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[Incidental diagnosis of an ostium-secundum-type interatrial communication during coronary surgery]
B Forés1, M Olmos, A Ortiz de Salazar
1Servicio de Anestesiología y Reanimación, Hospital de Basurto, Avenida de Montevideo, 18 48013 Bilbao.
Insights
A large atrial septal defect was unexpectedly diagnosed during heart surgery for coronary artery bypass grafting. Surgical closure of the defect resolved pulmonary hypertension and high cardiac output, highlighting the importance of intraoperative monitoring.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Diagnostics
Background:
- A 73-year-old woman presented for coronary revascularization with severe triple-vessel coronary artery disease.
- Preoperative assessment indicated mild mitral and moderate tricuspid insufficiency, alongside moderate-to-severe pulmonary hypertension.
- Left ventricular function was preserved, with no initial suspicion of intracardiac shunting.
Observation:
- Intraoperative pulmonary artery catheterization revealed elevated pulmonary hypertension and unexpectedly high cardiac output.
- Blood gas analysis showed a significant increase in PO2 and oxygen saturation from peripheral veins to the right atrium.
- These findings raised suspicion for an undiagnosed atrial septal defect.
Findings:
- Intraoperative echocardiography confirmed a 3 cm ostium secundum atrial septal defect.
- The atrial septal defect was surgically closed concurrently with coronary artery bypass grafting.
- Post-closure, oximetric measurements normalized, and pulmonary artery pressures decreased.
Implications:
- This case underscores the critical role of invasive hemodynamic monitoring and transesophageal echocardiography during cardiac surgery.
- Intraoperative diagnostics can reveal unexpected intracardiac defects missed in preoperative evaluations.
- Prompt identification and management of such defects are crucial for optimizing surgical outcomes and patient recovery.
Abstract:
Preoperative assessment of a 73-year-old woman scheduled for coronary revascularization revealed signs of severe disease in three coronary vessels, mild mitral valve insufficiency, moderate tricuspid insufficiency and moderate-to-severe pulmonary hypertension, with preserved left ventricular function. During surgery pulmonary artery catheter measurements confirmed pulmonary hypertension and the presence of very high cardiac output, leading to suspicion of atrial septal defect. Peripheral vein and right atrial blood samples revealed a sudden increase of 23 mm Hg in PO2 and of 22% in oxygen saturation. Finding the opening in the wall of the right atrium gave diagnostic confirmation of an ostium secundum defect 3 cm in diameter. The defect was closed and the coronary vessel bypasses were created. Upon weaning from extracorporeal circulation, the sudden oximetric increase was seen to have disappeared and pulmonary artery pressures had decreased. Postoperative course was satisfactory, with normal sinus rhythms alternating with episodes of atrial fibrillation. We stress the importance of invasive hemodynamic monitoring and transesophageal echography during heart surgery to confirm diagnoses that have not been established during preoperative assessment.