Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome*

Objective:Right-to-left shunting across a patent foramen ovale may occur in acute respiratory distress syndrome as a result of pulmonary hypertension and positive-pressure mechanical ventilation. The shunt may worsen the hypoxemia. The objective of our study was to determine the prevalence, clinical implications, and prognosis of patent foramen ovale shunting during acute respiratory distress syndrome. Design:Prospective study. Setting:Medical intensive care unit of a university hospital in Créteil, France. Patients:Two hundred three consecutive patients with acute respiratory distress syndrome. Interventions:Patent foramen ovale shunting was detected by using transesophageal echocardiography with modified gelatin contrast. Moderate-to-large shunting was defined as right-to-left passage of at least 10 bubbles through a valve-like structure within three cardiac cycles after complete opacification of the right atrium. In 85 patients without and 31 with shunting, the influence of the positive end-expiratory pressure level on shunting was studied. Measurements and Results:The prevalence of moderate-to-large patent foramen ovale shunting was 19.2% (39 patients). Compared to those in the group without shunting, the patients in group with shunting had larger right ventricle dimensions, higher pulmonary artery systolic pressure, and a higher prevalence of cor pulmonale. Compared to patients without shunting, patients with shunting had a poorer Pao2/Fio2 ratio response to positive end-expiratory pressure, more often required prone positioning and nitric oxide as adjunctive interventions, and had fewer ventilator-free and intensive care unit-free days within the first 28 days. Conclusions:Moderate-to-large patent foramen ovale shunting occurred in 19.2% of patients with acute respiratory distress syndrome, in keeping with findings from autopsy studies. Patent foramen ovale was associated with a poor oxygenation response to positive end-expiratory pressure, greater use of adjunctive interventions, and a longer intensive care unit stay.

[1]  R. Madsen,et al.  Observer Variation in the Echocardiographic Measurement of Maximum Atrial Septal Excursion: A Comparison of M‐Mode with Two‐Dimensional or Transesophageal Echocardiography , 2009, Echocardiography.

[2]  M. Dellborg,et al.  Sensitivity for detection of patent foramen ovale increased with increasing number of contrast injections: a descriptive study with contrast transesophageal echocardiography. , 2008, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[3]  N. Anguel,et al.  Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome , 2008, Intensive Care Medicine.

[4]  F. Falter,et al.  Evaluation of hypoxemic patients with transesophageal echocardiography , 2007, Critical care medicine.

[5]  A. Manolis,et al.  End-inspiratory occlusion maneuver during transesophageal echocardiography for patent foramen ovale detection in intensive care unit patients , 2007, Intensive Care Medicine.

[6]  K. Chergui,et al.  Bedside echocardiographic evaluation of hemodynamics in sepsis: is a qualitative evaluation sufficient? , 2006, Intensive Care Medicine.

[7]  A. Wilmer,et al.  Acute intracardiac right-to-left shunt in a patient with acute respiratory distress syndrome and shock successfully treated with nitric oxide. , 2006, British journal of anaesthesia.

[8]  P. Bongrand,et al.  Comparison of prone positioning and high-frequency oscillatory ventilation in patients with acute respiratory distress syndrome* , 2005, Critical care medicine.

[9]  A. Cheung,et al.  Diagnosis of patent foramen ovale with multiplane transesophageal echocardiography in adult cardiac surgical patients. , 2004, Journal of cardiothoracic and vascular anesthesia.

[10]  F. Michard,et al.  Monitoring right-to-left intracardiac shunt in acute respiratory distress syndrome. , 2004, Critical care medicine.

[11]  L. Kritharides,et al.  Agitated colloid is superior to saline and equivalent to levovist in enhancing tricuspid regurgitation Doppler envelope and in the opacification of right heart chambers: a quantitative, qualitative, and cost-effectiveness study. , 2002, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[12]  J. Coste,et al.  Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. , 2001, The New England journal of medicine.

[13]  G. Plotnick,et al.  Patent foramen ovale: a review of associated conditions and the impact of physiological size. , 2001, Journal of the American College of Cardiology.

[14]  B Jonson,et al.  Alveolar derecruitment at decremental positive end-expiratory pressure levels in acute lung injury: comparison with the lower inflection point, oxygenation, and compliance. , 2001, American journal of respiratory and critical care medicine.

[15]  F. Jardin,et al.  Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis , 2001, Critical care medicine.

[16]  C. Greim,et al.  The Detection of Interatrial Flow Patency in Awake and Anesthetized Patients: A Comparative Study Using Transnasal Transesophageal Echocardiography , 2001, Anesthesia and Analgesia.

[17]  H. Schuchlenz,et al.  The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events. , 2000, The American journal of medicine.

[18]  D. Perrotin,et al.  Right-to-left interatrial shunt in ARDS: dramatic improvement in prone position , 1999, Intensive Care Medicine.

[19]  D. Russell,et al.  Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease. , 1999, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[20]  J. Gossage,et al.  Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. , 1998, Chest.

[21]  J. Carlet,et al.  Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study , 1998, Intensive Care Medicine.

[22]  G. Hamann,et al.  Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale , 1998, Neurology.

[23]  J. Motin,et al.  Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease. , 1997, Chest.

[24]  J. Bourdarias,et al.  Echocardiographic pattern of acute cor pulmonale. , 1997, Chest.

[25]  M. Brock,et al.  [Intraoperative contrast echocardiography for detection of a patient foramen ovale using a provocation test and ventilation with PEEP respiration]. , 1996, Der Anaesthesist.

[26]  W. Gersony,et al.  Blade balloon atrial septostomy in patients with severe primary pulmonary hypertension. , 1995, Circulation.

[27]  J. Motin,et al.  [Effects of mechanical ventilation with PEEP on right to left intra-cardiac shunt caused by patent foramen ovale]. , 1995, Annales francaises d'anesthesie et de reanimation.

[28]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[29]  S. Rich,et al.  The prevalence and significance of a patent foramen ovale in pulmonary hypertension. , 1993, Chest.

[30]  R. Rossaint,et al.  Inhaled nitric oxide for the adult respiratory distress syndrome. , 1993, The New England journal of medicine.

[31]  H. Just,et al.  Patent foramen ovale in patients with haemodynamically significant pulmonary embolism , 1992, The Lancet.

[32]  C. Henke,et al.  Profound hypoxemia precipitated by positive end-expiratory pressure: induction of an intracardiac shunt. , 1992, Critical care medicine.

[33]  S. Black,et al.  Intraoperative detection of patent foramen ovale by transesophageal echocardiography. , 1991, Anesthesiology.

[34]  W. Edwards,et al.  Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. , 1984, Mayo Clinic proceedings.

[35]  J. Richalet,et al.  Postoperative hypoxemia due to opening of a patent foramen ovale confirmed by a right atrium-left atrium pressure gradient during mechanical ventilation. , 1982, Anesthesiology.