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Response to the letter of Webb T. et al. for the article “Patent foramen ovale and neurosurgery in sitting position: a systemic review”
- Bernhard Meier, Ali-Reza Fathi, Parham Eshtehardi (19 May 2009)
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Preoperative percutaneous patent foramen ovale closure prior to neurosurgery in the sitting position
- Stephen T Webb, Andrew A Klein, Patrick A Calvert, Evelyn M Lee, and Leonard M Shapiro (11 May 2009)
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Bernhard Meier , Ali-Reza Fathi, Parham Eshtehardi
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We are obliged to Dr Webb whose comments beautifully complements our article on percutaneous patent foramen ovale (PFO) closure prior to neurosurgery in the sitting position. We have nothing to add to his comments other than that the benefit of PFO closure is not limited to the day of neurosurgery. In fact it persists for the rest of the life of the patient and potentially protects against subsequent paradoxical stroke, myocardial infarction, or other systemic embolism. Not to mention that PFO carriers often suffer from migraine independent of their problem requiring neurosurgery and that migraine symptoms may improve. Ali-Reza Fathi, Parham Eshtehardi, Bernhard Meier, Conflict of Interest:None declared |
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Stephen T Webb, Consultant in Anaesthesia & Intensive Care Papworth Hospital NHS Foundation Trust, Andrew A Klein, Patrick A Calvert, Evelyn M Lee, and Leonard M Shapiro
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Editor, We wish to congratulate Dr Fathi, Dr Eshtehardi and Dr Meier on their systematic review of air embolism associated with neurosurgery in the sitting position and patent foramen ovale (PFO) closure (1). Percutaneous PFO closure can be performed relatively easily with excellent results in a specialist high-volume centre such as ours. 524 percutaneous atrial septal closures have been performed at our centre since 1994 with a major complication rate is 0.19% including no deaths. Results of a recent audit demonstrated that 94% of patients were highly satisfied with their care. We perform percutaneous atrial septal closure under general anaesthesia with intraoperative transoesophageal echocardiographic and fluoroscopic guidance. This procedure has been routinely performed as a day case in our centre since 2006 (2). We agree with the authors that preoperative percutaneous PFO closure should be considered prior to neurosurgery in the sitting position. However, the advantages of the sitting versus the horizontal operative position need to be clarified before exposing patients to the small but definite risk of an additional procedure. Although the incidence of venous air embolism is higher in the sitting compared to the horizontal position, there appears to be less need for blood transfusion and improved facial nerve function after neurosurgery in the sitting position (3-5). If neurosurgeons, neuroanaesthetists and patients believe that the advantages of the sitting operative position outweigh the modest risk of percutaneous PFO closure then we would be prepared to close PFOs for this indication. It should be remembered that, regardless of position, paradoxical air embolism across a PFO may occur during neurosurgical procedures. Paradoxical air embolism may be associated with events during induction of or emergence from anaesthesia. The valsalva manoeuvre is known to transiently increase right atrial pressure so that it exceeds left atrial pressure, but coughing, breath-holding, straining or struggling may have a similar effect. We suggest that all patients undergoing elective neurosurgery in the sitting position should be screened for PFO and considered for percutaneous closure. This strategy will permit safer surgery to be performed in the most appropriate position. References 1. Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009; 102: 588-96. 2. Calvert P, Klein A. Anaesthesia for percutaneous closure of atrial septal defects. Continuing Education in Anaesthesia, Critical Care & Pain 2008; 8: 16-20. 3. Duke DA, Lynch JJ, Harner SG, Faust RJ, Ebersold MJ. Venous air embolism in sitting and supine patients undergoing vestibular schwannoma resection. Neurosurgery 1998; 42: 1282-6; discussion 1286-7. 4. Orliaguet GA, Hanafi M, Meyer PG, Blanot S, Jarreau MM, Bresson D, et al. Is the sitting or the prone position best for surgery for posterior fossa tumours in children? Paediatr Anaesth 2001; 11: 541-7. 5. Black S, Ockert DB, Oliver WC, Jr., Cucchiara RF. Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions. Anesthesiology 1988; 69: 49-56. Conflict of Interest:None declared |
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