Commentary 2

Abstract

Sukernik and associates describe care of an elderly patient scheduled for CABG with assist of cardiopulmonary bypass. During routine intraoperative transesophageal examination, the patient was found to have an aneurysmal interatrial septum and a small left-to-right shunt through a patent foramen ovale. A decision was made not to surgically close the patent foramen ovale. The patient had an uneventful perioperative course and was discharged to home a week after surgery. However, she subsequently developed left subclavian artery thrombosis (successfully treated) and TEE at this time revealed substantial right-to-left shunting across the patent foramen ovale. Furthermore, popliteal vein thrombosis was discovered, representing a possible source of embolic material. This case report highlights an important and topical dilemma: if a patent foramen ovale is detected via routine TEE echocardiography in a patient scheduled for cardiac surgery (with or without cardiopulmonary bypass), what is the correct clinical management? The increasing popularity of off-pump CABG (to avoid detrimental physiologic effects of cardiopulmonary bypass) further complicates this dilemma: should the patent foramen ovale be surgically repaired (adding increased risk associated with alterations in and/or initiation of cardiopulmonary bypass) or should the patent foramen ovale be left alone? There is no easy answer, yet new data recently published may assist in the decision-making process.