Skip Navigation LinksHome > August 2010 - Volume 113 - Issue 2 > Patent Foramen Ovale, Bubble Test, and Major Spine Surgery
doi: 10.1097/ALN.0b013e3181e3d8c6
Education: Images in Anesthesiology

Patent Foramen Ovale, Bubble Test, and Major Spine Surgery

Hamada, Sophie Rym M.D.; Mantz, Jean M.D., Ph.D.

Free Access
Supplemental Author Material
Article Outline
Collapse Box

Author Information

POSTOPERATIVE paradoxical embolism resulting from patent foramen ovale (PFO) is a serious complication associated with major surgery. The prevalence of PFO in the general population ranges from 10 to 15% (contrast echocardiography1) to 27.3% (autopsy series). Preoperative diagnosis of PFO is rarely performed except in special settings such as surgery in the sitting position. In this case, a 68-yr-old patient, having undergone thoracolumbar laminectomy and arthrodesis (T12–L1 levels), presented with a bilateral segmentary pulmonary embolism and a left parietooccipital stroke on postoperative day 1. Because of both venous and arterial embolism, PFO was suspected and confirmed with transesophageal echocardiography sensitized with the bubble test.2 Contrast material was prepared by mixing 9 ml normal saline with 1 ml air through a three-way stopcock. This is known to produce 152 ± 79 microbubbles/mm3 with a diameter of 30–100 μm. A PFO is considered to be present when at least one bubble is seen in the left atrium (LA) within three cardiac cycles after total opacification of the right atrium3 (RA, dotted line) (see Supplemental Digital Content 1, which is a video showing bubbles in the left atrium immediately after total opacification of the right atrium, The arrow shows right-to-left shunting across the septum secundum not far from the aorta (Ao). Echocardiography with the bubble test is a safe, sensitive, and specific method to detect PFO. We suggest that systematic, prospective evaluation with bubble testing might be used for high-risk patients undergoing major spine surgery.
Back to Top | Article Outline


Figure. No caption a...
Image Tools
1.Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y: Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318:1148–52

2.Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J: Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001; 345:1740–6

3.Homma S, Di Tullio MR, Sacco RL, Mihalatos D, Li Mandri G, Mohr JP: Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke 1994; 25:582–6

Supplemental Digital Content

Back to Top | Article Outline

© 2010 American Society of Anesthesiologists, Inc.

Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.

Article Tools