Right atrial to left atrial shunt through foramen ovale during pneumoperitoneum for laparoscopic cholecystectomy

Patent foramen ovale: Its significance in anesthesia and intensive care: An illustrated case

Patent foramen ovale (PFO) is defined as a valve-like opening at the level of foramen ovale or between septum primum and secundum without evidence of the anatomical defect. Paradoxical embolism (PDE) is an embolus passing through a defect PFO leading to end-organ dysfunction. PDE in septic shock is not yet reported in the literature. A 49-year male presented to the emergency department with shortness of breath since one day and pain in the left side of the chest. Chest x0 -ray revealed middle-left lobe pneumonia with pleural effusion; he was started on Co-amoxiclav, and admitted to the ward. After 6 h, his chest pain suddenly significantly increased difficulty in breathing and his oxygen saturation dropped. X-ray of the chest showed left pneumothorax, chest drain was inserted and he was intubated. He became hemodynamically unstable with maximum ventilatory support and noradrenalin. On day 4, he was found to have new pansystolic murmur in the tricuspid area. An echocardiogram revealed global hypokinesia, two mobile thrombi in the right atrial cavity, and PFO. It was noticed that his right toe had blackish discoloration. An angiogram showed occlusion of the right superficial femoral artery and immediately an embolectomy. On day 11, he was transferred to the ward. PDE needs a high index of suspicion in septic shock patients with ARDS. PDE requires PEEP adjustment, early anticoagulation, and thromboprophylaxis.

Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open?

An obese patient with cholelithiasis and acute cholecystitis was scheduled for an emergency laparoscopic cholecystectomy. On preoperative workup, a 5-year-old echocardiogram showed a large patent foramen ovale (PFO) with a right-to-left shunt that was open at rest. Noting both the benefits of laparoscopic surgery and the substantial incidence of PFO in the general population (10% to 30%), the attending and consulting surgeons reasoned that the benefits of laparoscopy greatly exceeded an immeasurably small risk of paradoxical emboli.