Dynamic Shunting Across a Patent Foramen Ovale in Adult Cardiac Surgery—Perioperative Challenges and Management

Patel, Prakash A.; Hall, Andrew; Augoustides, John; Patel, Saumil; Feinman, Jared W.; Weber, Beth; Gutsche, Jacob T.; Fabbro, Michael; Maldonado, Yasdet

doi:10.1053/j.jvca.2017.05.031

Cited by 2 publications

(3 citation statements)

References 69 publications

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“…Optimization of airway pressure (especially PEEP) during mechanical ventilation, patient position, fluids, and vasoconstrictor drugs may play a role in maintaining a pressure gradient between the right and left atrium, thus limiting RLS [24][25][26]. Positive inotropic drugs (e.g., epinephrine, milrinone), nitric oxide, or both may also limit RLS in the setting of pulmonary hypertension or right ventricular failure [27,28]. Extubation occurred 14 h after surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Shunt reversal, under certain circumstances, can cause hypoxemia and acute respiratory failure [4]. Platypnea orthodeoxia syndrome is one the possible clinical manifestation of RLS [28]. In the perioperative setting of cardiac surgery, for example, reopening of PFO has been associated with worsening respiratory outcomes, need for reintubation, and a longer ICU length of stay [29].…”

Section: Discussionmentioning

confidence: 99%

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Transcranial Doppler Ultrasound and Transesophageal Echocardiography for Intraoperative Diagnosis and Monitoring of Patent Foramen Ovale in Non-Cardiac Surgery

Bianchini,

Vitale,

Romano

et al. 2024

Applied Sciences

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Background: perioperative stroke is one of the major complications after surgery. Patent foramen ovale (PFO) increases the risk of stroke in non-cardiac surgery by right-to-left shunt related to intraoperative hemodynamic alterations, leading to paradoxical embolism. Transesophageal echocardiography is the best tool for obtaining anatomical confirmation of PFO and essential details such as the PFO measure and the degree and direction of the shunt. Despite this, preoperative PFO screening is not routinely performed. Methods and results: we described the features of ten consecutive patients undergoing major abdominal surgery at the Abdominal Organ Transplant Intensive Care Unit, IRCCS Sant’Orsola, Bologna, Italy, who were screened for PFO using a PFO diagnostic and monitoring standardized intraoperative protocol by transesophageal echocardiography and transcranial color Doppler ultrasound. Finally, we highlighted the neurological and respiratory outcomes, the course and the management of three patients with intracardiac and extracardiac shunts. Conclusions: identifying an unknown PFO by a TCCD-TEE approach allowed the intraoperative monitoring of the shunt direction. It prevents the risk of complications secondary to paradoxical embolism in non-cardiac high-embolic-risk surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Transcranial Doppler Ultrasound and Transesophageal Echocardiography for Intraoperative Diagnosis and Monitoring of Patent Foramen Ovale in Non-Cardiac Surgery

Bianchini,

Vitale,

Romano

et al. 2024

Applied Sciences

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“… 3 , 4 , 5 The right atrial hypertension may stretch a patent foramen ovale to allow right-to-left shunting, which can be reduced with medical and surgical interventions. 3 , 4 , 5 , 12 , 13 …”

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confidence: 99%

Commentary: Carbon dioxide embolism during vein harvesting—Directed transesophageal echocardiography for diagnosis and hemodynamic rescue

Augoustides

2020

JTCVS Techniques

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Endoscopic saphenous vein harvesting has matured as a minimally invasive technique for vascular conduit during coronary artery bypass grafting. 1 The complications of this technique include gas embolism. 2-4 The roles of transesophageal echocardiography in the management of this catastrophic complication can be lifesaving. 3,4 The case reported by Kawabori and colleagues 5 in this issue highlights the central role of transesophageal echocardiography in this setting. During conduit harvest, significant carbon dioxide embolism resulted in cardiac arrest. The vigilant team instituted prompt cardiopulmonary bypass and echocardiographic-directed management. The case was complicated by right ventricular failure, requiring aggressive pharmacologic support and delayed sternal closure. The patient had a complete recovery, with no neurologic sequelae. How might this case inform the conduct of endoscopic vein harvest in light of the current literature? One option is to avoid an endoscopic approach in select patients, given its reported reduced graft patency. 6 This decision could be guided by a new risk score for saphenous vein graft failure. 7 Further trials will refine the conduct of saphenous vein harvest to enhance patency, including attention to a notouch technique. 8,9 What are our options when an endoscopic approach is selected for vein harvest? Clearly, meticulous technique with careful carbon dioxide insufflation remains essential. 1-3 Transesophageal echocardiography can allow rapid diagnosis of gas embolism, as exemplified by this case. 5 Although this diagnostic modality is still debated in coronary artery bypass grafting, it should be available to evaluate hemodynamic compromise. 3,4,10 The midesophageal bicaval view can capture the passage of gas emboli and suggest the likely source. 3-5 If the gas emboli access the right atrium through the inferior vena cava, the source is below the diaphragm. 5,11 If the gas emboli access the right atrium from the superior vena cava, the source is above the diaphragm. 3-5 Furthermore, in gas embolism, the right atrial pressure is commonly elevated. 3-5 Right coronary ischemia is common, resulting in bradycardia and right ventricular failure. 3-5 The right atrial hypertension may stretch a patent foramen ovale to allow right-to-left shunting, which can be reduced with medical and surgical interventions. 3-5,12,13 So, where do we go from here? This complex case has focused attention on transesophageal echocardiography for hemodynamic rescue in carbon dioxide embolism. 5 It can reliably diagnose this complication and guide an integrated management response. 3-5 In this case, the heart team proceeded with bicaval cannulation for cardiopulmonary bypass. The inferior vena caval cannula coupled with a

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Dynamic Shunting Across a Patent Foramen Ovale in Adult Cardiac Surgery—Perioperative Challenges and Management

Cited by 2 publications

References 69 publications

Transcranial Doppler Ultrasound and Transesophageal Echocardiography for Intraoperative Diagnosis and Monitoring of Patent Foramen Ovale in Non-Cardiac Surgery

Transcranial Doppler Ultrasound and Transesophageal Echocardiography for Intraoperative Diagnosis and Monitoring of Patent Foramen Ovale in Non-Cardiac Surgery

Commentary: Carbon dioxide embolism during vein harvesting—Directed transesophageal echocardiography for diagnosis and hemodynamic rescue

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