Interatrial Shunting After Major Thoracic Surgery: A Rare but Clinically Significant Event

Risk factors and complications associated with intra-operative or post-operative identification of a PFO in cardiac surgery patients: A cohort study

Introduction

It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes.

Methods

We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications.

Results

Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; p = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; p = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event.

Conclusion

Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.

Acute Intraoperative Hypoxemia During Right Pneumonectomy-The Heart and Lung Interaction: A Case Report

A 75-year-old woman with a history of right-upper lobectomy for adenocarcinoma presented for a right completion pneumonectomy due to 2 new fluorodeoxyglucose-avid densities on the remaining lung. After uneventful anesthetic induction and surgical resection with modest blood loss, the patient developed refractory hypoxemia on emergence without significant hemodynamic changes. Despite delivery of fraction of inspired oxygen (Fio2) = 1.0, confirmed position of the double-lumen tube, and exclusion of common causes of hypoxemia, hypoxemia persisted. An emergent transesophageal echocardiogram revealed a significant intracardiac shunt due to a patent foramen ovale. Specific cardiorespiratory management to achieve a positive left-right heart pressure gradient resulted in prompt normoxemia and successful extubation.

Platypnea-orthodeoxia syndrome after open prostatectomy and cystolithotomy: Coincidence or unknown pathophysiology?

A few cases of platypnea-orthodeoxia syndrome have been described in the literature, some of them after thoracic or upper abdominal surgeries. In most cases, hypoxemia in the upright or sitting position, which is the main clinical symptom for this uncommon diagnosis, is usually related to a dynamic right to left cardiac shunt induced by anatomical changes in the relative position between the inferior vena cava and the atria in the presence of a patent foramen ovale. In this case report, we describe a situation in which platypnea-orthodeoxia syndrome developed acutely before surgery but that became severely exacerbated after an open urologic surgery without a clear acute anatomical change that could be responsible for triggering the syndrome. This case might suggest that the pathophysiology of acute platypnea-orthodeoxia syndrome is not completely elucidated and that other possible triggers for acute clinical manifestation in addition to acute anatomical thoracic changes must be explored.

Patent foramen ovale diagnosis: The importance of provocative maneuvers

Patent foramen ovale (PFO) is a frequent congenital anomaly, but massive right-to-left shunt (RTLS) is normally prevented by higher pressures in left heart chambers. However, mechanical ventilation with positive end-expiratory pressure (PEEP) can significantly increase right atrial pressure, accentuating the RTLS, mainly after major cardiothoracic surgery. We report a patient admitted to the intensive care unit after cardiac surgery. Pre- and intraoperative transesophageal echocardiography only described an aneurysmal interatrial septum with no shunt. However, high-PEEP ventilation induced a paradoxical response with life-threatening hypoxemia, triggering further echocardiographic evaluation, revealing massive RTLS across a stretch PFO. Provocative maneuvers (Valsalva/PEEP) significantly increase echocardiographic sensitivity, unmasking silent PFO. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:58-61, 2017.