased research concerning in water recompression and flying after diving. This article will give physicians an understanding of the dangers divers encounter and the current treatment recommendations. We will also explore some controversies in diving medicine.
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Affiliation(s)
- Wayne Anderson
- Morton Plant Mease Family Medicine Residency Program, Department of Family Medicine, University of South Florida College of Medicine, Tampa, FL
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40
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Abstract
Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people it is a benign finding; however, in some the PFO can open widely, enabling a paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised controlled trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this review considers the evidence for PFO closure in cryptogenic stroke. The review also addresses other potential indications for closure, including systemic embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. It lays out the pre-procedural investigations and preparation for the procedure. Finally, it gives an overview of the procedure itself, including discussion of closure devices.
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Affiliation(s)
- Joel P Giblett
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK.,Division of Cardiovascular Medicine, University of Cambridge Cambridge, UK
| | - Omar Abdul-Samad
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Leonard M Shapiro
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Bushra S Rana
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK.,Division of Cardiovascular Medicine, University of Cambridge Cambridge, UK
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41
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Koopsen R, Stella PR, Thijs KM, Rienks R. Persistent foramen ovale closure in divers with a history of decompression sickness. Neth Heart J 2018; 26:535-539. [PMID: 30178210 PMCID: PMC6220018 DOI: 10.1007/s12471-018-1153-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To study the effect of percutaneous patent foramen ovale (PFO) closure in divers with a history of decompression sickness (DCS). Study design (1) Retrospective study of patient records and (2) telephonic follow-up. Patients with unexplained decompression sickness, who were referred to a cardiologist with a focus on diving medicine between 2000 and 2017, were included in the study Results A total of 62 divers with DCS were included. In all cases transoesophageal echocardiography (TEE) was performed, showing 29 PFOs and 6 atrial septum defects (ASDs) in total n = 35 (56%). The highest prevalence was found in divers with cutaneous and vestibular DCS. At follow-up (mean follow-up duration 6.8 years), 21 PFOs/ASDs were closed using a percutaneous procedure. One diver was lost to follow-up. One diver quit diving. The remaining divers were able to resume unrestricted diving; there was no recurrence of major DCS. Of the divers with an open PFO or ASD, 14 were included of whom 7 are currently diving. All (except one diver with a small PFO) divers are using a conservative diving profile to reduce nitrogen load and the appearance of venous nitrogen bubbles. There was no recurrence of major DCS in this group. Conclusion Percutaneous PFO closure may be an effective and safe treatment for divers who have suffered a major DCS to return to unrestricted diving. Alternatively, conservative treatment seems safe when divers refrain from unrestricted diving and use a conservative technique in order to reduce nitrogen load.
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Affiliation(s)
- R Koopsen
- Utrecht University, Utrecht, The Netherlands.
| | - P R Stella
- Department of Cardiology, University Medical Center, Utrecht, The Netherlands
| | - K M Thijs
- Department of Sports Medicine, University Medical Center, Utrecht, The Netherlands
| | - R Rienks
- Department of Cardiology, University Medical Center, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
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42
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Neill J, Lin CH. A Review of Transcatheter Closure of Patent Foramen Ovale. Methodist Debakey Cardiovasc J 2018; 13:152-159. [PMID: 29744000 DOI: 10.14797/mdcj-13-3-152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
A patent foramen ovale (PFO) is a common variant in cardiac anatomy found in 25% to 30% of U.S. adults. While PFOs are a normal part of fetal development and commonly seen in asymptomatic adults, they have been implicated in a variety of pathophysiologic conditions. The most clinically important of these is paradoxical embolization of venous thrombus resulting in stroke or systemic embolism. Various devices can be used to close PFOs via a transcatheter approach to prevent recurrent stroke. Data regarding the safety and effectiveness of these devices is rapidly evolving, with recent long-term results suggesting efficacy in preventing secondary stroke in carefully selected patients. This review discusses historical data on PFO occurrence and treatment, a risk score that can assess the likelihood of a stroke being attributable to a PFO, a variety of other conditions that may be linked to PFOs, and current research regarding the role transcatheter closure plays in their treatment.
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Affiliation(s)
- John Neill
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - C Huie Lin
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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43
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Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders. J Am Heart Assoc 2018; 7:JAHA.117.007146. [PMID: 29910192 PMCID: PMC6220531 DOI: 10.1161/jaha.117.007146] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Fareed Moses S Collado
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Marie-France Poulin
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Joshua J Murphy
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Hani Jneid
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
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Moses KL, Seymour M, Beshish A, Baker KR, Pegelow DF, Lamers LJ, Eldridge MW, Bates ML. Inspiratory and expiratory resistance cause right-to-left bubble passage through the foramen ovale. Physiol Rep 2018; 6:e13719. [PMID: 29952137 PMCID: PMC6021277 DOI: 10.14814/phy2.13719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 11/29/2022] Open
Abstract
A patent foramen ovale (PFO) is linked to increased risk of decompression illness in divers. One theory is that venous gas emboli crossing the PFO can be minimized by avoiding lifting, straining and Valsalva maneuvers. Alternatively, we hypothesized that mild increases in external inspiratory and expiratory resistance, similar to that provided by a SCUBA regulator, recruit the PFO. Nine healthy adults with a Valsalva-proven PFO completed three randomized trials (inspiratory, expiratory, and combined external loading) with six levels of increasing external resistance (2-20 cmH2 O/L/sec). An agitated saline contrast echocardiogram was performed at each level to determine foramen ovale patency. Contrary to our hypothesis, there was no relationship between the number of subjects recruiting their PFO and the level of external resistance. In fact, at least 50% of participants recruited their PFO during 14 of 18 trials and there was no difference between the combined inspiratory, expiratory, or combined external resistance trials (P > 0.05). We further examined the relationship between PFO recruitment and intrathoracic pressure, estimated from esophageal pressure. Esophageal pressure was not different between participants with and without a recruited PFO. Intrasubject variability was the most important predictor of PFO patency, suggesting that some individuals are more likely to recruit their PFO in the face of even mild external resistance. Right-to-left bubble passage through the PFO occurs in conditions that are physiologically relevant to divers. Transthoracic echocardiography with mild external breathing resistance may be a tool to identify divers that are at risk of PFO-related decompression illness.
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Affiliation(s)
- Kayla L. Moses
- John Rankin Laboratory of Pulmonary MedicineDepartment of PediatricsCritical Care DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
- Department of KinesiologyUniversity of Wisconsin‐MadisonMadisonWisconsin
| | - McKayla Seymour
- Department of Health and Human PhysiologyUniversity of IowaIowa CityIowa
| | - Arij Beshish
- John Rankin Laboratory of Pulmonary MedicineDepartment of PediatricsCritical Care DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Kim R. Baker
- Adult Echocardiography LaboratoryUniversity of Wisconsin Hospitals and ClinicsMadisonWisconsin
| | - David F. Pegelow
- John Rankin Laboratory of Pulmonary MedicineDepartment of PediatricsCritical Care DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Luke J. Lamers
- Division of Pediatric CardiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Marlowe W. Eldridge
- John Rankin Laboratory of Pulmonary MedicineDepartment of PediatricsCritical Care DivisionUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
- Department of KinesiologyUniversity of Wisconsin‐MadisonMadisonWisconsin
- Department of Biomedical EngineeringUniversity of Wisconsin‐MadisonIowa CityIowa
| | - Melissa L. Bates
- Department of Health and Human PhysiologyUniversity of IowaIowa CityIowa
- Stead Family Department of PediatricsUniversity of IowaIowa CityIowa
- Holden Comprehensive Cancer CenterUniversity of IowaIowa CityIowa
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45
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Arieli R, Marmur A. A biophysical vascular bubble model for devising decompression procedures. Physiol Rep 2017; 5:5/6/e13191. [PMID: 28320890 PMCID: PMC5371562 DOI: 10.14814/phy2.13191] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/07/2017] [Accepted: 02/11/2017] [Indexed: 12/14/2022] Open
Abstract
Vascular bubble models, which present a realistic biophysical approach, hold great promise for devising suitable diver decompression procedures. Nanobubbles were found to nucleate on a flat hydrophobic surface, expanding to form bubbles after decompression. Such active hydrophobic spots (AHS) were formed from lung surfactants on the luminal aspect of ovine blood vessels. Many of the phenomena observed in these bubbling vessels correlated with those known to occur in diving. On the basis of our previous studies, which proposed a new model for the formation of arterial bubbles, we now suggest the biophysical model presented herein. There are two phases of bubble expansion after decompression. The first is an extended initiation phase, during which nanobubbles are transformed into gas micronuclei and begin to expand. The second, shorter phase is one of simple diffusion‐driven growth, the inert gas tension in the blood remaining almost constant during bubble expansion. Detachment of the bubble occurs when its buoyancy exceeds the intermembrane force. Three mechanisms underlying the appearance of arterial bubbles should be considered: patent foramen ovale, intrapulmonary arteriovenous anastomoses, and the evolution of bubbles in the distal arteries with preference for the spinal cord. Other parameters that may be quantified include age, acclimation, distribution of bubble volume, AHS, individual sensitivity, and frequency of bubble formation. We believe that the vascular bubble model we propose adheres more closely to proven physiological processes. Its predictability may therefore be higher than other models, with appropriate adjustments for decompression illness (DCI) data.
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Affiliation(s)
- Ran Arieli
- Israel Naval Medical Institute, Haifa, and Eliachar Research Laboratory, Western Galilee Medical Center, Nahariya, Israel
| | - Abraham Marmur
- Department of Chemical Engineering, Technion-Israel Institute of Technology, Haifa, Israel
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46
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LAUTRIDOU JACKY, BUZZACOTT PETER, BELHOMME MARC, DUGRENOT EMMANUEL, LAFÈRE PIERRE, BALESTRA COSTANTINO, GUERRERO FRANÇOIS. Evidence of Heritable Determinants of Decompression Sickness in Rats. Med Sci Sports Exerc 2017; 49:2433-2438. [DOI: 10.1249/mss.0000000000001385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Paradoxical embolism should be suspected in front of a clinical phenomenon of thromboembolism associated with an anatomical right-to-left shunt. Others potential cardiac sources of thromboembolism must be ruled out. Strokes constitute the most frequent clinical manifestations of paradoxical embolism. Right-to-left left shunts are in connection with intracardiac defects (atrial septal defect and patent foramen ovale) or pulmonary arteriovenous malformations. The probability that a discovered PFO is stroke-related can be evaluated by a score. Therapeutic approaches for secondary prevention of recurrent stroke include antithrombotic and/or percutaneous treatments. The choice strategy begins to be clearer with the recent results of randomized controlled studies.
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Affiliation(s)
- P Aubry
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier de Gonesse, 95500 Gonesse, France.
| | - H Demian
- Service de cardiologie, centre hospitalier de Gonesse, 95500 Gonesse, France
| | - E Brochet
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - J-M Juliard
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
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48
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Jasper R, Blankenship JC. Patent foramen ovale closure to prevent secondary neurologic events. Eur J Intern Med 2017; 44:1-11. [PMID: 28684051 DOI: 10.1016/j.ejim.2017.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 04/16/2017] [Accepted: 06/15/2017] [Indexed: 11/15/2022]
Abstract
In October of 2016 the United States Food and Drug Administration approved the Amplatzer Patent Foramen Ovale (PFO) occluder device for use in patients with cryptogenic stroke, to reduce the risk of recurrent stroke. This event followed 15years of off-label use of atrial septal occluder devices, 3 randomized trials, and enormous controversy over the efficacy of this procedure. While none of the trials reached the primary endpoint needed to prove the efficacy of PFO closure in preventing recurrent stroke, meta-analyses and 5-year follow-up of 1 trial suggest that PFO closure decreases the risk of recurrent stroke, especially in sub-groups with large shunts and atrial septal aneurysms, and especially when the Amplatzer device (rather than other devices) is used. While the relative reduction in stroke associated with PFO closure is large (about 50%), the absolute reduction is low (1-2%) and must be balanced against complications of the procedure (about 3%). Thus, PFO closure is restricted to patients with cryptogenic stroke, and depends heavily on patients' personal preferences. Uncertainties about the etiology of stroke in patients with PFO and the efficacy of PFO closure cause a difficult problem for the internal medicine specialist. At one extreme the internist may wonder if every patient with a documented PFO should be referred to a cardiologist. At the other extreme, supported by specialty society guidelines, internists may conclude that PFO closure is rarely necessary. In this paper we review the current status of PFO closure and suggest a rational strategy for this procedure.
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Affiliation(s)
- Rosie Jasper
- Department of Internal Medicine, Geisinger Medical Center, 100 North Academy Drive, Danville, PA, United States.
| | - James C Blankenship
- Department of Cardiology, Geisinger Medical Center, 100 North Academy Drive, Danville, PA, United States
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49
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Gempp E, Lyard M, Louge P. Reliability of right-to-left shunt screening in the prevention of scuba diving related-decompression sickness. Int J Cardiol 2017; 248:155-158. [PMID: 28864135 DOI: 10.1016/j.ijcard.2017.08.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/14/2017] [Accepted: 08/23/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the relationship between right-to-left shunt (RLS) and the clinical features of decompression sickness (DCS) in scuba divers and to determine the potential benefit for screening this anatomical predisposition in primary prevention. METHODS 634 injured divers treated in a single referral hyperbaric facility for different types of DCS were retrospectively compared to 259 healthy divers. All subjects had a RLS screening by contrast Transcranial Doppler (TCD) ultrasound according to a standardized method. The number of bubbles detected defined the degree of RLS (small if 5-20 bubbles, large if >20 bubbles). RESULTS TCD detected 63% RLS in DCS group versus 32% in the control group (p<0.0001) The overall prevalence of RLS was higher in divers presenting a cerebral DCS (OR, 5.3 [95% CI, 3.2-8.9]; p<0.0001), a spinal cord DCS (OR, 2.1 [95% CI, 1.4-3.1]; p<0.0001), an inner ear DCS (OR, 11.8 [95% CI, 7.4-19]; p<0.0001) and a cutaneous DCS (OR, 17.3 [95% CI, 3.9-77]; p<0.0001) compared to the control group, but not in divers experiencing ambiguous symptoms or musculoskeletal DCS. There was in increased risk of DCS with the size of RLS. The determination of diagnostic accuracy of TCD testing through the estimation of likelihood ratios revealed that predetermination of RLS did not change significantly the prediction of developing or not a DCS event. CONCLUSION The assessment of RLS remains indicated after an initial episode of spinal cord, cerebral, inner ear and cutaneous form of DCS but this approach is definitely not recommended in routine practice.
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Affiliation(s)
- Emmanuel Gempp
- French Navy Diving School, Toulon, France; Department of Diving and Hyperbaric Medicine, Sainte Anne's Military Hospital, Toulon, France.
| | | | - Pierre Louge
- Department of Diving and Hyperbaric Medicine, Sainte Anne's Military Hospital, Toulon, France
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50
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Lafère P, Balestra C, Caers D, Germonpré P. Patent Foramen Ovale (PFO), Personality Traits, and Iterative Decompression Sickness. Retrospective Analysis of 209 Cases. Front Psychol 2017; 8:1328. [PMID: 28824507 PMCID: PMC5539185 DOI: 10.3389/fpsyg.2017.01328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/19/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction: There is a need to evaluate the influence of risk factors such as patency of foramen ovale (PFO) or "daredevil" psychological profile on contra-indication policy after a decompression sickness (DCS). Methods: By crossing information obtained from Belgian Hyperbaric Centers, DAN Emergency Hotline, the press, and Internet diving forums, it was possible to be accountable for the majority if not all DCS, which have occurred in Belgium from January 1993 to June 2013. From the available 594 records we excluded all cases with tentative diagnosis, medullary DCS or unreliability of reported dive profile, leaving 209 divers records with cerebral DCS for analysis. Demographics, dive parameters, and PFO grading were recorded. Twenty-three injured divers were tested using the Zuckerman's Sensation Seeking Scale V and compared to a matched group not involved in risky activities. Results: 41.2% of all injured came for iterative DCS. The average depth significantly increases with previous occurrences of DCS (1st DCS: 31.8 ± 7.9 mfw; 2nd DCS: 35.5 ± 9.8 mfw; 3rd DCS: 43.4 ± 6.1 mfw). There is also an increase of PFO prevalence among multiple injured divers (1st DCS: 66.4% 2nd & 3rd DCS: 100%) with a significant increase in PFO grade. Multiple-times injured significantly scored higher than control group on thrill and adventure seeking (TAS), experience seeking, boredom susceptibility and total score. Conclusion: There is an inability of injured diver to adopt conservative dive profile after a DCS. Further work is needed to ascertain whether selected personality characteristics or PFO should be taken into account in the clearance decision to resume diving.
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Affiliation(s)
- Pierre Lafère
- Laboratoire ORPHY-EA4324, Université de Bretagne OccidentaleBrest, France.,Research and Education, Divers Alert Network EuropeRosetto, Italy
| | - Costantino Balestra
- Research and Education, Divers Alert Network EuropeRosetto, Italy.,Anatomical Research and Clinical Studies, Vrije Universiteit BrusselBrussels, Belgium.,Motor Sciences, Université libre de BruxellesBrussels, Belgium.,Anatomical Research Training and Education, Vrije Universiteit BrusselBrussels, Belgium.,Environmental, Occupational, Ageing (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-BrabantBrussels, Belgium
| | - Dirk Caers
- Centre for Hyperbaric Oxygen Therapy, Military Hospital Queen AstridBrussels, Belgium
| | - Peter Germonpré
- Research and Education, Divers Alert Network EuropeRosetto, Italy.,Centre for Hyperbaric Oxygen Therapy, Military Hospital Queen AstridBrussels, Belgium
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