Three cases of intracardiac right-to-left shunt at the atrial level complicating right ventricular failure (RV) are described. Severe hypoxemia resulted in 2 patients and stroke in the third. This was a consequence of right ventricular infarction causing right-sided heart failure resulting in high right-sided pressures. Echocardiography demonstrated the shunts. A review of the literature on this uncommon problem suggested management strategies based on the limited experience with this condition.
Get full access to this article
View all access options for this article.
References
1.
IsnerJRobertsWC. Right ventricular infarction complicating left ventricular infarction secondary to coronary artery disease. Am J Cardiol1978;42: 885–94.
2.
HagenPTScholzDGEdwardsWD. Incidence and size of patent foramen ovale during the first 10 decades of life: An autopsy study of 965 normal hearts. Mayo Clin Proc1984;59: 17–20.
3.
PinskyMR. Cardiopulmonary interactions: The effects of negative and positive changes in pleural pressure on cardiac output. In: DantzkerDR, editor. Cardiopulmonary critical care. 2nd ed. Philadelphia: Saunders, 1991: 87–120.
4.
LemairFRichaletJBCarletJBunn-BuissonCMacLeanC. Postoperative hypoxemia due to opening of a patent foramen ovale confirmed by a right atrium-to-left atrium pressure gradient during mechanical ventilation. Anesthesiology1982;57: 223–33.
5.
LahamRJHoKKDouglasPSFahertyCELockJEBaimDS. Right ventricular infarction complicated by acute right to left shunting. Am J Cardiol1994;74: 824–6.
6.
UppstromELKernMJMezeiLMrosekDLabovitzA. Balloon catheter closure of patent foramen ovale complicating right ventricular infarction: Improvement of hypoxia and intracardiac venous shunting. Am Heart J1989;116: 1092–7.
7.
LaineJFSlamaMPetitpretzZGerardPMotteG. Danger of vasodilator therapy for pulmonary hypertension in patent foramen ovale. Chest1986;89: 894–5.
8.
BroderickTMDillonJC. Therapeutic balloon occlusion and pharmacologic therapy of a right-to-left atrial shunt produced by right ventricular infarction. Am Heart J1989;118: 1044–7.
9.
RietveldAPMerrmanLEssedCETrimbosJBHagemeijerF. Right to left shunt with severe hypoxemia at the atrial level in a patient with hemodynamically important right ventricular infarction. J Am Coll Cardiol1983;2: 776–9.
10.
BansalRCMarsaRJHollandDBeehlerCGoldPM. Severe hypoxemia due to shunting through a patent foramen ovale: A correctable complication of right ventricular infarction. J Am Coll Cardiol1985;5: 188–92.
11.
KruegerSKLappeDL. Right-to-left shunt through patent foramen ovale complicating right ventricular infarction. Successful percutaneous catheter closure. Chest1988;94: 1100–1.
12.
GudipatiCVNagelhoutDASerotaHDeligonulULabovitzAJKernMJ. Transesophageal echocardiographic guidance for balloon catheter occlusion of patent foramen ovale complicating right ventricular infarction. Am Heart J1991;121: 919–22.
13.
CoxDTaylorJNandaNC. Refractory hypoxemia in right ventricular infarction from right-to-left shunting via a patent foramen ovale: Efficacy of contrast transesophageal echocardiography. Am J Med1991;91: 653–5.
14.
SterlingIStevensEDe MarneffeMRenardM. Hypoxemie arterielle refractaire et shunt interauriculaire droit-gauche au cours de l'infarctus myocardique du ventricule droit. Arch Mal Coeur1990;83: 425–7.
15.
GainesWEPierceWSProphetGAHoltzmanK. Pulmonary circulatory support. A quantitative comparison of four methods [see comments]. J Thorac Cardiovasc Surg1984;88: 958–64.
16.
AmselBJRodrigusIDe PaepRDe RaedtHMoulijnAC. Right-to-left flow through a patent foramen ovale in acute right ventricular infarction. Two case reports and a proposal for management. Chest1995;108: 1468–70.
17.
O'NeillMJJrChrostowskiAMHarrisonLHJr. A rapid method for determining the need for mechanical support of the right ventricle. Ann Thorac Surg1988;46: 106–7.
18.
AndersonHIIISteimleCShapiroMDeliusRChapmanRHirschlR. Extracorporeal life support for adult cardiorespiratory failure. Surgery1993;114: 161–72.
19.
SteelePKirchDEllisJVogelRBattockD. Prompt return to normal of depressed right ventricular ejection fraction in acute inferior infarction. Br Heart J1977;39: 1319–23.
20.
MorrisALDonenN. Hypoxia and intracardiac right to left shunt: Complicating inferior myocardial infarction with right ventricular extension. Arch Intern Med1978;138: 1405–6.
21.
MannoBVBemisCECarverJMintzGS. Right ventricular infarction complicated by right to left shunt. J Am Coll Cardiol1983;1: 554–7.
22.
DeSioJMGoodnoughSRHajduckzokZD. The effect of positive end-expiratory pressure on right-to-left shunting at the atrial level as documented by transesophageal echocardiography. Anesthesiology1992;77: 1033–6.
23.
SilverMTLievermanEHThibaultGE. Refractory hypoxemia in inferior myocardial infarction from right to left shunting through a patent foramen ovale: A case report and review of the literature. Clin Cardiol1994;17: 627–30.
