To close or not to close a patent foramen ovale: That is the question.
Al-Darzi W, Zlatopolsky M, Abu Sayf A, and Awdish RL. To close or not to close a patent foramen ovale: That is the question. J Gen Intern Med 2017; 32(2):S624-S625.
J Gen Intern Med
LEARNING OBJECTIVE #1: Recognizing that cardiac shunting often occur in setting of severe pulmonary hypertension (PH) and serves to relieve the severe increase in the right sided pressures. LEARNING OBJECTIVE #2: Recognizing one of the contraindications to patent foramen ovale (PFO) closure. CASE: A 65-year old female presented to Heart Failure clinic after a follow up transthoracic echocardiography (TTE). She complained of dyspnea, bilateral lower extremity edema, and right 4th digit pain. On physical exam, patient was noted to have darkening of her right 4th digits. She had hypoxia with higher oxygen requirement than baseline. Past medical history is significant for Interstitial Lung Disease (ILD), Pulmonary Hypertension (PH) groups (2 and 3), coronary artery disease with three prior stents, and chronic diastolic dysfunction. Her TTE showed EF of 50%, pulmonary artery systolic pressure of 60 mmHg, and large (greater than 20 bubbles) PFO, that is new, with predominantly right to left shunting across the atrial septum. Patient was hospitalized due to concern for paradoxical emboli and for her hypoxia. Right heart catheterization (RHC) was done that showedmean Pulmonary arterial pressure of 45 mmHg, wedge pressure of 8 mmHg, cardiac index of 2.13 L/min/m2, pulmonary vascular resistance of 840 dynes.sec.cm-5 (10.5 Wood units), and systemic vascular resistance (SVR) of 797.84 dynes.sec.cm-5 at rest. CT angiography was done that showed acute pulmonary embolus (PE) to segmental branches of right lower lobe and demonstrated stable ILD. An upper extremity arterial study demonstrated reduced perfusion to the right 4th digit attributable to a possible embolic event. High intensity heparin was initiated. Risks and Benefits of PFO closure were discussed at a multi-disciplinary meeting. Given that patient's PVR > 2/3 of SVR in the RHC, PFO closure was deferred. The patient was ultimately discharged on warfarin. IMPACT: Careful decision making in PFO closure should be pursued for PH patients, even in presence of a known indication for closure. One of the contraindications to PFO closure is the irreversible pulmonary hypertension (PVR >2/3 SVR or pulmonary artery pressure > 2/3 systemic arterial pressure). It is important to recognize that closure of PFO in those situations could precipitate decompensation of right ventricular (RV) function and sudden drop in cardiac output which could be fatal. DISCUSSION: While PFO closure may be pursued in cases of paradoxical emboli, a risk/benefit analysis, especially looking at PH, is necessary. In this case, acute PE is the likely cause of acute rise in the right sided cardiac pressures. Eventually, the acute PFO provided a necessary outflow tract for right sided pressure overload.