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Usefulness of percutaneous closure of patent foramen ovale
for hypoxia
Alyssa G. Munkres, MPH, Timothy N. Ball, MD, Themistokles Chamogeorgakis, MD, Kenneth A. Ausloos, MD,
Shelley A. Hall, MD, and James W. Choi, MD
We report a patient with hypoxia secondary to a right-to-left shunt through
a patent foramen ovale, following aortic root, valve, and arch replacement due to an aortic dissection in the setting of the Marfan syndrome.
Following the operation, he failed extubation twice due to hypoxia. An
extensive workup revealed a right-to-left shunt previously not seen. The
patent foramen ovale was closed using a percutaneous closure device.
Following closure, our patient was extubated without difficulty and has
done well postoperatively.
A
pproximately 25% of the general population is estimated
to have a patent foramen ovale (PFO). These small atrial
septal defects, present from birth, are usually asymptomatic and found incidentally by echocardiogram or
at autopsy (1). We describe the benefit of closure of a PFO for
postoperative hypoxia.
CASE DESCRIPTION
A 23-year-old Hispanic man with the Marfan syndrome
presented with acute chest pain that radiated to his back. The diagnosis of a dilated aortic root and a type B aortic dissection was
made quickly by computed tomography scan with contrast. He
underwent surgical repair using a two-staged “elephant trunk”
procedure. The initial stage of the procedure consists of an aortic
valve, root, and arch replacement, including leaving an elephant
trunk portion of the graft that hangs down into the descending aorta. Finally the descending thoracic aorta is wrapped at
that level of the diaphragm. The second stage of the procedure
uses a stent graft, via an endovascular approach, to connect the
elephant trunk with the wrapped portion of the aorta. Following the first stage, his postoperative course was complicated by
recurrent hypoxia. He underwent two attempted extubations on
postoperative days 1 and 7, but the hypoxia persisted. A PFO
with a significant right-to-left shunt was found on transesophageal echocardiogram with bubble study (Figure 1).
On postoperative day 9, a percutaneous closure procedure
was performed via the right femoral vein. A #25 Amplatzer
Cribriform Septal Occluder (AGA Medical Corp., Plymouth,
MN) was deployed in the PFO, and placement was confirmed
with intracardiac echocardiography and fluoroscopy (Figure 2).
A negative echocardiographic bubble study at the conclusion of
204
Figure 1. Transesophageal echocardiogram with bubble study, showing rightto-left shunt through a patent foramen ovale. RA indicates right atrium, LA, left
atrium; PFO, patent foramen ovale.
the procedure confirmed resolution of the right-to-left shunt.
On day 10, extubation was successful and normal oxygen saturation was maintained. The patient was discharged from the
hospital on postoperative day 22. Five weeks later, he underwent
stage 2 of the “elephant trunk” procedure without postoperative
respiratory complications. He continues to do well 5 months
following the second stage of the procedure.
DISCUSSION
Despite the severity of potential consequences of a PFO,
hypothesized benefits of closing PFOs, specifically for migraine
headaches and strokes, have not resulted in clinical benefit over
standard medical management. Three large randomized controlled trials, RESPECT (2), CLOSURE I (3), and PC Trial (4),
failed to show a benefit of PFO closure over medical management for the prevention of recurrent paradoxical embolism. The
RESPECT trial did, however, demonstrate increased safety and
From the Division of Cardiology, Department of Internal Medicine, Baylor Hamilton
Heart and Vascular Hospital and Baylor University Medical Center at Dallas.
Corresponding author: James W. Choi, MD, Cardiology Consultants of Texas,
Baylor Heart and Vascular Hospital, 621 N. Hall Street, Suite 400, Dallas, TX 75226
(e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2015;28(2):204–206
Figure 2. A cineflourographic image of the #25 Amplatzer Cribriform Septal
Occluder (AGA Medical Corp, Plymouth, MN) following deployment.
efficacy of the Amplatzer PFO Occluder device over the previously used STARFlex Septal Closure System (2, 4). While there
is ample evidence through observational studies for the efficacy
of PFO closure in prevention of recurrent embolic strokes, no
studies have been able to provide evidence for significant benefit
Table 1. Previously published cases discussing closure of patent
foramen ovale for hypoxia
Clinical setting
First author
(reference)
PostDlabal (7)
pneumonectomy Vacek (8)
Closure method
Surgical
Hypoxia
lessened
+
Surgical
+
Hazard (9)
Percutaneous—balloon
+*
Berry (10)
Surgical
+
Landzberg (11)
Percutaneous—clamshell
+
Godart (12)
Percutaneous—button
+
Alfaifi (13)
Surgical
+
Mall (14)
Surgical
+
Pai (15)
Percutaneous—Amplatzer
+
Thoracic aortic
maneurysm
Chopard (16)
Percutaneous—Amplatzer
+
Townsend (17)
Surgical
+
Left ventricular
assist device
Loforte (18)
Percutaneous—Amplatzer
+
Nguyen (19)
Percutaneous—Das AngelWings
+
Kavarana (20)
Percutaneous—CardioSeal
+
Coronary
bypass
Schoevaerdts (21) Surgical
(two patients)
+
Aortic root
replacement
Brugts (22)
+
*Temporarily.
April 2015
Percutaneous—Amplatzer
over standard anticoagulation. With respect to the treatment of
migraines, retrospective studies have shown a significant decrease
in severity and frequency with closure of the PFOs (5). Unfortunately, the MIST trial revealed increased morbidity associated
with PFO closure for patients with migraine headaches (6).
There is a growing body of evidence for examining the role
of PFOs in hypoxia. Classically, patients present with platypnea-orthodeoxia syndrome, positional hypoxia associated with
the sensation of difficulty breathing, relieved in a recumbent
position. Additionally, there are rare reports of acquired rightto-left shunts following cardiac or pulmonary surgery, detailed
in Table 1 (7–22). Hypoxia secondary to PFO is believed to
develop from an abnormal anatomic relation between the vena
cava and the atrial septum, which directs venous blood flow from
the inferior vena cava toward the atrial septum. The change in
direction of blood flow can occur with positional changes or following a cardiopulmonary insult or operation, which distort the
mediastinum and stretch the atrial septum (23). Acquired shunts
have also been described secondary to a dilated aortic root that
alters the atrial septum resulting in a shunt (24). As was the case
with our patient, closure of the PFO in patients with hypoxia
secondary to a right-to-left interatrial shunt has been shown to
significantly reduce hypoxemia and associated symptoms.
Although research on the effects of PFO closure for the
treatment of hypoxia has been promising, it has been limited
to small reports, predominantly case studies. Notably, in all of
the cases detailed in Table 1, hypoxia improved immediately
following PFO closure. Similarly, the case studies of patients
with platypnea-orthodeoxia syndrome undergoing PFO closure
report a significant postprocedural increase in blood oxygen
saturation and excellent long-term outcomes (23, 25).
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Baylor University Medical Center Proceedings
Volume 28, Number 2