Acute mountain sickness (AMS) commonly plagues people who travel to high altitude and can be life threatening. Clinically, AMS is defined by a constellation of symptoms as outlined in the Lake Louise Criteria. The underl...Acute mountain sickness (AMS) commonly plagues people who travel to high altitude and can be life threatening. Clinically, AMS is defined by a constellation of symptoms as outlined in the Lake Louise Criteria. The underlying etiology is thought to be related to a decrease in partial pressure of oxygen leading to tissue hypoxia. Patent foramen ovale (PFO) has been postulated to play a role in AMS through right-to-left shunt, which can worsen hypoxemia. Recent data demonstrate a higher prevalence of PFO in hikers with AMS. Future studies are needed to further elucidate the relationship between PFO and AMS.
Although the most common clinical manifestations of a patent foramen ovale (PFO) are cryptogenic stroke and migraine with aura, PFO is also associated with platypnea-orthodeoxia syndrome, obstructive sleep apnea, and chr...Although the most common clinical manifestations of a patent foramen ovale (PFO) are cryptogenic stroke and migraine with aura, PFO is also associated with platypnea-orthodeoxia syndrome, obstructive sleep apnea, and chronic obstructive pulmonary disease with hypoxemia out of proportion to the extent of pulmonary disease. This article will discuss these conditions and summarize the related literature.
The pathophysiology of migraine remains poorly understood. Like most migraine preventive therapies, patent foramen ovale (PFO) closure was never intended for the treatment of migraine. After closure of PFO for other reas...The pathophysiology of migraine remains poorly understood. Like most migraine preventive therapies, patent foramen ovale (PFO) closure was never intended for the treatment of migraine. After closure of PFO for other reasons, migraine symptom reduction/elimination was noted in some patients. Subsequent small trials failed to prove its benefit. There is significant evidence suggesting a platelet-mediated mechanism linking migraines to PFO. The GORE RELIEF Clinical Study is a randomized, blinded, placebo- and sham-controlled trial, currently enrolling. The study design is meant to optimize patient selection using thienopyridine responsiveness as an inclusion criterion.
Paradoxic embolism through a patent foramen ovale (PFO) is a common cause of ischemic stroke, accounting for 1 in 20 of all ischemic strokes. Neurologists play the leading role in diagnosing PFO-associated stroke, determ...Paradoxic embolism through a patent foramen ovale (PFO) is a common cause of ischemic stroke, accounting for 1 in 20 of all ischemic strokes. Neurologists play the leading role in diagnosing PFO-associated stroke, determining that a cerebral infarct is embolic in distribution and excluding other potential stroke mechanisms. Among patients aged 18 to 60 years old with a PFO and an otherwise cryptogenic stroke, the PFO-Associated Stroke Causal Likelihood classification system should be used to identify the 85% of patients likely to benefit from PFO closure and the 15% of patients likely to be harmed by PFO closure.
Noninvasive and invasive imaging modalities play important roles for the detection of patent foramen ovale (PFO). Transthoracic echocardiography or transcranial Doppler bubble study can be used for initial noninvasive PF...Noninvasive and invasive imaging modalities play important roles for the detection of patent foramen ovale (PFO). Transthoracic echocardiography or transcranial Doppler bubble study can be used for initial noninvasive PFO screening. For diagnostic confirmation, transesophageal echocardiography bubble study can be utilized, a semiinvasive confirmatory test that can directly visualize a PFO. In selective cases when the diagnosis is in doubt, PFO can be accurately diagnosed invasively with right heart catheterization. Understanding the advantages and limitations of each diagnostic option will help clinicians choose the appropriate test for patients presenting with a PFO-associated condition who may benefit from percutaneous device closure.
Patent foramen ovale (PFO) is a common finding in the general population but may lead to serious conditions such as stroke from paradoxical embolism and platypnea orthodeoxia. A thorough understanding of the interatrial...Patent foramen ovale (PFO) is a common finding in the general population but may lead to serious conditions such as stroke from paradoxical embolism and platypnea orthodeoxia. A thorough understanding of the interatrial septal anatomy along with its assessment by different imaging modalities is critical in performing safe transcatheter PFO closure. Investigating the anatomy and right heart to left heart flows using transesophageal echocardiography or intracardiac echocardiography imaging must be done before undertaking closure of a PFO.
This introductory article provides many key lessons that I have learned in my 23 years of studying patent foramen ovale (PFO). It discusses issues related to the diagnosis, clinical presentation, and treatment of PFO.This introductory article provides many key lessons that I have learned in my 23 years of studying patent foramen ovale (PFO). It discusses issues related to the diagnosis, clinical presentation, and treatment of PFO.
Mitral valve stenosis remains highly prevalent among the US population although with dramatically shifting demographics. The significance of rheumatic mitral disease in developing nations persists, despite improvements i...Mitral valve stenosis remains highly prevalent among the US population although with dramatically shifting demographics. The significance of rheumatic mitral disease in developing nations persists, despite improvements in preventative measures and early detection, and its presence in developed countries is still evident as observed through international migration. In addition, the substantial growth in the aging population with a heightened occurrence of concurrent cardiovascular risk factors is leading to an increased prevalence of chronic calcific degeneration and degeneration of previously repaired or replaced valves. This article aims to review various transcatheter therapies in the treatment of mitral valve stenosis.
Gaznabi S, Miranda J, Lorenzatti D
… +12 more, Piña P, Balasubramanian SS, Desai D, Desai A, Ho EC, Scotti A, Gongora CA, Schenone AL, Garcia MJ, Latib A, Parwani P, Slipczuk L
Current guidelines of aortic stenosis (AS) management focus on valve parameters, LV systolic dysfunction, and symptoms; however, emerging data suggest that there may be benefit of aortic valve replacement before it becom...Current guidelines of aortic stenosis (AS) management focus on valve parameters, LV systolic dysfunction, and symptoms; however, emerging data suggest that there may be benefit of aortic valve replacement before it becomes severe by present criteria. Myocardial assessment using novel multimodality imaging techniques exhibits subclinical myocardial injury and remodeling at various stages before guideline-directed interventions, which predicts adverse outcomes. This raises the question of whether implementing serial myocardial assessment should become part of the standard appraisal, thereby identifying high-risk patients aiming to minimize adverse outcomes.
Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typ...Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.
Atrioventricular (AV) valve disease is a major burden in our Indian subcontinent, where rheumatic heart disease is still prevalent, when compared to the Western world, where degenerative heart disease is more prevalent....Atrioventricular (AV) valve disease is a major burden in our Indian subcontinent, where rheumatic heart disease is still prevalent, when compared to the Western world, where degenerative heart disease is more prevalent. Worldwide, nearly 300,000 valve replacements are done every year but not without complications. These challenges can be multidimensional and multiscalar with the macroscopic and microscopic properties of the native patient tissue interacting with the mechanical and bioprosthetic heart valves and rings. Understanding the complex and variable anatomy of the AV valves is essential to know the exact pathophysiology of the disease and to decide the treatment of choice.
The left atrial appendage (LAA) has gained increasing attention in the field of cardiology as a potential site for intervention in patients with atrial fibrillation (AF) and an elevated risk of thromboembolic events. Lef...The left atrial appendage (LAA) has gained increasing attention in the field of cardiology as a potential site for intervention in patients with atrial fibrillation (AF) and an elevated risk of thromboembolic events. Left atrial appendage occlusion (LAAO) has emerged as a promising therapeutic strategy to mitigate the risk of stroke and systemic embolism, especially in individuals who are unsuitable candidates for long-term anticoagulation therapy. This review aims to provide a comprehensive analysis of the current state of LAAO, encompassing its anatomic considerations, procedural techniques, clinical outcomes, and future directions.
Self-expanding valves (SEV) and balloon-expandable valves (BEV) for transcatheter aortic valve implantation (TAVI) have their own features. There is a growing interest in long-term outcomes with the adoption of lifetime...Self-expanding valves (SEV) and balloon-expandable valves (BEV) for transcatheter aortic valve implantation (TAVI) have their own features. There is a growing interest in long-term outcomes with the adoption of lifetime management in younger patients. To evaluate late outcomes in TAVI with SEV versus BEV, we performed a study-level meta-analysis of reconstructed time-to-event data published by May 31, 2023. We found no statistically significant difference in all-cause death after TAVI with SEV versus BEV. Randomized controlled trials are warranted to validate our results.
Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to i...Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).
Echocardiography, in all its forms (transthoracic echocardiography [TTE], transesophageal echocardiography [TEE], and intracardiac echocardiography [ICE]), is pivotal for the evaluation, guidance, and follow-up of transc...Echocardiography, in all its forms (transthoracic echocardiography [TTE], transesophageal echocardiography [TEE], and intracardiac echocardiography [ICE]), is pivotal for the evaluation, guidance, and follow-up of transcatheter tricuspid edge-to-edge repair (TV-TEER) therapies. Although two-dimensional (2D) echocardiography remains essential, three-dimensional (3D) echo with multiplanar reconstruction (MPR) has revolutionized the field of structural imaging. In addition, the advent of 3D ICE has added an important modality to the imaging toolbox, particularly helpful when intraprocedural TEE images are challenging. In this review, we provide a detailed, step-by-step approach for advanced echocardiographic guidance of TV-TEER using 3D MPR.
Electrosurgery has emerged as a groundbreaking tool in the field of structural cardiac interventions, revolutionizing the approach to complex cardiac conditions. This review delves into the core principles, procedural te...Electrosurgery has emerged as a groundbreaking tool in the field of structural cardiac interventions, revolutionizing the approach to complex cardiac conditions. This review delves into the core principles, procedural techniques, outcomes, and potential challenges associated with various electrosurgical procedures within the realm of structural cardiology. Five key electrosurgical procedures performed in complex structural interventions are highlighted in this review. They are the Transcaval Access, BASILICA, LAMPOON, ELASTIC/ELASTA-Clip, and SESAME procedures. While these electrosurgery procedures hold promise and have demonstrated positive outcomes, their technical intricacies, patient selection criteria, and the need for further research remain important considerations. As technology continues to evolve and more data becomes available, electrosurgery is poised to continue shaping the landscape of cardiac care, offering minimally invasive alternatives, and improving patient outcomes in complex structural cardiac interventions.
Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascul...Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascularization in these patients who are referred for transcatheter aortic valve replacement (TAVR). This article aims to show that in patients without high-grade proximal coronary artery disease, revascularization after TAVR is safe, feasible, and practical. Additionally, the use of preoperative TAVR computed tomographic angiography might be used in both intermediate and high-risk patients rather than invasive coronary angiography to assess for significant proximal coronary artery disease to help guide the timing of revascularization.
Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life suppor...Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.