Reply to the Editor:
In a letter to the Editor, Drs Ozyuksel and Cetin comment on our editorial commentary
1
on an original article by Morita and colleagues.2
To be clear, the former incorrectly credited DrCaton and me with the case presentation rather than Dr Morita and associates, who authored the case report. Drs Ozyuksel and Cetin describe techniques to mitigate cardiopulmonary dysfunction due to positioning during off-pump coronary artery bypass (OPCAB) surgery. I agree that these are worthwhile maneuvers, providing probable benefit at low risk to patients. Drs Ozyuksel and Cetin suspect that shunts through a patent foramen ovale (PFO) are more likely to manifest detrimentally when positioning the heart to address left-sided lesions. However, among the limited published case reports of desaturation due to PFO shunting,2
, 3
, 4
, 5
, 6
all 3 reports that mention the targets being addressed during desaturation describe this occurring while addressing right-sided lesions.2
, 3
, 5
Another point that Drs Ozyuksel and Cetin make is that PFO is not a benign pathology in OPCAB patients. I counter that the fact that PFO is so common and yet infrequently results in shunting sufficient to cause desaturation during OPCAB demonstrates its generally benign nature. The point of our commentary was that PFO is usually untroubling but can take a turn for the worse, and that turn appears to be more commonly toward right-sided lesions.
References
- A benign patent foramen ovale in off-pump coronary artery bypass can suddenly take a right turn, but can it be tolerated?.J Thorac Cardiovasc Surg. 2016; 152: e23-e24
- Right-to-left shunt through a patent foramen ovale during off-pump coronary artery bypass.J Thorac Cardiovasc Surg. 2016; 152: e21-e22
- Pitfalls in undetected patent foramen ovale in off pump cases.Ann Thorac Surg. 1999; 67: 546-548
- The impact of a newly diagnosed patent foramen ovale patients undergoing off-pump coronary artery bypass grafting: case series of eleven patients.Anesth Analg. 2002; 95: 1142-1146
- Patent foramen ovale: a potential cause of refractory hypoxemia in off-pump coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 38-39
- Transesophageal echocardiographic and oximetric evidence of intraoperative reversal of flow through a patent foramen ovale during an off-pump coronary artery bypass grafting.J Clin Anesth. 2005; 17: 617-620
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- Patent foramen ovale is not a benign pathology in patients undergoing off-pump coronary artery bypass: A word of cautionThe Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 2
- PreviewWe thank Bozinovski and Caton1 for their valuable article entitled “A Benign PFO in OPCAB Can Suddenly Take a Right Turn, but Maybe It Can't Tolerate It.” They present a case with desaturation due to right-to-left shunt through a patent foramen ovale (PFO) during off-pump coronary artery bypass (OPCAB). Although rare, this is an extremely important problem in the OPCAB procedure. PFO is a frequent pathology with an estimated prevalence of 25%.2 However, in cases without a known PFO, intermittent intra-atrial shunting due to an elevated right atrial pressure may be an important problem during OPCAB.
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