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Ann Thorac Surg 1999;67:546-548
© 1999 The Society of Thoracic Surgeons

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Case Reports

Pitfalls of undetected patent foramen ovale in off-pump cases

^a Department of Cardiothoracic Surgery, Buffalo General Hospital, State University of New York at Buffalo, Buffalo, New York, USA

Accepted for publication July 28, 1998.

Address reprint requests to Dr Lajos, 100 High St, Buffalo, NY 14203

	Abstract

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We describe pitfalls of a hitherto undetected patent foramen ovale during the conduct of an off-bypass coronary revascularization. Manipulation of the heart resulted in right-to-left shunt and severe desaturation requiring institution of cardiopulmonary bypass to close the patent foramen ovale and complete the revascularization.

	Introduction

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Comorbid conditions make cardiopulmonary bypass (CPB) a high-risk procedure. With recent advances, revascularization can be done without the use of CPB, by using mechanical stabilization of the target coronary artery on a beating heart [1]. This method is being applied to high-risk patients to avoid the increased risk from CPB. We describe a situation that is likely to become more frequent as coronary revascularization without CPB becomes more popular. It would be detrimental, even fatal, to the patient if not recognized or corrected promptly.

An 82-year-old white man with metastatic prostate carcinoma, chronic obstructive pulmonary disease, and carotid artery disease presented with unstable angina and triple-vessel coronary artery disease and over 90% stenosis of left main coronary artery. His ejection fraction was 35%. Because of comorbid conditions (80% right carotid artery stenosis and carcinoma of the prostate), we thought that CPB should be avoided in this patient during coronary revascularization. During the operation, a midsternotomy was performed and adequate saphenous vein segment was harvested from both legs for grafts to the left anterior descending artery, D₁, OM₁, distal right coronary artery and acute marginal branch of the right coronary artery.

As is advisable off bypass, revascularization of the left anterior descending artery and its diagonal branch was first done in a sequential manner and the proximal graft anastomosis was attached to a punch aortotomy. During the construction of the distal anastomosis, wet lap sponges (Medical Action Industries, Inc, Asheville, NC) were placed lateral and below the left heart to elevate the left ventricle. The target coronary arteries were stabilized by a CTS multivessel stabilizer (Cardiothoracic Systems, Inc, Cupertino, CA) without incident. The acute marginal artery of the right coronary artery was identified. The acute margin of the right ventricle was elevated by placing a wet lap sponge under the diaphragmatic surface. As preparation was made to start the distal anastomosis, we noticed that the arterial blood had darkened, most prominently in the previously placed graft to the left anterior descending artery and diagonal artery. Meanwhile, oxygen saturation on monitors dropped to a low of 80%. Inspiratory pressure was normal, there was equal expansion of both lungs, and the fraction of inspired oxygen was 100%. However, the arterial partial pressure of oxygen was 32 mm Hg.

The blood pressure registered a moderate decrease to approximately 80 mm Hg and the right atrial pressure, which was 7 to 9 mm Hg, increased to 15 to 17 mm Hg. The right side of the heart, however, looked empty and small.

Removal of the sponge from underneath the right ventricle drastically reversed the situation. Transesophageal echocardiography was performed immediately. It showed no defect, but a floppy atrial septum (Fig 1). However, when the wet lap sponge was placed under the diaphragmatic surface, the right atrial pressure increased and a significant right-to-left shunt developed at the upper part of the patent foramen ovale (Fig 2).

View larger version (69K): [in this window] [in a new window]   Fig 1. The floppy intraatrial septum is shown.

View larger version (12K): [in this window] [in a new window]   Fig 2. Color Doppler image shows a significant right-to-left shunt while a wet lap sponge was placed under the diaphragmatic surface of the right ventricle.

View larger version (14K): [in this window] [in a new window]   Fig 3. Postoperative repair is shown.

Once the shunt was detected, we realized that revascularization could not be completed without CPB. The shunt through the patent foramen ovale could also pose problems if the patient required prolonged postoperative ventilatory support [2, 3]. Hence the decision was made to go on bypass, complete the revascularization, and close the patent foramen ovale.

The incidence of patent foramen ovale in the general population is 25% to 30% [4]. With the increased number of operations being done without CPB, this situation is sure to be encountered more often. Cardiac mobilization, associated with sudden and persistent arterial desaturation when ventilatory and hemodynamic causes can be ruled out, should indicate possible right-to-left shunt. With intraoperative transesophageal echocardiography, this problem should be easily recognizable.

	References

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1. Bergsland J., Hasnain S., Lewin A.N., Bhayana J.N., Lajos T.Z., Salerno T.A. Coronary artery bypass grafting without cardiopulmonary bypass—an attractive alternative in high risk patients. Eur J Cardiothorac Surg 1997;11:876-880.[Abstract/Free Full Text]
2. Byrick R.J., Kolton M., Hart J.T., Forbath P.G. Hypoxemia following cardiopulmonary bypass. Anesthesiology 1980;53:172-174.[Medline]
3. Moskowitz C., Podolsky L.A., Meyerowitz C.B., Jacobs L.E., Kotler M.N. Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology?. J Am Soc Echocardiography 1992;5:259-270.[Medline]
4. Kollar A. Patent foramen ovale as a potential source of morbidity following cardiac surgery in adults. Contemporary Surg Residents 1997;5:6-11.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohammed Akhter Thomas Z. Lajos Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Akhter, M. Articles by Lajos, T. Z. Search for Related Content PubMed PubMed Citation Articles by Akhter, M. Articles by Lajos, T. Z.