Potential Role of Patent Foramen Ovale in Exacerbating Hypoxemia in Chronic Pulmonary Disease

Abstract

Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.

Percutaneous Closure of Patent Foramen Ovale in the Setting of Pulmonary Embolism (Right-Left Shunt Causing Severe Hypoxia)

“…Fenster et al 2 performed a study where 97 patients with underlying chronic pulmonary disease had an improvement in NYHA functional class (51% of patients; P < 0.001) and reduced supplemental oxygen requirements (34% of patients; P < 0.001) after PFO closure. 1 Closing the PFO in the setting of a PE can yield similar effects as seen in patients with other lung disease. Our patient suffered from low oxygen saturation due to the PE, which worsened from the R-L shunting through the PFO after endotracheal intubation.…”

“…For instance, in the setting of a chronic obstructive pulmonary disease (COPD), a patient with PFO will have an increase in rightsided heart pressures resulting in hypoxemia. Michael et al 1 reported that PFO found in 12 of 22 patients with COPD had an increased chance of hypoxemia compared to patients without PFO. In these patients, PFO closure was associated with an improvement of SaO2 (10.1% average improvement; P < 0.001) and an improvement in the New York Health Association (NYHA) functional class (1.5 median improvement in class; P = 0.008).…”

Association Between Arterial Oxygen Saturation and Lung Ultrasound B-Lines After Competitive Deep Breath-Hold Diving

“…While persistent post-dive hypoxemia may have multiple causes: (1) ventilation/perfusion mismatch due to atelectasis ( Fahlman et al, 2009 ; Schipke et al, 2019 ). (2) increased right-to-left shunt; via increased strain on the right ventricle ( Scherhag et al, 2005 ) and/or chronic pulmonary hypertension ( Vestin, 2015 ), so if right atrial pressure becomes higher than left atrial pressure right-to-left shunting can occur ( Layoun et al, 2017 ). A third cause could be diffusion limitation due to increased extravascular lung water ( Picano et al, 2006 ; Boussuges et al, 2011 ; Picano and Pellikka, 2016 ).…”

Obstructing Chiari Network Facilitating Blood Flow Across a Patent Foramen Ovale Causing Hypoxia

“…Cryptogenic stroke is associated with a high-risk PFO score (≥2), which includes a Chiari network ( 7 ). However, PFO closure has been found to be beneficial in a variety of cases, such as reducing recurrent stroke or transient ischemic attacks compared with medical therapy ( 8 ), alleviating symptoms in patients with platypnea-orthodeoxia ( 9 ), and can potentially improve quality of life in patients with chronic obstructive pulmonary disease with hypoxemia ( 10 ).…”