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From the Departments of *Anesthesiology, and Surgery, The University of AL at Birmingham, Birmingham, Alabama.
Address correspondence and reprint requests to Thomas M. Burch, MD, Department of Anesthesiology, The University of AL at Birmingham, 1621 14th Ave. S, Birmingham, AL 35205. Address e-mail to tburch333{at}yahoo.com.
A 77-yr-old women presented to an outside hospital complaining of shortness of breath and transient diploplia. A transthoracic echocardiogram revealed an intracardiac mass and, due to the high risk of systemic embolization, she was transferred to our institution for emergency surgical removal. In the operating room, after induction of general anesthesia, transesophageal echocardiography (TEE) was performed, revealing a large serpentine mass in the right atrium extending across an aneurysmal interatrial septum into the left atrium through a patent foramen ovale (PFO). The end sections of this horseshoe-shaped mass repeatedly descended into both ventricles during diastole and then flipped back into the atria before atrioventricular valve closure and ventricular systole. (Figs. 1 and 2, Video clips 1–4; please see video loop at www.anesthesia-analgesia.org). TEE was used to guide placement of a left subclavian central line and bicaval cannulation. During placement of these devices, a bicaval view revealed that neither the central line wire nor the venous cannulae entered the right atrium and interfered with the thrombus. The proximal pulmonary arteries were examined in the midesophageal ascending aortic short axis view, and no thrombus was seen. The thrombus was removed and the PFO was closed. Postoperatively, the patient was neurologically intact and was discharged 7 days after admission. Of interest, the patient's symptom of dyspnea was due to distal pulmonary artery emboli (unseen on TEE) from deep venous thromboses. We think the pulmonary emboli increased right atrial pressure and thereby facilitated right-to-left flow and "trapping" of the large thrombus in the PFO.
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10 mm of excursion.1 Motion mode (M-mode) can be helpful when measuring excursion, which should be measured from the maximal point of the bulging to an imaginary line connecting the non-aneurysmal segments of the septum primum at the base of the aneurysm. Aneurysmal interatrial septums may contribute to paradoxical emboli by three mechanisms:
Although intraoperative closure of an isolated PFO found incidentally during cardiac surgery is controversial, patients with a PFO and an aneurysmal interatrial septum should be strongly considered for intraoperative PFO closure, given the increased risk for paradoxical emboli.5–7 Outpatients found to have an aneurysmal interatrial septum and a PFO should be strongly considered for transcatheter treatment with a closure device, since these patients are at increased risk of recurrent paradoxical emboli, and because transcatheter treatment has been shown to decrease the risk of recurrent cerebral events.1,2–4
TEE aids in PFO detection in patients presenting with symptoms consistent with paradoxical embolism.8,5 Every comprehensive TEE examination should include interrogation of the interatrial septum for a PFO or atrial septal defect using color flow Doppler and, if necessary, contrast echocardiography. Color flow Doppler examination of the septum should be performed in multiple views, especially the four-chamber and bicaval views. The color flow Doppler Nyquist limit should be serially decreased to 20–40 cm/s, since flow across the septum is low velocity. If color flow Doppler is negative, and excluding a PFO is essential (for example, in a patient undergoing left ventricular assist device placement) then a contrast examination should be performed. Agitated saline contrast should be injected IV while imaging the septum. In ventilated patients, this should be performed with and without the release of 25 cm H2O positive airway pressure. The release of positive airway pressure provokes a transient increase in right atrial pressure which presses the contrast medium against the septum. Visualization of contrast medium crossing into the left atrium within 3–5 cardiac cycles is consistent with a positive contrast study. A contrast study with release of positive airway pressure significantly improves PFO detection and should be conducted when color flow Doppler examination is negative and when excluding a septal defect is essential.2,6 In nonventilated patients, release of a valsalva maneuver will have results similar to the release of positive pressure in ventilated patients.
Footnotes
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
Accepted for publication November 13, 2007.
Supported by the Departments of Anesthesiology and Surgery.
REFERENCES
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  J. Huang, M. J. Bouvette, J. Zhou, G. J. Dwyer III, S. Bhopatkar, and A. Bhatia A Large Angiosarcoma of the Right Atrium Anesth. Analg., June 1, 2009; 108(6): 1755 - 1757. [Full Text] [PDF]
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U. Vellayappan, M. D. Attias, and M. S. Shulman Paradoxical Embolization by Amniotic Fluid Seen on the Transesophageal Echocardiography Anesth. Analg., April 1, 2009; 108(4): 1110 - 1112. [Full Text] [PDF]
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