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• W2113155624 abstract "Increasing numbers of off-pump coronary artery bypass graft (CABG) surgeries are being performed each year because of their potential advantage of avoiding extracorporeal circulation. With the advent of the cardiac stabilization system, now it is possible to perform complete revascularization, which is comparable with the conventional on-pump CABG surgery, without many consequences. The most common complication is hemodynamic compromise during off-pump CABG surgery. The possible causes of this could be right ventricular compression, left ventricle outflow tract compression, abnormal diastolic expansion of the left ventricle, ischemia caused by temporary coronary artery occlusion, mitral regurgitation, and inadequate filling pressures.1Couture P. Denault A. Limoqes P. et al.Mechanisms of hemodynamic changes during off-pump coronary artery bypass surgery.Can J Anaesth. 2002; 49: 835-849Crossref PubMed Scopus (59) Google Scholar We report a case of isolated hypoxemia caused by right-to-left shunting through an undiagnosed patent foramen ovale (PFO) during off-pump CABG surgery. A 55-year-old man with hypertension and coronary artery disease was admitted with double-vessel disease for surgical coronary revascularization. A preoperative workup showed good ventricular function and left ventricular hypertrophy with grade-1 diastolic dysfunction. Coronary artery disease was limited to the right coronary artery and the left anterior descending artery. All other values were within normal limits. It was planned to anastomose the left internal mammary artery to the left anterior descending artery and the saphenous venous graft to the posterior descending artery under a beating heart. All preoperative parameters were within normal limits. After graft harvesting, the left internal mammary artery was anastomosed with the left anterior descending artery, which was uneventful. The heart was lifted and positioned for the posterior descending artery using the Acrobat-I Vacuum Stabilizer System (MAQUET Medical India Pvt Ltd, Mumbai, India). The mean arterial pressure was stabilized around 70 mmHg using vasopressors and Trendelenburg positioning. All the hemodynamic parameters were within acceptable limits; the right atrial pressure was 18 to 20 mmHg before proceeding to the anastomosis. During anastomosis, the pulse oximetry saturation (SpO2) slowly decreased to <90%. FIO2 was increased to 100%. Airway pressure and lung compliance were within normal limits. Gross visualizations of lung movements were normal, and there was no evidence of a pneumothorax or a hemothorax. The SpO2 was confirmed with the arterial oxygen partial pressure, which showed a PaO2 level of 51 mmHg. In view of the elevated right atrial pressure and the altered cardiac anatomy, we assumed there was a PFO with a significant right-to-left shunt. The surgical team was informed, and it was requested that the heart be brought back down to the normal position. The SpO2 came back to 100% within a minute after the repositioning. At the end of surgery, a transesophageal echocardiogram (TEE) was performed. The TEE showed a PFO with a right-to-left shunt using an agitated saline contrast that was aggravated with an airway pressure release maneuver. Because the left atrial pressure is a little higher than the right atrial pressure, most small PFOs are nonfunctional. Most of them do not have any clinical significance in the general population except for their association with a few clinical conditions. However, because of the alterations in the hemodynamic variables during the perioperative period, PFOs may be more significant perioperatively. Whenever the right atrial pressure exceeds the left atrial pressure such as when pulmonary embolism, cardiac tamponade, tricuspid regurgitation, or right ventricular infarction occurs, a right-to-left shunt develops across the septum.2Schaller N. Wittau N. Kehm V. et al.Intraoperative pulmonary tumor embolism from renal cell carcinoma and a patent foramen ovale detected by transesophageal echocardiography.J Cardiothorac Vasc Anesth. 2011; 25: 145-147Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 3Grander W. Schachner T. Velik-Salchner C. et al.Patent foramen ovale and major pulmonary emboli.J Cardiothorac Vasc Anesth. 2011; 25: 841-843Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This would result in either hypoxemia if the shunt is large or paradoxic embolism through the PFO. Off-pump CABG surgeries are performed with unusual cardiac positions. The surgery requires elevating and rotating the heart to reach the lateral and posterior coronary vessels. These unusual positions are associated with anatomic distortions and chamber pressure variations. Sukernik et al4Sukernik M.R. Mets B. Kachulis B. et al.The impact of newly diagnosed patent foramen ovale in patients undergoing off-pump coronary artery bypass grafting: Case series of eleven patients.Anesth Analg. 2002; 95: 1142-1146Crossref PubMed Scopus (14) Google Scholar studied the impact of a newly diagnosed PFO in off-pump cardiac surgery. They found either a new appearance of the shunt or the disappearance of an existing shunt through PFO, but they concluded that it was safe to perform off-pump coronary artery surgery in patients with PFO. There was a case report in which the PFO was attributed to hypotension and hypoxemia and the procedure had to be performed under cardiopulmonary bypass along with closure of the PFO.5Akhter M. Lajos T.Z. Pitfalls of undetected patent foramen ovale in off-pump cases.Ann Thorac Surg. 1999; 67: 546-548Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Tabry et al6Tabry I. Villanueva L. Walker E. Patent foramen ovale causing refractory hypoxemia after off-pump coronary artery bypass: A Case report.Heart Surg Forum. 2003; 6: E74-E76PubMed Google Scholar encountered refractory hypoxemia during off-pump CABG surgery in which they confirmed a PFO causing a right-to-left shunt at the end of surgery. Later, because of severe hypoxemia, another surgery was required to close the PFO under cardiopulmonary bypass. In this case, because we do not routinely use transesophageal echocardiography in CABG surgeries, we were in a diagnostic dilemma for a few minutes. During that time, the surgical site became dark because of the deoxygenated blood. Because the anastomosis was almost finished, the rest of the perioperative period was uneventful. At times, an undiagnosed PFO can be catastrophic. Routine intraoperative screening for PFOs before heart elevation can be useful in averting these kinds of incidents either by preparedness or by avoiding the off-pump surgeries in patients with PFO because emergency conversions have a higher morbidity and mortality." @default.
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• W2113155624 title "Patent Foramen Ovale: A Potential Cause of Refractory Hypoxemia in Off-Pump Coronary Artery Bypass Surgery" @default.
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