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Nguyễn Lân Hiếu Question 1 51 yr old male with no past medical history presents with chest pain  ECG is normal  Stress echocardiogram is negative for ischemic changes  Color Doppler interrogation demonstrates a patent foramen ovale with a small bidirectional shunt  Agitated saline injection is positive for a small right-to-left shunt What is the best disposition for this patient? A. Cardiac MRI to evaluate right ventricular volume B. No further testing C. Clopidogrel 75 mg PO and Aspirin 325mg PO daily D. Device closure of the patent foramen ovale Question 1: Answer A. A patent foramen ovale should not result in right ventricular volume overload. Therefore, MRI is not indicated B. A patent foramen ovale is present in ~25% of the adult population. The chest pain is unrelated to this finding. C. No data supports medical therapy to prevent paradoxical emboli in an asymptomatic patient D. No data supports device or surgical closure to prevent paradoxical emboli in an asymptomatic patient Secundum ASDPatent foramen ovale Hagen et al. Mayo Clin Proc 59:17-20, 1984. Septum secundum Septum primum RA LA • Interatrial communication present in fetal life LARA • Lack of fusion between: – Septum primum – Septum secundum Patent Foramen Ovale (PFO) • Prevalence of PFO ~26% of population • ~35% age up to 30 yo  ~20% age > 80 yo Cabanes et al. J Am Soc Echocardiogr 15: 441-6, 2002. PFO Diagnosis • Ultrasound-based imaging modalities used in the detection of R  L shunt • Transthoracic echo with agitated saline / contrast • Small shunt: 1 - 10 bubbles in LA • Medium shunt: 10 - 30 bubbles • Large shunt: > 30 bubbles • Transesophageal echo with agitated saline / contrast • Transcranial Doppler ultrasonography with contrast • Cryptogenic stroke• Cryptogenic stroke Conditions/Pathology Associated with PFO • Paradoxical arterial embolism • Migraine • Platypnea – orthodeoxia syndrome • Decompression illness • Transient global amnesia • Obstructive sleep apnea • Liver transplantation complications • Varicose veins • Pacemaker wires Bugra et al. H. Throm Thrombolysis; 10:(1) 2007 Paradoxical Embolism from RL Shunts Question 2 A 30 year old female presents with a persistent cough  Chest x-ray demonstrates cardiomegaly  Echocardiogram demonstrates increased velocity across the pulmonary valve (peak velocity 2.2 m/sec) and moderate right heart chamber enlargement What is the next step in management? A. Annual evaluations to assess for ventricular dysfunction B. Cardiopulmonary exercise testing C. Additional echo imaging to demonstrate a secundum ASD D. Cardiac catheterization with balloon pulmonary valvuloplasty Question 2: Answer A. There is no indication of ventricular dysfunction B. Additional information required to explain chamber dilation. Exercise testing would not provide the needed information C. A hemodynamically significant ASD will result in right atrial and right ventricular dilation D. The increased flow acceleration across the pulmonary valve is mild. A valvuloplasty procedure is not indicated in this setting. Moreover, the ASD would result in increased flow and a “physiologic stenosis” of the valve that would resolve after ASD closure. Question 3 A 62 year old female presents with a murmur and exertional dyspnea  Past medical history is significant for systemic hypertension  Treated with a beta blocker and ACE inhibitor  2D echocardiogram demonstrates an 8mm secundum ASD with left-to- right shunting, normal left ventricular systolic function, moderate thickening of the left ventricular wall without regional wall motion abnormalities, mild right ventricular dilation with normal systolic function. No outflow tract obstruction was observed. What is the best intervention? A. Continuation of current medical therapy and 1 year follow-up B. Initiation of aspirin 325mg daily and 1 year follow-up C. Left and right heart catheterization D. Device closure of the ASD [...]...  ECG is normal  Echocardiography demonstrates a muscular ventricular septal defect with a peak systolic velocity of 5.2 m/sec Normal biventricular size & function Tricuspid regurgitation velocity estimates normal right ventricular pressure What is the most appropriate management? A No intervention B Restriction of vigorous physical activity and SBE prophylaxis C Cardiac catheterization to quantify