Management of Patent Foramen Ovale (PFO) in the Perioperative Period


Patent foramen ovale (PFO) is a common congenital heart anomaly that remains asymptomatic in most cases. However, in the perioperative period, PFO can become clinically significant, potentially leading to hypoxemia and paradoxical embolism. This article explores the management of PFO in various surgical contexts, highlighting its significance and potential complications.

PFO and Its Pathophysiology

A PFO is a persistent opening in the atrial septum that allows blood to pass from the right atrium (RA) to the left atrium (LA). While it is usually benign, certain conditions and surgical interventions can lead to right-to-left shunting, causing hypoxemia. The key factors influencing clinical significance include the size of the PFO, pressure gradients between the RA and LA, and the direction of blood flow through the PFO.

Perioperative Conditions with PFO Implications
Surgical ContextPFO ImplicationsManagement Strategies
Central Venous CatheterizationRisk of paradoxical embolism in venous air embolism cases.Consider hyperbaric oxygenation as treatment.
Mechanical VentilationIncreased right-to-left shunting with PEEP.Exercise caution in applying PEEP in known PFO cases.
NeurosurgeryRisk of paradoxical air embolism in sitting position.Preoperative PFO assessment and position change if necessary.
Orthopedic SurgeryIncreased risk of paradoxical embolism with deep venous thrombosis and fat embolism.Monitor for signs of embolism and provide appropriate management.
Thoracic SurgeryPlatypnea after right pneumonectomy.Recognize potential platypnea and manage accordingly.
Cardiac SurgeryTransient right ventricular dysfunction, pericardial effusion, or myocardial infarction.Monitor for hypoxemia and consider relevant interventions.
Other Surgical ProceduresRisk of pressure changes and air embolisms.Vigilant PFO management during specific procedures.
Clinical Significance of PFO in the Perioperative Period

The clinical significance of PFO in the perioperative period stems from its potential to cause hypoxemia and paradoxical embolism, leading to various complications, including stroke, peripheral embolism, and even death. The risk is further increased in patients with underlying conditions, such as deep venous thrombosis, cardiac abnormalities, or pulmonary hypertension.

Management Options

When a PFO is detected and becomes clinically significant in the perioperative period, several management options are available:

Management StrategyIndications
Inotropes and Nitric OxideReduce right atrial (RA) pressure and mitigate right-to-left shunting.
ThrombolysisCases involving thrombus formation to prevent further embolism.
AnticoagulationPrevent thrombus formation.
PFO ClosureOpen-heart surgery or percutaneous procedure when necessary.

Understanding the clinical significance of PFO in the perioperative period is essential for healthcare providers and surgeons. Recognizing the associated risks and promptly implementing management strategies can help mitigate potential complications, ensuring the safety of patients undergoing various surgical procedures. Close collaboration between cardiologists, anesthesiologists, and surgeons is crucial for optimal patient care.


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