title: Profound hypoxemia resulting from shunting across an inadvertent atrial septal tear after left ventricular assist device placement.
abstract: Defects within the interatrial septum (IAS) can be a source of significant right-to-left shunting and hypoxemia, particularly after placement of a left ventricular assist device (LVAD). We report a case of LVAD placement in which an unrecognized IAS tear occurred intraoperatively, leading to profound arterial desaturation. Transesophageal echocardiography (TEE) was instrumental in making the diagnosis. Certain intraoperative events increased the pressure gradient between the right and left atria, aggravating hypoxemia. We recommend that patients undergoing LVAD placement be screened intraoperatively with TEE for unrecognized IAS defects. Re-examination of the IAS should occur on weaning from cardiopulmonary bypass.
  
  
  CONCLUSIONS
  A traumatic atrial septal defect after atrial cannulation caused a right-to-left intracardiac shunt on initiation of left ventricular assist device support that was further aggravated by chest closure and pleural suction, culminating in severe hypoxemia.
authors.affiliation: Departments of *Anesthesia and Perioperative Care, and †Surgery, University of California, San Francisco, San Francisco, California.
authors.forename: James E
authors.initials: JE
authors.lastname: Baker
authors.forename: Greg
authors.initials: G
authors.lastname: Stratmann
authors.forename: Charles
authors.initials: C
authors.lastname: Hoopes
authors.forename: R
authors.initials: R
authors.lastname: Donateillo
authors.forename: Elaine
authors.initials: E
authors.lastname: Tseng
authors.forename: I A
authors.initials: IA
authors.lastname: Russell
mesh_terms: D000328:Adult; D001026:Coronary Artery Bypass; D017548:Echocardiography, Transesophageal; D017809:Fatal Outcome; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000473:pathology; D006353:Heart-Assist Devices; D006801:Humans; D000860:Hypoxia / Q000209:etiology*; D008297:Male; D019919:Prosthesis Implantation; D012086:Reoperation