A sudden right-to-left shunt: the importance of evaluating patent foramen ovale during exercise

Submitted: October 5, 2022
Accepted: February 16, 2023
Published: March 7, 2023
Abstract Views: 942
PDF: 269
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Authors

A 55-year-old male affected by heart failure with reduced ejection fraction and a history of a transient cerebrovascular accident was accepted to the Cardiology Department for worsening dyspnea. A cardiopulmonary exercise test was performed after therapy optimization to further evaluate exercise intolerance. A rapid increase in the minute ventilation/carbon dioxide production slope, end-tidal oxygen pressure, and respiratory exchange ratio, with a concomitant decrease in end-tidal carbon dioxide pressure and oxygen saturation, were observed during the test. These findings indicate exercise-induced pulmonary hypertension leading to a right-to-left shunt. Subsequent echocardiography with a bubble test unveiled the presence of an unknown patent foramen ovale. It is, therefore, necessary to exclude a right-to-left shunt by cardiopulmonary exercise testing, particularly in patients predisposed to develop pulmonary hypertension during exercise. Indeed, this eventuality might potentially provoke severe cardiovascular embolisms. However, the patent foramen ovale closure in patients with heart failure with reduced ejection fraction is still debated because of its potential hemodynamic worsening.

Dimensions

Altmetric

PlumX Metrics

Downloads

Download data is not yet available.

Citations

McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-726.
Pritchard A, Burns P, Correia J, et al. ARTP statement on cardiopulmonary exercise testing 2021. BMJ Open Respir Res 2021;8:e001121.
Wasserman K. Principles of exercise testing and interpretation: including pathophysiology and clinical applications. 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.
Rana BS, Shapiro LM, McCarthy KP, Ho SY. Three-dimensional imaging of the atrial septum and patent foramen ovale anatomy: defining the morphological phenotypes of patent foramen ovale. Eur J Echocardiogr 2010;11:i19-25.
Pristipino C, Sievert H, D'Ascenzo F, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EuroIntervention 2019;14:1389-402.
Barron AJ, Wensel R, Francis DP, Malik I. The role for cardiopulmonary exercise testing in patients with atrial septal defects: a review. Int J Cardiol 2012;161:68-72.
Kavinsky CJ, Szerlip M, Goldsweig AM, et al. SCAI guidelines for the management of patent foramen ovale. J Soc Cardiovasc Angiogr Interv 2022;1:100039.
Sun X-G, Hansen JE, Oudiz RJ, Wasserman K. Gas Exchange detection of exercise-induced right-to-left shunt in patients with primary pulmonary hypertension. Circulation 2002;105:54-60.
Segreti A, Grigioni F, Campodonico J, et al. Chemoreceptor hyperactivity in heart failure: is lactate the culprit? Eur J Prev Cardiol 2021;28:e8-e10.
Butler J, Chomsky DB, Wilson JR. Pulmonary hypertension and exercise intolerance in patients with heart failure. J Am Coll Cardiol 1999;34:1802-6.
Lynch JJ, Schuchard GH, Gross CM, Wann LS. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol 1984;53:1478-80.
Lovering AT, Stickland MK, Amann M, et al. Effect of a patent foramen ovale on pulmonary gas exchange efficiency at rest and during exercise. J Appl Physiol (1985) 2011;110:1354-61.
Yoshiba S, Kojima T, Oyanagi T, et al. Late recovery of the cardiopulmonary exercise capacity after transcatheter amplatzer device closures for atrial septal defects in adults. Heart Vessels 2021;36:710-6.
Cammalleri V, Romeo F, Ussia GP. Hemodynamic complications during transcatheter MitraClip repair in presence of congenital atrial septal defect. Catheter Cardiovasc Interv 2016;88:307-11.
Baumgartner H, De Backer J. The ESC clinical practice guidelines for the management of adult congenital heart disease 2020. Eur Heart J 2020;41:4153-4.
Park J, Choi HM, Hwang IC, et al. Abstract 9538: Impact of device closure on heart failure progression in patients with patent foramen ovale. Circulation 2022;146:A9538.
Antoine S, Maldonado AP, Rivas J, et al. Patent foramen ovale, friend or foe in heart failure patients? J Am Coll Cardiol 2019;73:S985.
Ussia GP, Cammalleri V, Marchei M, et al. Hemodynamic patterns of residual interatrial communication after transcatheter MitraClip repair. J Cardiovasc Med (Hagerstown) 2014;15:343-9.

How to Cite

Crispino, Simone Pasquale, Andrea Segreti, Ylenia La Porta, Paola Liporace, Myriam Carpenito, Valeria Cammalleri, and Francesco Grigioni. 2023. “A Sudden Right-to-Left Shunt: The Importance of Evaluating Patent Foramen Ovale During Exercise”. Monaldi Archives for Chest Disease 94 (1). https://doi.org/10.4081/monaldi.2023.2443.