1688 34. Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, Kutalek SP, Sharma A; Dual Chamber and VVI Implantable Defibrillator Trial Investigators. Dualchamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA 2002;288:3115 – 3123. 35. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE; ESC Committee for Practice Guidelines (CPG), Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S; Document Reviewers, Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Ba¨nsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, Van Gelder IC, Wilson CM. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013;34:2281–2329.
C.E. Raphael et al.
36. Salukhe TV, Briceno NI, Ferenczi EA, Sutton R, Francis DP. Is there benefit in implanting defibrillators in patients with severe heart failure? Heart 2010;96:599 –603. 37. Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the ‘DEALE’). Am J Med 1982;73:883 –888. 38. Schowalter M, Gelbrich G, Sto¨rk S, Langguth JP, Morbach C, Ertl G, Faller H, Angermann CE. Generic and disease-specific health-related quality of life in patients with chronic systolic heart failure: impact of depression. Clin Res Cardiol 2013;102: 269 –278. 39. Borne RT, Peterson PN, Greenlee R, Heidenreich PA, Wang Y, Curtis JP, Tzou WS, Varosy PD, Kremers MS, Masoudi FA. Temporal trends in patient characteristics and outcomes among Medicare beneficiaries undergoing primary prevention implantable cardioverter-defibrillator placement in the United States, 2006 –2010. Results from the National Cardiovascular Data Registry’s Implantable CardioverterDefibrillator Registry. Circulation 2014;130:845 –853. 40. Krahn AD, Lee DS, Birnie D, Healey JS, Crystal E, Dorian P, Simpson CS, Khaykin Y, Cameron D, Janmohamed A, Yee R, Austin PC, Chen Z, Hardy J, Tu JV; Ontario ICD Database Investigators. Predictors of short-term complications after implantable cardioverter-defibrillator replacement: results from the Ontario ICD Database. Circ Arrhythm Electrophysiol 2011;4:136 –142.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv045 Online publish-ahead-of-print 6 March 2015
.............................................................................................................................................................................
Thrombus trapped in patent foramen ovale Pavan Chandrala*, Kate Johnson, and Hisham Hallani Department of Cardiology, Nepean Hospital, Derby St, Kingswood, NSW, Australia
A 63-year-old man was hospitalized with 2 days of increasing dyspnoea and presyncope. He had developed confusion, dysarthria, and a left-sided facial droop that morning. Three weeks previously the patient had suffered a urinary tract infection and had taken prolonged bed rest. His only background was hypertension. Clinical assessment revealed tachypnoea, sinus tachycardia, and a mild left-sided motor deficit. Laboratory testing revealed elevated high-sensitivity troponin (5122 ng/L), positive D dimer and elevated urea (20 mmol/L), and creatinine (420 mmol/L). Transoesophageal echocardiography (TOE) illustrated a mobile mass crossing the interatrial septum and present in both atria and ventricles. Doppler ultrasound revealed a right lower limb deep vein thrombosis (DVT). Brain magnetic resonance imaging demonstrated multiple small strokes. Thrombophilia screening was negative. He was diagnosed with a thrombus straddling a patent foramen ovale (PFO) causing coronary, pulmonary, renal, and cerebral embolism. The patient was heparinized and surgical thombectomy was arranged for the subsequent day. However, preoperative TOE showed the thrombus was no longer present. The patient was transitioned to warfarin therapy. His dyspnoea, neurological signs, and renal function gradually improved. He remains well 1 month after discharge and is due for percutaneous PFO closure as soon as possible. Both PFO and DVT are relatively common. Thrombus entrapped in a PFO is an uncommon finding with potentially devastating consequences. Usually pulmonary embolism elevates right heart pressures facilitating thrombus entering a PFO where it becomes entrapped and propagates. Ideal treatment is unknown due to its low incidence; however, anticoagulation and surgical thrombectomy are the mainstay. Thrombolysis can be attempted if in extremis. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from by guest on July 9, 2015
* Corresponding author. Tel: +61 2 4734 1719, Fax: +61 2 4734 3066, Email: [email protected]
C.E. Raphael et al.
36. Salukhe TV, Briceno NI, Ferenczi EA, Sutton R, Francis DP. Is there benefit in implanting defibrillators in patients with severe heart failure? Heart 2010;96:599 –603. 37. Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the ‘DEALE’). Am J Med 1982;73:883 –888. 38. Schowalter M, Gelbrich G, Sto¨rk S, Langguth JP, Morbach C, Ertl G, Faller H, Angermann CE. Generic and disease-specific health-related quality of life in patients with chronic systolic heart failure: impact of depression. Clin Res Cardiol 2013;102: 269 –278. 39. Borne RT, Peterson PN, Greenlee R, Heidenreich PA, Wang Y, Curtis JP, Tzou WS, Varosy PD, Kremers MS, Masoudi FA. Temporal trends in patient characteristics and outcomes among Medicare beneficiaries undergoing primary prevention implantable cardioverter-defibrillator placement in the United States, 2006 –2010. Results from the National Cardiovascular Data Registry’s Implantable CardioverterDefibrillator Registry. Circulation 2014;130:845 –853. 40. Krahn AD, Lee DS, Birnie D, Healey JS, Crystal E, Dorian P, Simpson CS, Khaykin Y, Cameron D, Janmohamed A, Yee R, Austin PC, Chen Z, Hardy J, Tu JV; Ontario ICD Database Investigators. Predictors of short-term complications after implantable cardioverter-defibrillator replacement: results from the Ontario ICD Database. Circ Arrhythm Electrophysiol 2011;4:136 –142.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv045 Online publish-ahead-of-print 6 March 2015
.............................................................................................................................................................................
Thrombus trapped in patent foramen ovale Pavan Chandrala*, Kate Johnson, and Hisham Hallani Department of Cardiology, Nepean Hospital, Derby St, Kingswood, NSW, Australia
A 63-year-old man was hospitalized with 2 days of increasing dyspnoea and presyncope. He had developed confusion, dysarthria, and a left-sided facial droop that morning. Three weeks previously the patient had suffered a urinary tract infection and had taken prolonged bed rest. His only background was hypertension. Clinical assessment revealed tachypnoea, sinus tachycardia, and a mild left-sided motor deficit. Laboratory testing revealed elevated high-sensitivity troponin (5122 ng/L), positive D dimer and elevated urea (20 mmol/L), and creatinine (420 mmol/L). Transoesophageal echocardiography (TOE) illustrated a mobile mass crossing the interatrial septum and present in both atria and ventricles. Doppler ultrasound revealed a right lower limb deep vein thrombosis (DVT). Brain magnetic resonance imaging demonstrated multiple small strokes. Thrombophilia screening was negative. He was diagnosed with a thrombus straddling a patent foramen ovale (PFO) causing coronary, pulmonary, renal, and cerebral embolism. The patient was heparinized and surgical thombectomy was arranged for the subsequent day. However, preoperative TOE showed the thrombus was no longer present. The patient was transitioned to warfarin therapy. His dyspnoea, neurological signs, and renal function gradually improved. He remains well 1 month after discharge and is due for percutaneous PFO closure as soon as possible. Both PFO and DVT are relatively common. Thrombus entrapped in a PFO is an uncommon finding with potentially devastating consequences. Usually pulmonary embolism elevates right heart pressures facilitating thrombus entering a PFO where it becomes entrapped and propagates. Ideal treatment is unknown due to its low incidence; however, anticoagulation and surgical thrombectomy are the mainstay. Thrombolysis can be attempted if in extremis. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from by guest on July 9, 2015
* Corresponding author. Tel: +61 2 4734 1719, Fax: +61 2 4734 3066, Email: [email protected]
