Risk Factors and Complications Associated with Intra-operative or Post-operative Identification of a PFO in Cardiac Surgery Patients: A Cohort Study

Overview

Journal Front Neurol

Specialty Neurology

Date 2023 Jan 27

PMID 36703625

Authors

Driss Laghlam

Lucas Coroyer

Paul-Jun Martial

Philippe Estagnasie

Pierre Squara

Lee S Nguyen

Affiliations

Soon will be listed here.

Abstract

Introduction: It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes.

Methods: We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications.

Results: Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event.

Conclusion: Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.

References

Kasner S, Messe S . Is Patent Foramen Ovale a Risk Factor for Perioperative Stroke?. JAMA. 2018; 319(5):446-447. DOI: 10.1001/jama.2017.21902. View

Taleb Bendiab T, Brusset A, Estagnasie P, Squara P, Nguyen L . Performance of EuroSCORE II and Society of Thoracic Surgeons risk scores in elderly patients undergoing aortic valve replacement surgery. Arch Cardiovasc Dis. 2021; 114(6-7):474-481. DOI: 10.1016/j.acvd.2020.12.004. View

Gaudino M, Rahouma M, Di Mauro M, Yanagawa B, Abouarab A, Demetres M . Early Versus Delayed Stroke After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2019; 8(13):e012447. PMC: 6662344. DOI: 10.1161/JAHA.119.012447. View

Hogue Jr C, Murphy S, Schechtman K, Davila-Roman V . Risk factors for early or delayed stroke after cardiac surgery. Circulation. 1999; 100(6):642-7. DOI: 10.1161/01.cir.100.6.642. View

Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Manios E, Spengos K . Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis. Stroke. 2014; 46(1):176-81. DOI: 10.1161/STROKEAHA.114.007240. View

Soliman A, Shanoudy H, Liu J, RUSSELL D, Jarmukli N . Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease. J Am Soc Echocardiogr. 1999; 12(2):99-105. DOI: 10.1016/s0894-7317(99)70121-5. View

Mas J, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L . Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med. 2017; 377(11):1011-1021. DOI: 10.1056/NEJMoa1705915. View

Nguyen L, Baudinaud P, Brusset A, Nicot F, Pechmajou L, Salem J . Heart failure with preserved ejection fraction as an independent risk factor of mortality after cardiothoracic surgery. J Thorac Cardiovasc Surg. 2018; 156(1):188-193.e2. DOI: 10.1016/j.jtcvs.2018.02.011. View

Saver J, Carroll J, Thaler D, Smalling R, MacDonald L, Marks D . Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med. 2017; 377(11):1022-1032. DOI: 10.1056/NEJMoa1610057. View

10.

Laghlam D, Le M, Srour A, Monsonego R, Estagnasie P, Brusset A . Diaphragm Dysfunction After Cardiac Surgery: Reappraisal. J Cardiothorac Vasc Anesth. 2021; 35(11):3241-3247. DOI: 10.1053/j.jvca.2021.02.023. View

11.

Eicher J, Bonniaud P, Baudouin N, Petit A, Bertaux G, Donal E . Hypoxaemia associated with an enlarged aortic root: a new syndrome?. Heart. 2005; 91(8):1030-5. PMC: 1769048. DOI: 10.1136/hrt.2003.027839. View

12.

Cabanes L, Mas J, Cohen A, Amarenco P, Cabanes P, Oubary P . Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke. 1993; 24(12):1865-73. DOI: 10.1161/01.str.24.12.1865. View

13.

Ahmad Y, Howard J, Arnold A, Shin M, Cook C, Petraco R . Patent foramen ovale closure vs. medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials. Eur Heart J. 2018; 39(18):1638-1649. PMC: 5946888. DOI: 10.1093/eurheartj/ehy121. View

14.

Krasuski R, Hart S, Allen D, Qureshi A, Pettersson G, Houghtaling P . Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival. JAMA. 2009; 302(3):290-7. DOI: 10.1001/jama.2009.1012. View

15.

Sondergaard L, Kasner S, Rhodes J, Andersen G, Iversen H, Nielsen-Kudsk J . Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med. 2017; 377(11):1033-1042. DOI: 10.1056/NEJMoa1707404. View

16.

Godart F, Rey C, Prat A, Vincentelli A, Chmait A, Francart C . Atrial right-to-left shunting causing severe hypoxaemia despite normal right-sided pressures. Report of 11 consecutive cases corrected by percutaneous closure. Eur Heart J. 2000; 21(6):483-9. DOI: 10.1053/euhj.1999.1944. View

17.

Ng S, Sugarbaker D, Frendl G . Interatrial shunting after major thoracic surgery: a rare but clinically significant event. Ann Thorac Surg. 2012; 93(5):1647-51. DOI: 10.1016/j.athoracsur.2012.02.029. View

18.

Ng P, Ng A, Subramaniam B, Burns S, Herisson F, Timm F . Association of Preoperatively Diagnosed Patent Foramen Ovale With Perioperative Ischemic Stroke. JAMA. 2018; 319(5):452-462. PMC: 5839297. DOI: 10.1001/jama.2017.21899. View

19.

Lo T, Jarral O, Shipolini A, McCormack D . Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?. Interact Cardiovasc Thorac Surg. 2011; 12(5):794-8. DOI: 10.1510/icvts.2011.265835. View

20.

Cujec B, Polasek P, Mayers I, Johnson D . Positive end-expiratory pressure increases the right-to-left shunt in mechanically ventilated patients with patent foramen ovale. Ann Intern Med. 1993; 119(9):887-94. DOI: 10.7326/0003-4819-119-9-199311010-00004. View