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.

Paradoxical air embolism resulted in acute myocardial infarction and massive ischemic brain injury in a patient operated on in a sitting position

“…При этом стоит отметить, что воздушная эмболия коронарных сосудов, описанная во всех литературных источни-ках, проявлявшаяся изменениями на электрокардио-граммах и гемодинамической нестабильностью, ре-грессировала в течение небольшого промежутка времени (до 30 мин), на фоне инотропной и инфу-зионной терапии. Также во всех наблюдениях от-мечалось преимущественное попадание воздушных эмболов в правую коронарную артерию [7,8].…”

Coronary Embolic Phenomena: High-Impact, Low-Frequency Events

“…Following the initial management, dual antiplatelet inhibition would be recommended for these patients [107] for a duration of 6-12 months as per the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines [108].…”

“…It has been reported that air embolism can complicate a variety of invasive procedures involving the vasculature, from central venous access placement to coronary artery bypass grafting [105,106]. In the context of CEPs, the presence of patent foramen ovale (PFO) plays an important contributory role [107]. Though rarely reported, air embolism due to decompression illnesses or due to iatrogenic causes may also cause coronary embolism.…”