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Intermittent atrial level right‐to‐left shunt with temporary hypoxemia in a patient during support with a left ventricular assist device
Author(s) -
Kilger E.,
Strom C.,
Frey L.,
Felbinger T.W.,
Pichler B.,
Tichy M.,
Rank N.,
Wheeldon D.,
Kesel K.,
Schmitz C.,
Reichenspurner H.,
Polasek J.,
Weis F.,
Goetz A. E.
Publication year - 2000
Publication title -
acta anaesthesiologica scandinavica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.738
H-Index - 107
eISSN - 1399-6576
pISSN - 0001-5172
DOI - 10.1034/j.1399-6576.2000.440122.x
Subject(s) - medicine , shunt (medical) , patent foramen ovale , cardiology , right to left shunt , ventricle , hypoxemia , intracardiac injection , ventricular assist device , ventricular pressure , anesthesia , hemodynamics , heart failure , migraine
We report a 56‐year‐old male patient developing hypoxemia after surgical replacement of infected valves of a left ventricular assist device (LVAD, Novacor TM ) which had supported him during the previous 15 months. Contrast transesophageal echocardiography (TEE) revealed an atrial septal defect with intermittent right‐to‐left shunt across a patent foramen ovale. We postulate that the shunt detected in this patient occurred as a consequence of reduced pulmonary vascular compliance due to positive end‐expiratory pressure (PEEP) and an increase of mean intrathoracic pressure. Furthermore, we hypothesize that synchronized LVAD operation exacerbates any potential right‐to‐left shunt due to the profound left ventricular unloading which occurs during LVAD support. In this first report of a right‐to‐left shunt from a previously unrecognized patent foramen ovale in a Novacor TM patient, the subsequent transient hypoxemia could be managed by avoiding PEEP of more than 3 mmHg, and mean airway pressure of more than 11 mmHg and by careful volume replacement in order to prevent the pump from completely emptying the left ventricle (LV) and the left atrium (LA). Thus, prior to every LVAD implantation a transesophageal contrast echocardiography with Valsalva maneuver should be performed to identify intracardiac right‐to‐left shunt.