이형석, 최정현

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A risk of paradoxical emboli in patients with acute PE with coexisting PFO : A Case-Report

부산대학교병원 내과

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이형석, 최정현

Introduction: The patent foramen ovale (PFO) exists in approximately 25% of the general population and it can be found in up to 40% of patients with embolic stroke of undetermined source. So PFO is a well-documented risk factor of paradoxical systemic embolization, including ischemic stroke.

Paradoxical embolization has been observed in patients with acute Pumonary Embolism (PE) with coexisting PFO. A rapid increase in right atrial pressure during Valsalva maneuver or cough can result in right-to-left atrial shunt and paradoxical embolization. Therefore, careful attention is needed when treating patient with acute PE with coexisting PFO. Case report: A 77-year-old man visited our hospital for acute onset chest pain and dyspnea. At admission, on physical examination, there was no cardiac murmur with regular heart beat and a normal sound of lungs. His chest x-ray had no abnormal findings.

Electrocardiogram showed sinus tachycardia with RBBB. In laboratory tests, D-dimer elevated by 36 ug/mL. And thrombus at both main pulmonary ar- teries detected in the chest CT (figure 1). Echocardiography showed D-shaped LV, LV diastolic dysfunction, and small shunt flow noted from LA to RA (thought to be a PFO). After he was diagnosed as acute PE with PFO, we started anticoagulation with oxygenating and stabilizing blood pressure using in- otropics through central vein catheter. As breathing difficulties improved and blood pressure stabilized, the CVC was removed and moved to the general ward. However, there was bleeding and hematoma on the CVC remove site, and despite two attempts to embolize, bleeding persisted and we stopped the anicoagulation. On the fifth day of suspension, he was found lying down in front of the bathroom with left hemiparesis and dysarthria. A brain CT was done and right MCA infarction was found (figure 2). Discussion: The patient suffered stroke immediately after leaving the bathroom, possibly due to para- doxical embolization in a situation where right atrial pressure can be raised. In a situation where anticoagulation is interrupted by bleeding, PE patients with PFOs will have to prevent stroke through measures such as absolute bed rest.

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The Neutrophil to Lymphocyte Ratio as a Predictor for Unexpected Cardiac ICU Readmission

인하대학교 의과대학 내과학교실

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서성하 , 이만종

Background/Aims: The neutrophil-to-lymphocyte ratio (NLR) is reliable marker for inflammation, and easily measured from complete blood count (CBC). The NLR is known to be significantly associated with clinical outcome in patients with various cardiovascular disease. Aim We sought to inves- tigate whether NLR is predicted early cardiac intensive care unit (CICU) readmission after index CICU discharge. Methods: Study Population 546 pa- tients who transferred to general ward from cardiac ICU were analyzed for one year of 2017 at INHA university hospital. (age : 67 ± 15 years , male 63 %) Single center, retrospective study Neutrophil to Lymphocyte Ratio NLR measured at the time of admission and CICU discharge NLR was calculated as the ratio of the neutrophil count to the lymphocyte count Exclusion criteria Patients with conditions that might affect white blood cell counts Admissions with- out the emergency center Patients with prolonged ICU stay more than 1 month Expectable or planned ICU readmission Results: Of a total of 602 patients, 39 (6.5%) patients were expired during index CICU

admission. Among patients who underwent CICU dis- charge, 23 (4.2%) patients had unexpectedly transferred to CICU within 48 hours after CICU discharge. In the pa- tients with CICU readmission, hospital mortality, National early warning score (NEWS) at CICU discharge, and NLR at CICU discharge were significantly elevated.

(p<0.006, p<0.001, and p<0.001) Among all of CICU re- admission, only 13 patients (56%) were survived to discharge. In logistic regression analysis, predictors for CICU readmission were a history of diabetes mellitus, lower left ventricular ejection fraction, high NLR at CICU discharge, and NEWS ≥ 5 at CICU discharge.

Conclusions: NLR and NEWS at the time of CICU dis- charge are robust predictor for unexpected ICU readmission. NLR and NEWS might be practical and easily calculated marker for determining ICU discharge.