title: Paradoxical cardiac and cerebral arterial gas embolus during percutaneous lead extraction in a patient with a patent foramen ovale.
abstract: A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures.
authors.affiliation: Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia. Electronic address: clarearnott88@gmail.com.
authors.forename: Clare
authors.initials: C
authors.lastname: Arnott
authors.affiliation: Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia.
authors.forename: Keith
authors.initials: K
authors.lastname: Kelly
authors.affiliation: Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia; Hyperbaric Unit, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia.
authors.forename: Darren
authors.initials: D
authors.lastname: Wolfers
authors.affiliation: Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia.
authors.forename: Gregory
authors.initials: G
authors.lastname: Cranney
authors.affiliation: Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick 2023, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Giles
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D002533:Cerebral Angiography; D002536:Cerebral Arteries / Q000000981:diagnostic imaging; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D017548:Echocardiography, Transesophageal; D004618:Embolism, Air / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D006931:Hyperbaric Oxygenation; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000628:therapy
keywords: Cerebral infarction; Hyperbaric oxygen therapy; Lead extraction; Myocardial infarction; Paradoxical embolus; Patent foramen ovale