A 73 year old woman presented with profound central cyanosis and a history of a minor stroke. She had normal heart morphology, normal pulmonary artery pressure, and a normal coronary angiography. A patent foramen ovale (PFO) with a massive right to left shunt was demonstrated at the atrial level, with normal pulmonary venous saturations and PO 2 values. This rare, age related case of right ventricular diastolic dysfunction in a normotensive patient revealed a generous PFO allowing a pronounced right to left shunt.A 73 year old woman presented with recent onset cyanosis and a past history of a minor stroke. Room air arterial PO 2 was 40 mm Hg. Transoesophageal echocardiography revealed a patent foramen ovale (PFO) with a large right to left shunt. No other anomaly was seen.Cardiac catheterisation disclosed normal coronary arteries and normal pulmonary pressure. Right ventricular (RV) diastolic pressure was slightly higher than left ventricular (LV) diastolic pressure. On 100% Fi O 2 , pulmonary venous P O 2 was 540 mm Hg and the left atrial P O 2 was 97 mm Hg. Balloon occlusion of the PFO served to test the tolerance of PFO occlusion and to measure the effective stretched defect size. Immediate post-transcatheter PFO closure using a 24 mm atrial septal defect (ASD) Amplatzer occluder resulted in a rise of arterial PO 2 to 320 mm Hg. Other causes of the atrial level right to left shunt such as pulmonary disease, pulmonary vascular disease, RV hypertrophy, RV systolic dysfunction, right atrial myxoma, tricuspid valve disease, and pericardial effusion were excluded. This rare, age related case of RV diastolic dysfunction in a normotensive patient revealed a generous PFO allowing a pronounced right to left shunt. DISCUSSIONA persistent right to left shunt at the atrial level across a PFO has previously been described in relation to RV dysfunction or elevation of the pulmonary pressure in conditions such as chronic obstructive pulmonary disease, or pulmonale, recurrent pulmonary embolism, tricuspid valve dysfunction, RV infarction, and right sided myxoma.1 A significant right to left shunt via PFO has rarely been described without underlying cardiac or pulmonary disease.2-4 Several theoretical pathophysiological explanations were offered to explain such a phenomenon. Preferential streaming of the blood from the inferior vena cava across the PFO and transatrial septal pressure gradients were suggested as the likely cause for the haemodynamic state. This is a case report of a 73 year old woman who presented with profound central cyanosis and a history of a minor stroke. She had normal heart morphology, normal pulmonary artery pressure and a normal coronary angiography. A massive right to left shunt was demonstrated at atrial level with normal pulmonary venous saturations and PO 2 values. The reason for this huge right to left shunt at the PFO level is illustrated by the diastolic pressure curves representing compliance differences between right and left ventricles (fig 1). This is probably an age related phenomenon in t...

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Elevated levels of plasma lipoprotein(a) [Lp(a)] have frequently been associated with coronary artery disease (CAD). Recently Lp(a) was fractionated into two species with different affinities for Lysine-Sepharose. The influence of lysine-binding heterogeneity of Lp(a) on its cardiovascular pathogenicity has not previously been studied. The authors have determined plasma levels of total Lp(a), its lysine-binding [lys+] and unretained [lys-] species in 67 male CAD patients undergoing cardiac catheterization. Forty-three patients have severe CAD (two- or three-vessel disease) and 24 patients have less pronounced CAD (one-vessel disease or less than 50% narrowing of coronary vessels). All patients were ranked in order of their Lp(a) levels and then grouped into quartiles. The prevalence of severe CAD was significantly higher in the upper Lp(a) quartile as compared with the other three quartiles (odds ratio 10-5; chi-square 11.2; P = 0.0008). Similar results were obtained when the same analysis was carried out for [lys+] and [lys-] species of Lp(a) (odds ratio 11.52 and 3.3, respectively; chi-square 12.3 and 4.34, respectively; P = 0.0004 and 0.037, respectively). Thus, measurement of either species of Lp(a) does not provide any additional improvement in the prediction of CAD as compared to the estimation of total Lp(a) levels.

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