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Johannes J Mager - One of the best experts on this subject based on the ideXlab platform.
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grade of pulmonary right to left Shunt on contrast echocardiography and cerebral complications a striking association
Chest, 2013Co-Authors: Sebastiaan Velthuis, Marco W F Van Gent, Pietro Gazzaniga, Guido Manfredi, Cesare Danesino, Wouter J Schonewille, Cornelis J J Westermann, Repke J Snijder, Elisabetta Buscarini, Johannes J MagerAbstract:Background A pulmonary Right-to-Left Shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary Shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary Shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). Methods We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary Shunt grading on TTCE (grade 0, no microbubbles; grade 1, 100 microbubbles) was performed according to contrast opacification of the left ventricle. Cerebral complications were defined as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confirmed by appropriate imaging techniques. Results A pulmonary RLS was present in 530 out of 1,038 patients (51.1%; mean age, 44.3 ± 15.6 years; 58.6% women). The presence of a cerebral manifestation (n = 51) differed significantly among pulmonary Shunt grades on TTCE: 1.4%, 0.4%, 6.5%, and 20.9% for grades 0, 1, 2 and 3, respectively. A pulmonary Shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95% CI, 0.05-4.13; P = .47), whereas pulmonary Shunt grade 2 (OR, 4.78; 95% CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95% CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. Conclusions The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.
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grading of pulmonary right to left Shunt with transthoracic contrast echocardiography does it predict the indication for embolotherapy
Chest, 2009Co-Authors: Marco W F Van Gent, Cornelis J J Westermann, Repke J Snijder, Martijn C. Post, Martin J Swaans, H W M Plokker, Tim T Overtoom, Johannes J MagerAbstract:Rationale Pulmonary arteriovenous malformations (PAVMs) are associated with severe neurologic complications in patients with hereditary hemorrhagic telangiectasia (HHT). Therefore, screening is warranted. Transthoracic contrast echocardiography (TTCE) can effectively detect a pulmonary Right-to-Left Shunt (RLS). Objectives To determine prospectively the predictive value of TTCE grading to detect PAVMs on high-resolution CT (HRCT) scans of the chest and the indication for embolotherapy. Methods Three hundred seventeen patients, referred for possible HHT, were screened for PAVMs. Patients who underwent both chest HRCT scanning and TTCE were included in the study (n = 281). For the purposes of this study we used a 3-point grading scale, and Shunt grades 3 and 4 according to the classification model of Barzilai et al were combined. Embolotherapy was performed of all PAVMs judged large enough for treatment. Results Echocardiographic criteria for a pulmonary RLS were present in 105 patients (41%) [mean (+/- SD) age, 43.7 +/- 15.7 years; female gender, 63%]. Chest HRCT scan findings were positive in 55 patients (52%) in this group. The positive predictive value of Shunt grade for the presence of PAVMs on chest HRCT scans was 22.9% for grade 1 (n = 35), 34.8% for grade 2 (n = 23), and 83.0% for grade 3 (n = 47), respectively. None of the patients with PAVMs seen on chest HRCT scans and a TTCE grade 1 (n = 8) or 2 (n = 8) were candidates for embolotherapy. Of 39 patients with TTCE grade 3 and PAVMs seen on chest HRCT scans, 26 patients (67%) underwent embolotherapy. Conclusion An increased echocardiographic Shunt grade correlates with an increased probability of PAVMs seen on chest HRCT scans. Only patients with a TTCE grade 3 displayed PAVMs on chest HRCT scans that were large enough for embolotherapy.
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a pulmonary right to left Shunt in patients with hereditary hemorrhagic telangiectasia is associated with an increased prevalence of migraine
Chest, 2005Co-Authors: Martijn C. Post, Johannes J Mager, Tom G W Letteboer, Thijs H W Plokker, Johannes C Kelder, C. J. J. WestermannAbstract:Introduction Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal-dominant vascular dysplasia with a high prevalence of pulmonary arteriovenous malformation (PAVM). Recent studies report an increased prevalence of migraine in patients with a cardiac Right-to-Left Shunt. The aim of our study was to evaluate whether there is also an increased prevalence of migraine in patients with a pulmonary Right-to-Left Shunt (PAVM). Methods All patients with HHT referred to our hospital till April 2004 with or without PAVM and with or without migraine were included in the study. Results In total, 538 HHT patients (41.6% men; mean age ± SD, 39.3 ± 18.6 years) could be included. PAVM was present in 208 patients (38.7%; mean age, 39.3 ± 17.6 years). Significantly more women were present in the PAVM subgroup compared to the non-PAVM subgroup, 65.4% vs 53.9% (p = 0.009). Migraine occurred in 88 patients with HHT, a prevalence of 16.4%. The prevalence of migraine in women with HHT was significantly higher compared to men, 19.4% vs 12.1%, respectively (p = 0.03) The prevalence of migraine in patients with PAVM was 21.2%, which was significantly higher then in patients without PAVM, 13.3% (p = 0.02). The occurrence of PAVM in the patients with migraine is significantly higher than in those without migraine, 50.0% vs 36.4%, respectively (p = 0.02). Conclusion This study showed a higher prevalence of PAVM in patients with migraine and HHT. The Right-to-Left Shunt due to the PAVM might play a causal role in the pathogenesis of migraine in patients with HHT. This needs to be determined in further studies.
Jonathan M. Tobis - One of the best experts on this subject based on the ideXlab platform.
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tct 738 the degree of right to left Shunt is associated with visual aura due to migraine
Journal of the American College of Cardiology, 2015Co-Authors: Yasufumi Kijima, Rubine Gevorgyan, Nicholas Miller, Nabil Noureddin, Jonathan M. TobisAbstract:Cardiac or pulmonary Right-to-Left Shunt (RLS) is associated with aura with or without migraine headache. A quantitative relation between visual aura and degree of RLS is not completely established. The aim of this study was to assess the relationship between the degree of RLS and visual aura with
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Visual migraine aura with or without headache: association with right to left Shunt and assessment following transcutaneous closure
Clinical ophthalmology (Auckland N.Z.), 2012Co-Authors: M. Khalid Mojadidi, Hamidreza Khessali, Rubine Gevorgyan, Ralph D. Levinson, Jonathan M. TobisAbstract:Right to left Shunting, usually caused by a patent foramen ovale (PFO), is associated with migraine and visual aura. It is unknown if patients who present with visual aura without headache behave similarly to those experiencing typical migraine headache with aura. The purpose of this study was to assess the prevalence of right to left Shunting in patients who present with migraine aura without headache and evaluate the response to PFO closure. The records of patients referred to the Interventional Cardiology program at the University of California at Los Angeles for suspected intracardiac right to left Shunt were reviewed. Individuals with visual auras with or without migraine headaches were divided into three groups: group A (aura + migraine), migraine aura during or within 60 minutes of headache; group B (migraine aura unrelated to headache), migraine aura and headache temporally unrelated; and group C (migraine aura only), isolated migraine visual aura without a history of headaches. The presence of right to left Shunt was assessed using transcranial Doppler with an agitated saline test. PFO closure was performed in 80 patients. Residual headache and migraine visual aura were assessed 3 and 12 months after the procedure. The control group consisted of 200 patients referred for diagnostic cardiac catheterization. Of 590 referred patients, 225 had migraine visual aura with or without headache. The prevalence of right to left Shunt was similar (P = 0.66) in groups B (21/29, 72%) and C (14/21, 67%). Group A patients had a higher prevalence of right to left Shunt (168/175, 96%) due to selection bias. The prevalence of right to left Shunt in the control group was significantly (P < 0.0001) lower (36/200, 18%) than in groups A, B, and C. At 12 months after PFO closure, visual aura was resolved in 52%, 75%, and 80% of patients in groups A, B, and C, respectively (difference not statistically significant). There is an increased prevalence of PFO among patients with migraine aura without headache. The closure of PFO correlates with improvement of the visual aura, suggesting a causative association between the presence of PFO and both visual aura and migraine headaches. Ophthalmologists should be aware of the association of right to left Shunts with visual aura.
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Visual migraine aura with or without headache: association with right to left Shunt and assessment following transcutaneous closure
Clinical ophthalmology (Auckland N.Z.), 2012Co-Authors: M. Khalid Mojadidi, Hamidreza Khessali, Rubine Gevorgyan, Ralph D. Levinson, Jonathan M. TobisAbstract:Author(s): Mojadidi, M Khalid; Khessali, Hamidreza; Gevorgyan, Rubine; Levinson, Ralph D; Tobis, Jonathan M | Abstract: BackgroundRight to left Shunting, usually caused by a patent foramen ovale (PFO), is associated with migraine and visual aura. It is unknown if patients who present with visual aura without headache behave similarly to those experiencing typical migraine headache with aura. The purpose of this study was to assess the prevalence of right to left Shunting in patients who present with migraine aura without headache and evaluate the response to PFO closure.MethodsThe records of patients referred to the Interventional Cardiology program at the University of California at Los Angeles for suspected intracardiac right to left Shunt were reviewed. Individuals with visual auras with or without migraine headaches were divided into three groups: group A (aura + migraine), migraine aura during or within 60 minutes of headache; group B (migraine aura unrelated to headache), migraine aura and headache temporally unrelated; and group C (migraine aura only), isolated migraine visual aura without a history of headaches. The presence of right to left Shunt was assessed using transcranial Doppler with an agitated saline test. PFO closure was performed in 80 patients. Residual headache and migraine visual aura were assessed 3 and 12 months after the procedure. The control group consisted of 200 patients referred for diagnostic cardiac catheterization.ResultsOf 590 referred patients, 225 had migraine visual aura with or without headache. The prevalence of right to left Shunt was similar (P = 0.66) in groups B (21/29, 72%) and C (14/21, 67%). Group A patients had a higher prevalence of right to left Shunt (168/175, 96%) due to selection bias. The prevalence of right to left Shunt in the control group was significantly (P l 0.0001) lower (36/200, 18%) than in groups A, B, and C. At 12 months after PFO closure, visual aura was resolved in 52%, 75%, and 80% of patients in groups A, B, and C, respectively (difference not statistically significant).ConclusionThere is an increased prevalence of PFO among patients with migraine aura without headache. The closure of PFO correlates with improvement of the visual aura, suggesting a causative association between the presence of PFO and both visual aura and migraine headaches. Ophthalmologists should be aware of the association of right to left Shunts with visual aura.
A L Horowitz - One of the best experts on this subject based on the ideXlab platform.
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systemic to pulmonary venous communication right to left Shunt in superior vena cava obstruction demonstrated by spiral ct
British Journal of Radiology, 1999Co-Authors: A L HorowitzAbstract:An unusual case of systemic vein to pulmonary vein communication in superior vena cava obstruction is reported. This was a Right-to-Left Shunt, demonstrated by spiral CT and aided by three-dimensional reconstruction. The pulmonary venous Shunts were mainly seen in fibro-atelectatic lung where prominent bridging veins were concentrated.
Anne Greenough - One of the best experts on this subject based on the ideXlab platform.
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Ventilation/perfusion ratio and right to left Shunt in healthy newborn infants
Journal of Clinical Monitoring and Computing, 2017Co-Authors: Theodore Dassios, Kamal Ali, Thomas Rossor, Anne GreenoughAbstract:Oxygenation impairment can be assessed non-invasively by determining the degree of Right-to-Left Shunt and ventilation/perfusion (V_A/Q) inequality. These indices have been used in sick newborn infants, but normative values have not been reported which are essential to determine the magnitude of the abnormality. We, therefore, aimed to measure the Shunt and V_A/Q in infants with no history of respiratory conditions and determine if there was any effect of supine or prone position and the reproducibility of the data. Data were analysed from infants who had undergone a hypoxic challenge and in a subset who had been assessed in the supine or prone position. Transcutaneous oxygen saturations (SpO_2) were recorded at fractions of inspired oxygen (F_IO_2) of 0.21 and 0.15. Two independent raters used a computer software algorithm which analysed and fitted paired data for F_IO_2 and SpO_2 and derived a curve which represented the best fit for each infant’s data and calculated the Shunt and V_A/Q. The raters ability to interpret the SpO_2 value which corresponded to a given F_IO_2 was compared. The downwards displacement of the F_IO_2 versus SpO_2 curve was used to estimate the degree of Right-to-Left Shunt and the rightwards shift of the curve was used to calculate the V_A/Q ratio. The mean (SD) gestational age of the 145 infants was 39 (1.6) weeks, their birth weight was 2990 (578) gms and median (range) postnatal age at measurement 3 (1–8) days. The mean (SD) V_A/Q ratio was 0.95 (0.21). None of the infants had a Right-to-Left Shunt. No significant differences were found in V_A/Q in the supine compared to the prone position. The intraclass correlation coefficient of V_A/Q between two independent raters was 0.968 (95% CI 0.947–0.980), p
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Ventilation/perfusion ratio and right to left Shunt in healthy newborn infants
Journal of clinical monitoring and computing, 2016Co-Authors: Theodore Dassios, Kamal Ali, Thomas Rossor, Anne GreenoughAbstract:Oxygenation impairment can be assessed non-invasively by determining the degree of Right-to-Left Shunt and ventilation/perfusion (VA/Q) inequality. These indices have been used in sick newborn infants, but normative values have not been reported which are essential to determine the magnitude of the abnormality. We, therefore, aimed to measure the Shunt and VA/Q in infants with no history of respiratory conditions and determine if there was any effect of supine or prone position and the reproducibility of the data. Data were analysed from infants who had undergone a hypoxic challenge and in a subset who had been assessed in the supine or prone position. Transcutaneous oxygen saturations (SpO2) were recorded at fractions of inspired oxygen (FIO2) of 0.21 and 0.15. Two independent raters used a computer software algorithm which analysed and fitted paired data for FIO2 and SpO2 and derived a curve which represented the best fit for each infant’s data and calculated the Shunt and VA/Q. The raters ability to interpret the SpO2 value which corresponded to a given FIO2 was compared. The downwards displacement of the FIO2 versus SpO2 curve was used to estimate the degree of Right-to-Left Shunt and the rightwards shift of the curve was used to calculate the VA/Q ratio. The mean (SD) gestational age of the 145 infants was 39 (1.6) weeks, their birth weight was 2990 (578) gms and median (range) postnatal age at measurement 3 (1–8) days. The mean (SD) VA/Q ratio was 0.95 (0.21). None of the infants had a Right-to-Left Shunt. No significant differences were found in VA/Q in the supine compared to the prone position. The intraclass correlation coefficient of VA/Q between two independent raters was 0.968 (95% CI 0.947–0.980), p < 0.001. Right-to-Left Shunt and VA/Q ratio in healthy newborn infants were similar in the prone compared to the supine position.
Siddique Chaudhary - One of the best experts on this subject based on the ideXlab platform.
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Oesophageal Variceal-Pulmonary Venous Fistula - A Rare Cause of a Right-to-Left Shunt
European journal of case reports in internal medicine, 2020Co-Authors: Neeraja Swaminathan, Siddique ChaudharyAbstract:Oesophageal varices are a dilated submucosal venous plexus in the lower third of the oesophagus which result from increased pressure in the portal venous system. The portal system is connected to the systemic circulation in specific locations referred to as sites of portosystemic anastomosis. An increase in portal venous pressure is therefore reflected at these anastomotic sites, causing manifestations such as oesophageal varices, rectal varices, caput medusae and splenorenal Shunts. Varices do not cause symptoms until they leak or rupture and this is the main complication which requires prompt treatment. Here, we present a post-liver transplant patient with metastatic hepatocellular carcinoma who had oesophageal varices that fistularized with a left pulmonary vein, thus creating a Right-to-Left Shunt. Right-to-Left Shunts are usually intracardiac or intrapulmonary in location. The complications of a Right-to-Left Shunt include predominantly hypoxia, cyanosis and, sometimes, paradoxical emboli in the case of intracardiac Shunts. This patient had a very uncommon cause of such a Shunt caused by a direct fistulous connection. LEARNING POINTS Right-to-Left Shunts create a ventilation-perfusion mismatch.Recognizing situations where there is a connection between the systemic circulation and pulmonary circulation without intermediate oxygenation is important because of possible clinical implications such as hypoxia.
