Profound Patent Foramen Ovale Shunting Unmasked by An Episode of Atrial Fibrillation
Conference Proceeding - Restricted Access
Journal of the American College of Cardiology
Patent foramen ovale (PFO) is a cardiac congenital anomaly found in 25-30% of the population. Most patients with PFO are asymptomatic, but a variety of manifestations can occur. Indications for closure of PFO include cryptogenic strokes, platypnea-orthodeoxia syndrome, and decompression sickness.
A 67 year-old-woman with paroxysmal atrial fibrillation (afib) and severe tricuspid regurgitation (TR) who previously declined valve repair, developed afib with rapid ventricular response (RVR) requiring hospitalization. Patient subsequently became hypoxemic refractory to 100% FiO2 via mechanical ventilation. CT scan was negative for pulmonary embolism. Transesophageal echocardiogram showed severe TR with right atrial and ventricular enlargement and PFO with a large right-to-left interatrial shunt (Figure 1A).
It was believed that refractory hypoxemia was due to worsening right-to-left interatrial shunting. This likely occurred due to chronic, severe TR and changes in atrial compliance in the setting of afib with RVR, favoring more right-to-left shunting. Patient underwent transcatheter PFO closure with immediate resolution of hypoxia (Figure 1B). Repeat echocardiogram demonstrated no residual shunt (Figure 1C). TR was managed medically.
This case highlights that PFO shunting can acutely increase in the setting of chronic right heart overload and superimposed afib with RVR. Timely transcatheter PFO closure can be an effective intervention.
Swapna G, Ivan H, Mazen S. Profound Patent Foramen Ovale Shunting Unmasked by An Episode of Atrial Fibrillation. 2021;77(18):2395. Available from: https://doi.org/10.1016/S0735-1097(21)03750-5