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Re: PREVENTIVE CLOSURE OF A PATENT FORAMEN OVALE PRIOR TO TOTAL HIP REPLACEMENT
- Nigel J Harper, Donaldson AJ, Thomson HE, Kenny NW (14 April 2009)
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PREVENTIVE CLOSURE OF A PATENT FORAMEN OVALE PRIOR TO TOTAL HIP REPLACEMENT
- Benedicte Pigot, [Deborah Kirkham], [Luc Eyrolles], [Nadia Rosencher], [Denis Safran], and [Bernard Cholley] [ (7 April 2009)
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Bone cement implantation syndrome
- Baha Al-Shaikh (3 January 2009)
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Nigel J Harper , Donaldson AJ, Thomson HE, Kenny NW
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We thank Dr Pigot and colleagues for their interest in our review article. The authors describe a single case in which preoperative closure of a patent foramen ovale (PFO) almost certainly prevented paradoxical embolization of femoral canal contents during cemented elective hip replacement. This interesting case report is a helpful addition to the literature and we would support their recommendation that preoperative closure should be considered in patients with a PFO or other septal defect giving a history of stroke. However one would expect that percutaneous closure of a PFO would have already been performed in the majority of these patients for secondary prevention. Their case report may provide sufficient evidence to suggest that patients presenting for cemented hip replacement with a history of previous stroke should routinely undergo preoperative echocardiography if this has not been performed as part of their primary neurological investigations. Conflict of Interest:None declared |
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Benedicte Pigot, MD AP-HP and Université Paris 5, [Deborah Kirkham], [Luc Eyrolles], [Nadia Rosencher], [Denis Safran], and [Bernard Cholley] [
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We read with great interest the review by Donaldson et al. entitled Bone cement implementation syndrome published in the January 2009 issue of the British Journal of Anaesthesia.1 The possibility of paradoxical embolism with potential brain damage during total hip replacement (THR) is mentioned by the authors. However, the specific management of such patients was not been discussed in the “anaesthetic risk reduction” section of their review. Although there is no general agreement regarding the prevention of paradoxical embolism, we believe that closure of an atrial septal defect (ASD) may be a logical strategy prior to THR in patients at very high risk. A recent observation provided us with echocardiographic evidence that preoperative ASD occlusion could provide real protection against paradoxical embolism during THR. A 74 year-old lady evaluated at the anaesthetic consultation prior to elective right hip replacement reported having suffered two consecutive cerebellar ischaemic strokes in 2001. At that time, transoesophageal echocardiography (TOE) revealed interatrial septum aneurysm with a patent foramen ovale (PFO). A massive shunt with rapid, complete opacification of the left atrium was demonstrated after injection of ultrasound contrast medium in a peripheral vein. Since all other investigations were negative, it was considered highly probable that the iterative strokes were due to a paradoxical embolism originating from the interatrial septum aneurysm. The cerebellar syndrome recovered progressively and neurological status returned to normal after several weeks. Cardiologists recommended anticoagulation using fluindione, but decided that foramen ovale closure was not necessary. The question of the relevance of foramen ovale closure was raised again during the anaesthetic consultation. Considering the high risk of venous embolism associated with total hip replacement, the patient was scheduled for preoperative transcatheter closure of the PFO to avoid paradoxical systemic embolus during surgery. The percutaneous closure of the PFO (Cardiastar®, 30 mm) was successful and echocardiographic control at 3 months revealed that only minor shunting (less than 10 bubbles) persisted during the Valsalva manoeuvre. Oral anticoagulation was interrupted and replaced by platelet anti-aggregant therapy using clopidogrel (75 mg/d) and aspirin (100 mg/d) in the first 3 months following foramen ovale closure. Clopidogrel was then stopped and hip arthroplasty was carried out successfully under aspirin therapy alone. Intra-operative TOE revealed numerous echogenic emboli passing through the right atrium during femur reaming and prosthesis sealing. At the same time, the interatrial septum bulged into the left atrium, indicating that the pressure gradient was in favour of right to left shunting and, therefore, in favour of paradoxical embolism View Image. The patient suffered neither neurological deficit nor ischemic problems in the postoperative period, and remains well one year after the surgery. Percutaneous closure of a PFO is recommended for secondary prevention in patients with previous transient ischemic attacks, stroke, or peripheral embolism.2, 3 Paradoxical embolism to the brain following orthopaedic surgery in patients with PFO has previously been reported.4-6 However, there is no recommendation regarding what should be done in such patients prior to THR, which puts them at high risk for systemic emboli. In our patient, the history of repeated cerebellar strokes suggested that paradoxical embolism had already occurred, and therefore the risk of recurrence during hip replacement was very high. The intraoperative echocardiographic observations reassured us that this approach was likely to have been useful. We suggest that percutaneous foramen ovale closure may be a reasonable preliminary step prior to total hip replacement in patients with previous history of stroke and PFO. Large prospective trials are warranted to confirm the validity of this approach. References 1. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009; 102: 12-22 2. Windecker S, Wahl A, Nedeltchev K, et al. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol 2004; 44: 750-8 3. Balbi M, Casalino L, Gnecco G, et al. Percutaneous closure of patent foramen ovale in patients with presumed paradoxical embolism: periprocedural results and midterm risk of recurrent neurologic events. Am Heart J 2008; 156: 356-60 4. Byrick RJ, Korley RE, McKee MD, Schemitsch EH. Prolonged coma after unreamed, locked nailing of femoral shaft fracture. Anesthesiology 2001; 94: 163-5 5. Byrick RJ. Causes of brain injury during orthopedic surgery. Can J Anaesth 2004; 51: 867-70 6. Sasano N, Ishida S, Tetsu S, et al. Cerebral fat embolism diagnosed by magnetic resonance imaging at one, eight, and 50 days after hip arthroplasty: a case report. Can J Anaesth 2004; 51: 875-9 Conflict of Interest:None declared |
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Baha Al-Shaikh, Consulat Anaesthetist and Honorary Senior Lecturer Ashford, Kent. UK
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As an anaesthetist with a special interest in orthopaedic surgery, I read with great interest the paper written by AJ Donaldson et al (1). I would like to congratulate the authors for such an excellent review. However, I would like to raise the following points: The review was not as comprehensive as stated. It has been shown that the administration of an FiO2 of 0.5 during the insertion of the cement, reduces significantly the incidence of desaturation when compared with an FiO2 of 0.33 (2). The incidence in the reduction in arterial oxygen saturation (SpO2) was higher during the insertion of the femoral component which may be due to its higher vascularity and surface area and the larger amount of cement used when compared to the acetabular component. The reduction in SpO2 occurred within 1-4 min (median 1 (SD 0.93) min). In that study, there was no correlation between the incidence or degree of reduction in SpO2 and the general medical condition of the patients or the habit of smoking. As the utilization of a higher FiO2 decreased significantly the incidence of desaturation, implies that the desaturation was caused by ventilation perfusion inequalities rather than an increase in true right-left shunt. For the last 19 years, I have been administering an FiO2 of 0.5 to thousands of patients undergoing lower limb arthroplasty. During that period, I have had only one incident of cardiac arrest following femoral component insertion. In a complete audit cycle of 150 patients (unpublished personal data), we observed that inserting the cement ‘too early’ before it solidified, increased the incidence of desaturation to 10% of patients. Delaying the insertion of the cement for 45-60 sec reduced the incidence of desaturation to zero. As the authors mentioned, the intramedullary pressures may increase to more than 500 mmHg during cemented implants. This is of particular importance during total knee replacement despite the use of tourniquet (3). This problem can be of more significance as some of the surgeons insert the prostheses with the tourniquet deflated. References: 1. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009; 102:12-22. 2. Al-Shaikh B. Effect of inspired oxygen concentration on the incidence of desaturation in patients underging total hip replacement. Br J Anaesth 1991; 66: 580-2. 3. Al-Shaikh B. Desaturation during total knee replacement. Br J Anaesh 1991; 67:502. Conflict of Interest:None declared |
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