Stepwise Progression of Right-to-Left Atrial Shunting through a Combination of Patent Foramen Ovale and Tricuspid Regurgitation

Abstract

Patent foramen ovale is a common clinical finding that generally becomes a concern in the presence of transient ischemic attack or stroke. Rarely, patent foramen ovale is associated with hypoxemia in the presence of substantial right-to-left atrial shunting. We present the case of an 86-year-old woman with a pacemaker, who was initially asymptomatic notwithstanding a patent foramen ovale. Over 1.5 years, her symptoms progressed in a stepwise fashion, in the setting of progressive pacemaker-associated tricuspid regurgitation. Ultimately, the patient's symptoms and her hypoxemia resolved after percutaneous closure of her patent foramen ovale with use of a 25-mm "Cribriform" occluder device. This case highlights the fact that clinically significant right-to-left shunting requires an anatomic lesion, such as patent foramen ovale, together with elevated right atrial pressure, which in this case was contributed by severe tricuspid regurgitation.

Keywords: Echocardiography, transesophageal; echocardiography, transthoracic; foramen ovale, patent/complications/physiopathology/therapy; heart septal defects, atrial; pacemaker, dual-chamber; septal occluder device; tricuspid regurgitation.

Fig. 1.

Transthoracic echocardiogram (apical 4-chamber view with right ventricle on the right) shows incomplete coaptation of the tricuspid valve due to impingement of the pacemaker lead on the septal leaflet. Supplemental motion image is available for Figure 1.

Fig. 2.

Transesophageal echocardiogram (bicaval view, with zoom of the interatrial septum and simultaneous biplane view) shows right-to-left shunting upon injection of agitated saline. Supplemental motion image is available for Figure 2.

Fig. 3.

Transthoracic echocardiogram with color-flow Doppler (apical 4-chamber view with right ventricle on the right) shows severe tricuspid regurgitation. Supplemental motion image is available for Figure 3.

Fig. 4.

Continuous-wave Doppler interrogation of the tricuspid regurgitation jet shows a dense, early-peaking, V-shaped signal consistent with severe tricuspid regurgitation.

Fig. 5.

Transthoracic echocardiogram with color-flow Doppler (apical 4-chamber view with zoom of the interatrial septum and right atrium on the right) shows right-to-left flow across the patent foramen ovale. Supplemental motion image is available for Figure 5.