1/5. Right-to-left interatrial shunt in ARDS: dramatic improvement in prone position.The mechanisms leading to shunting through a patent foramen ovale include high right-sided cardiac pressures and respiratory factors due to mechanical ventilation and also anatomical changes in the right atrium as described in the platypnea-orthodeoxia syndrome. We report a patient with the adult respiratory distress syndrome (ARDS) who had a right-to-left atrial shunt which decreased in the prone position, after which oxygenation improved. The patient was admitted to the intensive care unit because of ARDS due to an invasive fungal infection. He had a history of chronic lymphocytic leukemia and paradoxical embolisms through a patent foramen ovale. Despite mechanical ventilation and antifungal treatment he developed severe ARDS. He was therefore turned to the prone position. blood gas values improved dramatically (arterial oxygen tension/fractional inspired oxygen ratio increasing from 59 to 278 torr). Transcranial Doppler sonography was performed with bubble study, which confirmed a massive right-to-left shunt in the supine position and which instantaneously decreased in the prone position. This case suggests that a decrease in right-to-left shunt in patients who have a patent foramen ovale could partly explain the improvement in hypoxemia in the prone position.- - - - - - - - - - ranking = 1keywords = ovale (Clic here for more details about this article) |
2/5. Libman-Sacks endocarditis in a pregnant woman with acute respiratory distress syndrome.BACKGROUND: Sterile fibrinous vegetations on the mitral valve (Libman-Sacks endocarditis) might be found in one-third of patients with antiphospholipid antibodies. Usually of minor hemodynamic significance, these vegetations might complicate acute respiratory distress syndrome in pregnancy. CASE: Despite delivery and aggressive medical therapy, a 17-year-old primigravida with pyelonephritis and acute respiratory distress syndrome suffered rapid decompensation. echocardiography showed mitral valve vegetations with severe regurgitation. blood cultures were negative, but antinuclear antibody test and lupus anticoagulant were positive. The patient died of massive cerebral infarction and brainstem herniation. autopsy found a patent foramen ovale and Libman-Sacks endocarditis. CONCLUSION: With rapid decompensation of acute respiratory distress syndrome in pregnancy, despite aggressive medical therapy, complicating processes must be considered, especially with antiphospholipid antibodies, which can be associated with sterile heart vegetations and subsequent fatal thromboembolism.- - - - - - - - - - ranking = 0.33333333333333keywords = ovale (Clic here for more details about this article) |
3/5. Severe pneumonia with pneumatoceles and patent foramen ovale in an infant: optimal ventilation strategy?We discuss a case of severe pneumonia with pneumatoceles in a 2-month old infant. Despite peak and plateau airway pressures kept below 30 and 25 cmH(2)O, respectively, the infant developed bilateral pneumothorax and pneumomediastinum caused by pneumatocele rupture, necessitating bilateral intercostal drainage. Application of positive end-expiratory pressure (PEEP) of 10 cmH(2)O at FIO(2) of 0.7 worsened oxygenation, and transthoracic echocardiography showed right-to-left shunting of blood through the patent foramen ovale. Therefore, PEEP had to be tapered to 6 cmH(2)O, and ventilation carried out at FIO(2) of 1 until the lung condition improved. The open lung strategy of higher increments of PEEP and lower FIO(2) for lung protective ventilation actually proved deleterious to our patient. We conclude that a subset of patients with acute respiratory distress syndrome with refractory hypoxaemia may have right-to-left shunting of blood through a patent foramen ovale. This can be detected by echocardiography, and these patients may benefit from a ventilation strategy aimed at lowering pulmonary vascular resistance.- - - - - - - - - - ranking = 2keywords = ovale (Clic here for more details about this article) |
4/5. Persistent hypoxemia due to patent foramen ovale in a patient with adult respiratory distress syndrome.This report describes a patient in the recovery phase of the adult respiratory distress syndrome in whom the persistence of severe hypoxemia was not corrected by a high fractional concentration of oxygen in the inspired gas and positive end-expiratory pressure. A right-to-left interatrial shunt was diagnosed by M-mode and cross-sectional echocardiography with saline injection, and the presence of a patent foramen ovale was confirmed at the time of cardiac surgery.- - - - - - - - - - ranking = 1.6666666666667keywords = ovale (Clic here for more details about this article) |
5/5. Prolonged total extracorporeal lung assistance without systemic heparinization.A 16-year-old female developed severe ARDS in her single remaining lung following pneumonectomy for blunt trauma. Total extracorporeal lung assist (ECLA) for 40 days using a covalently heparin-coated circuit proved lifesaving. Systemic heparinization was not applied, as the heparinized surface by itself prevented clotting of the extracorporeal circuit. Systemic primary fibrinolysis developed but was not associated with major bleeding. A veno-right ventricular cannulation technique was used and maximum venous drainage for the extracorporeal circulation was achieved by elevating the bed 50 cm from the floor. This allowed extracorporeal blood flow (ECBF) approaching cardiac output (CO) and complete extracorporeal replacement of lung function. After 40 days, lung recovery allowed discontinuation of ECLA. Five days later the patient suffered serious lung collapse and was operated for a bronchopleural fistula. The patient was extubated 4 weeks after terminating ECLA and discharged in good condition 5 weeks later.- - - - - - - - - - ranking = 0.33333333333333keywords = ovale (Clic here for more details about this article) |