Patent foramen ovale diagnosis: The importance of provocative maneuvers

S. Mongodi, G. Via, M. Riccardi, G. Tavazzi, A. M. D'Armini, M. Maurelli, A. Braschi, F. Mojoli

Research output: Contribution to journalArticlepeer-review


Patent foramen ovale (PFO) is a frequent congenital anomaly, but massive right-to-left shunt (RTLS) is normally prevented by higher pressures in left heart chambers. However, mechanical ventilation with positive end-expiratory pressure (PEEP) can significantly increase right atrial pressure, accentuating the RTLS, mainly after major cardiothoracic surgery. We report a patient admitted to the intensive care unit after cardiac surgery. Pre- and intraoperative transesophageal echocardiography only described an aneurysmal interatrial septum with no shunt. However, high-PEEP ventilation induced a paradoxical response with life-threatening hypoxemia, triggering further echocardiographic evaluation, revealing massive RTLS across a stretch PFO. Provocative maneuvers (Valsalva/PEEP) significantly increase echocardiographic sensitivity, unmasking silent PFO. (c) 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:58-61, 2017.
Original languageEnglish
Pages (from-to)58-61
Number of pages4
JournalJournal of Clinical Ultrasound
Issue number1
Publication statusPublished - Jan 1 2017


  • Aged
  • Echocardiography, Transesophageal/methods
  • Foramen Ovale, Patent/diagnostic imaging/physiopathology
  • Humans
  • Male
  • Positive-Pressure Respiration
  • Ultrasonography, Doppler, Color/methods
  • Valsalva Maneuver
  • echocardiography
  • paradoxical response to positive end-expiratory pressure
  • patent foramen ovale
  • provocative maneuvers
  • right-to-left shunt


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