Abstract 15972: Laparoscopic Surgery in a Young Patient With a Preexisting Patent Foramen Ovale and a Large Right-to-Left Shunt: Should a Fatal Outcome Change Our Clinical Practice?
Introduction: Air embolism during laparoscopic surgery is common, but fatality is rare. There are multiple mechanisms, including pulmonary hypertension from air in the pulmonary circulation. This leads to opening of a patent foramen ovale (PFO), which results in a large arterial embolism and coronary occlusion that could lead to severe ischemia and death. We report the first case of fatal air embolism diagnosed by three-dimensional (3D) transesophageal echocardiography (TEE).
Results: A 30-year-old woman underwent laparoscopic surgery for peritoneal dialysis catheter placement. Immediately after carbon dioxide (CO2) insufflation, she became hypotensive and hypoxic. Immediate two-dimensional (2D) TEE revealed right and left heart opacification caused by bubbles (Figure: A,B) and asystole in all four chambers. Prior color Doppler TEE showed an aneurysmal atrial septum with a large shunt across a PFO (Figure: C). Three-dimensional TEE showed the entire heart opacified by bubbles (Figure: D) and decreased bubbles after therapeutic aspiration from the right atrial central line (Figure: E). Despite extensive resuscitative measures, including air aspiration and extracorporeal membrane oxygenation, she died.
Conclusion: This case raises the question whether patients scheduled for laparoscopic surgery should undergo transthoracic echocardiography to allow preventive measures if a large shunt exits. Preventive measures may include avoidance of Fowler’s position, image-guided CO2 insufflation of the abdomen to avoid direct injection into portal or other abdominal veins, intraoperative TEE monitoring or even consider preoperative closure of a PFO. With the high prevalence of PFO in the general population (25%) and the high number of laproscopic procedures, extra precautions should be entertained only in those with preexisting large right-to-left shunts.
- © 2013 by American Heart Association, Inc.