Delayed intracardial shunting and hypoxemia after massive pulmonary embolism in a patient with a biventricular assist de
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CASE REPORT
Open Access
Delayed intracardial shunting and hypoxemia after massive pulmonary embolism in a patient with a biventricular assist device Thomas Weig1*, Michael E Dolch1, Lorenz Frey1, Dirk Bruegger1, Peter Boekstegers3, Ralf Sodian2 and Michael Irlbeck1
Abstract We describe the interdisciplinary management of a 34-year-old woman with dilated cardiomyopathy three months postpartum on a cardiac biventricular assist device (BVAD) as bridge to heart transplantation with delayed onset of intracardial shunting and subsequent hypoxemia due to massive pulmonary embolism. After emergency surgical embolectomy pulmonary function was highly compromised (PaO2/FiO2 54) requiring bifemoral veno-venous extracorporeal membrane oxygenation. Transesophageal echocardiography detected atrial level hypoxemic rightto-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was achieved with a PFO occluder device. After placing the PFO occluder device oxygenation increased significantly (Δ paO2 119 Torr). The patient received heart transplantation 20 weeks after BVAD implantation and was discharged from ICU 3 weeks after transplantation. An increase in pulmonary vascular resistance in patients on BVAD can reopen a PFO resulting in atrial right-to-left shunting and subsequent hypoxemia. The case demonstrates the usefulness of transesophageal echocardiography examinations in the detection of this unexpected event. Percutaneous placement of a PFO occluder device is an appropriate strategy to stop intracardiac shunting through PFO in fixed elevation of pulmonary vascular resistance. Keywords: patent foramen ovale, hypoxemia, pulmonary embolism, ventricle-assist device, heart transplantation, septal occluder device
Background In a literature review, few cases of atrial level right-toleft shunt in patients with left ventricular assist devices are described. All these cases were detected either intraoperatively [1-3] or within the first postoperative days [4-7]. We describe a case of delayed onset of atrial level right-to-left shunt after massive pulmonary embolism on biventricular assist device (BVAD) support. Case Presentation
A 34 year old female patient was admitted to our hospital with dilated cardiomyopathy three months after birth of her third child. She had a known history of familial dilated cardiomyopathy. Recompensation was not * Correspondence: [email protected] 1 Department of Anaesthesiology, Ludwig-Maximilians-University, Munich, Germany Full list of author information is available at the end of the article
achieved despite maximum medical therapy and insertion of an intra-aortic balloon pump. BVAD [Excor, Berlin Heart, Berlin, Germany] was implanted using a biatrial cannulation technique as bridge to heart transplantation. Perioperative transesophageal echocardiography did not show a patent foramen ovale (PFO). Postoperative recovery was immediate and the patient was discharged from the ICU on the third postoperative day. Four weeks after device implantation the patient developed
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