A 50-year-old woman is being evaluated in the ward 5 days post hysterectomy. The nurse reported a sudden-onset left-sided facial droop and arm weakness. She has no chronic medical conditions. CT scan of the head shows a right middle cerebral artery territory acute infarction. Lower extremity ultrasound examination reveals a right femoral vein thrombus. No obvious cardiac structural abnormalities are detected on an echocardiogram. Agitated normal saline is injected into a peripheral vein to evaluate for abnormal right-to-left shunting. No bubbles are seen in the left side of the heart after several minutes. Which of the following is most appropriate to increase right-sided heart pressure to reveal an obscure intracardiac shunt?

Question

A 50-year-old woman is being evaluated in the ward 5 days post hysterectomy. The nurse reported a sudden-onset left-sided facial droop and arm weakness. She has no chronic medical conditions.  CT scan of the head shows a right middle cerebral artery territory acute infarction.  Lower extremity ultrasound examination reveals a right femoral vein thrombus.  No obvious cardiac structural abnormalities are detected on an echocardiogram.  Agitated normal saline is injected into a peripheral vein to evaluate for abnormal right-to-left shunting.  No bubbles are seen in the left side of the heart after several minutes.  Which of the following is most appropriate to increase right-sided heart pressure to reveal an obscure intracardiac shunt?

Quizplus · Accepted Answer

Eductional Objective: A patent foramen ovale PFO is a one-way tissue valve in the atrial septum that opens only when right atrial pressure exceeds left atrial pressure; venous return to the right atrium increases during the release (ie, relaxation) phase of a Valsalva maneuver and encourages opening of a PFO. Therefore, a thromboembolism from the venous circulation can cross through (PFO) to the arterial circulation..

A 50-Year-Old Woman Is Being Evaluated in the Ward 5