Patent Foramen Ovale Causing Refractory Hypoxemia after Off-Pump Coronary Artery Bypass: A Case Report
AbstractPatent foramen ovale (PFO) is not uncommon in the adult population undergoing cardiac surgery. Although usually innocent, PFO can cause severe hypoxemia, which can be reversed only by surgical or interventional interruption of the interatrial right-to-left shunt. Such a case is presented, and the diagnosis and pathophysiology are discussed.
Chen WJ, Kuan P Lien WP, Lin FY. 1992. Detection of patent foramen ovale by contrast transesophageal echocardiography. Chest 101:1515-20.nCujec B, Polasek P, Mayers I, Johnson D. 1993. Positive end-expiratory pressure increases the right-to-left shunt in mechanically ventilatedpatients with patent foramen ovale. Ann Intern Med 119:887-94.nDo QB, Goyer C, Chavanon O, Couture P, Denault A, Cartier R. 2002. Hemodynamic changes during off-pump CABG surgery. Eur J Cardiothoracic Surg 21:385-90.nDuff DF, Gutgesell GP. 1977. The use of saline or blood for ultrasonic detection of a right-to-left intracardiac shunt in the early postoperative patient. Am Heart J 94:402-6.nFedullo AJ, Swinburne AJ, Mathew TM, Ryan GF, Dvoretsky PM, Davidson KH. 1985. Hypoxemia from right to left shunting through patent foramen ovale. Am J Med Sci 289:164-6.nGodart F, Rey C, Prat A, et al. 2000. Atrial right to left shunting causing severe hypoxemia despite normal right sided pressures: report of 11 consecutive cases corrected by percutaneous closure. Eur Heart J 21:483-9.nKonstadt SN, Louie EK, Black S, Rao TL, Scanlon P. 1991. Intraoperative detection of patent foramen ovale by transesophageal echocardiography. Anesthesiology 74:212-6.nLamy C, Giannesini C, Zuber M, et al. 2002. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA study. Stroke 33:706-11.nLiu J, Shanoudy H, Liu J, Russell DC, Jarmukli NF. 1999. Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease. J Am Soc Echocardiogr 12:99-105.nMeier-Ewert HK, Labib SB, Schick EC, Gossman DE, Stix MS, Williamson CA. 2003. Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiogram. Mayo Clin Proc 78:103-6.nPiechaud JF. 2001. Hypoxemia related to right-to-left shunting through a patent foramen ovale: successful percutaneous treatment with the CardioSeal device. J Interv Cardiol 14:57-60.nScammon RE, Norris EH. 1918. On the time of the post natal obliteration of the fetal blood passages (foramen ovale, ductus arteriosus, ductus venosus). Anat Rec 150:165.nSchoevaerdts D, Gonzalez M, Evrard P, Buche M, Installe E. 2002. Patent foramen ovale, a cause of significant post-coronary bypass grafting morbidity. Cardiovasc Surg 10:615-720.nSorrentino M, Resnekov L. 1991. Patent foramen ovale associated with platypnea and orthodeoxia. Chest 100:1157-87.nSukernik MR, Mets B, Kachulis B, Oz MC, Bennett-Guerrero E. 2002. The impact of newly diagnosed patent foramen ovale in patients undergoing off-pump coronary artery bypass grafting: case series of eleven patients. Anaesth Analg 95:1142-6.nSztajzel R, Genoud D, Roth S, Mermillod B, Le Floch-Rohr J. 2002. Patent foramen ovale, a possible cause of symptomatic migraine: a study of 74 patients with acute ischemic stroke. Cerebrovasc Dis 13:102-6.nWang A, Bashore TM, Kisslo KB, Das GS, O'Laughlin MP, Harrison JK. 1999. Hypoxemia after prior cardiac surgery due to interatrial shunting and its treatment with a novel transcatheter occlusion device. Catheter Cardiovasc Interv 46:452-6.nAkhter M, Lajos TZ. 1999. Pitfalls of undetected patent foramen ovale in off-pump cases. Ann Thorac Surg 67:546-8.nAllan JJ, Marinelli C, Dellsperger KC, Winniford MD. 2001. Percutaneous balloon catheter closure of a patent foramen ovale in a patient with pulmonary disease, profound hypoxemia and normal right heart pressures. Clin Cardiol 20:307-9.nBakris NC, Siddiqi AJ, Fraser CD Jr, Mehta AC. 1997. Right to left interatrial shunt after pneumonectomy. Ann Thorac Surg 63:198-201.nBashour T, Kabbani S, Saalouke M, Cheng TO. 1983. Persistent eustachian valve causing severe cyanosis in atrial septal defect with normal right heart pressures. Angiology 34:79-83.nBeelke M, Angeli S, Del Sette M, et al. 2000. Obstructive sleep apnea can be provocative for right to left shunting through a patent foramen ovale. Sleep 25:856-62.n
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