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Patent foramen ovale and implantable cardioverter defibrillator
S M Broka1, L J De Roy, Y A Louagie
1Department of Anaesthesiology, UCL University Clinics of Mont-Godinne, Yvoir, Belgium. broka@anes.ucl.ac.be
Insights
A patent foramen ovale opening during internal cardioverter defibrillator implantation can cause a transient right-to-left shunt. This paradoxical embolism risk highlights potential neurologic injury during the procedure.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Internal cardioverter defibrillator (ICD) implantation is a common procedure for managing life-threatening ventricular arrhythmias.
- Defibrillation threshold (DFT) determination is a critical step during ICD implantation to ensure device efficacy.
- Patent foramen ovale (PFO) is a congenital heart defect that can predispose individuals to paradoxical embolism.
Observation:
- A case report details a patent foramen ovale (PFO) opening observed during defibrillation threshold determination in an ICD implantation setting.
- A transient right-to-left shunt across the PFO was confirmed intraoperatively using transesophageal echocontrast study.
- This shunt occurred secondary to modifications in intracardiac pressures during ventricular tachyarrhythmia and defibrillation.
Findings:
- The incident mechanism may involve a transient reversal of the interatrial pressure gradient.
- Pre-existing pulmonary hypertension and tricuspid regurgitation, combined with mechanical ventilation, likely contributed to the pressure changes.
- The transient shunt created a potential pathway for paradoxical embolism.
Implications:
- Paradoxical embolism is a potential, albeit rare, cause of neurologic injury during ICD implantation procedures.
- This case underscores the importance of considering PFO in patients undergoing ICD implantation, especially those with risk factors for interatrial pressure changes.
- Further investigation into the incidence and prevention of PFO-related complications during ICD procedures may be warranted.
Abstract:
A case of patent foramen ovale opening was observed concomitantly to a defibrillation threshold determination in the setting of an internal cardioverter defibrillator implantation. The subsequent transient right-to-left shunt was confirmed by a peroperative transoesophageal echocontrast study. The underlying mechanism of this incident may be related to a transient reversal of the interatrial gradient, due to the pre-existence of pulmonary hypertension and tricuspid regurgitation, associated with ongoing mechanical ventilation and modifications of intracardiac pressures regimen secondary to the succeeding ventricular tachyarrhythmia and defibrillation. Paradoxical embolism can be an aetiology for neurologic injury during internal cardioverter defibrillator implantation.