Rethinking the Implications of Large Eustachian Valve during Interventional and Surgical Atrial Septal Defect and Patent Foramen Ovale Closure Procedures | Chapter 10 | Medical Research and Its Applications Vol. 8

 

It is likely that a proportion of patients evaluated for transcatheter Patent Foramen Ovale (PFO) and ostium secundum Atrial Septal Defect (OS ASD) closure has actually different anatomical variants particularly common in the right atrium such as Eustachian valve (EV), Chiari network (CN), Thebesian valve and Crista Terminalis (CT). Notably, EV is usually considered to be a benign finding in the absence of associated cardiac anomalies, but it is frequently found in adult patients with septal abnormalities mainly PFO. Percutaneous PFO/OS ASD closure can be achieved safely and efficiently and nowadays represents a routine interventional procedure in the catheterization laboratory with two different clinical indications. PFO closure is usually effective in preventing recurrent embolic stroke/systemic arterial embolization having reduced the risk of recurrent stroke in patients with cryptogenic strokes in randomized clinical trials [1,2]. Of note, EV may actively facilitate the mechanism of paradoxical embolism by directing the blood from the Inferior Vena Cava (IVC) towards the interatrial septum via PFO into the left atrium. Therefore, the presence of such an anatomic variant may represent per se an increased risk factor for left circulation thromboembolism. OS ASD represents the second most common congenital heart defect, accounting for about 10% of all congenital heart defects in the adult population. ASD closure is indicated in patients with significant left-to-right shunt, right ventricular volume overload, and normal pulmonary vascular resistance. Transcatheter OS ASD closure using currently available devices has proven to be safe and effective in the majority of cases offering excellent closure rates and shorter hospital stays compared to surgery [3,4].

 

It is of paramount importance to identify by echocardiography imaging the EV and other anatomical variants in order to avoid misdiagnosis and complications when planning PFO/OS ASD percutaneous or surgical closure procedures where EV may interfere with a successful outcome.

 

 

Author(s) Details

 

Eustaquio Maria Onorato

Department of Cardiology, University Hospital, I.R.C.C.S. Ospedale Galeazzi - Sant’Ambrogio, Milan, Italy.

 

 

Please see the link:- https://doi.org/10.9734/bpi/mria/v8/335

A Case Study on Elicitation of Aura Migraine Via Pulmonary Arteriovenous Fistula | Chapter 8 | Medical Science: Trends and Innovations Vol. 2

A pulmonary arteriovenous fistula (PAVM) is defined as a congenital abnormal communication between the pulmonary artery and its tributary vein creating a low-resistance, high-flow right-to-left shunting (RLS) bypassing the capillary bed. PAVM is an abnormal blood vessel that creates a direct connection between a pulmonary artery and its tributary vein bypassing the capillary filter, establishing as a consequence of a low-resistance right-to-left shunting (RLS). The vast majority of PAVMs are congenital appearing more often in females than in males. A great number of patients with PAVMs are suffering concurrently from hereditary hemorrhagic telangiectasia (HHT) whose incidence is around 1 in 5,000. Very few cases of acquired PAVMs have been described in the literature. Paradoxical embolism through PAVMs can cause systemic desaturation, cyanosis, and serious cerebrovascular ischemic events (transient ischemic attacks, strokes, and intracranial abscess), even when the abnormal blood vessel is small (diameter <3 mm). Notably, it has been reported a high prevalence of aura migraine (MHA) symptoms in patients with PAVMs and concomitant HHT. In this study, the case of a young aura migraineur female patient without HHT in whom isolated PAVM below the detection limit of pulmonary angiography and chest computed tomography angiography (CTA) has been documented by contrast Transthoracic and Transesophageal Echocardiography (cTTE/TEE) showing a delayed (>17 s) RLS coming from left pulmonary veins to left atrium while a patent foramen ovale (PFO), small atrial septal defects or septum primum fenestration could not be detected despite several attempts. Contrast Transcranial Doppler (cTCD) confirmed a delayed (>16 s) RLS with two short “shower” patterns corroborating the diagnosis of an extra-cardiac RLS. During the right heart catheterization and pulmonary angiography, it was impossible to cross the interatrial septum with a multipurpose catheter. The patient was finally discharged with off-label thienopyridine agents (clopidogrel 75 mg die) in terms of primary prophylaxis for paradoxical right-to-left embolization of thrombotic material. Aura migraine symptoms were nearly abolished by P2Y12 platelet inhibition, suggesting a platelet-based mechanism. During 2 years of clinical follow-up on thienopyridine therapy, the resolution of aura migraine episodes was definitively accomplished with significant improvement in her quality of life. In summary, a case of a patient was presented with isolated intrapulmonary RLS below the detection limit of pulmonary angiography and CTA whose aura migraine symptoms resolved following P2Y12 platelet inhibition with a considerable improvement in her quality of life.

 

Author (s) Details

 

Eustaquio Maria Onorato
I.R.C.C.S. Ospedale Galeazzi-Sant’Ambrogio GSD, Milan, Italy.

 

Josephal Salvia
Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy.

 

Mariano Becchina
Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy.

 

Tommaso Cipolla
Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy.

 

Gian Paolo Anzola
Neurology Clinic and Rehabilitation Department, Casa di Cura Villa Barbarano, Brescia, Italy.

 

Please see the book here:- https://doi.org/10.9734/bpi/msti/v2/4056