title: Intermittent atrial level right-to-left shunt with temporary hypoxemia in a patient during support with a left ventricular assist device.
abstract: We report a 56-year-old male patient developing hypoxemia after surgical replacement of infected valves of a left ventricular assist device (LVAD, Novacor) 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 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.
authors.affiliation: Department of Anesthesiology, University of Munich, Germany.
authors.forename: E
authors.initials: E
authors.lastname: Kilger
authors.forename: C
authors.initials: C
authors.lastname: Strom
authors.forename: L
authors.initials: L
authors.lastname: Frey
authors.forename: T W
authors.initials: TW
authors.lastname: Felbinger
authors.forename: B
authors.initials: B
authors.lastname: Pichler
authors.forename: M
authors.initials: M
authors.lastname: Tichy
authors.forename: N
authors.initials: N
authors.lastname: Rank
authors.forename: D
authors.initials: D
authors.lastname: Wheeldon
authors.forename: K
authors.initials: K
authors.lastname: Kesel
authors.forename: C
authors.initials: C
authors.lastname: Schmitz
authors.forename: H
authors.initials: H
authors.lastname: Reichenspurner
authors.forename: J
authors.initials: J
authors.lastname: Polasek
authors.forename: F
authors.initials: F
authors.lastname: Weis
authors.forename: A E
authors.initials: AE
authors.lastname: Goetz
mesh_terms: D006344:Heart Septal Defects, Atrial / Q000150:complications*; D006353:Heart-Assist Devices; D006801:Humans; D000860:Hypoxia / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*