key: cord-0760169-p52ikn3u
authors: Fabre, Olivier; Rebet, Olivier; Hysi, Ilir
title: Right-to-left interatrial shunt in COVID-19 patients with pulmonary embolism
date: 2020-05-31
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.05.014
sha: 4e3e3174dbf17c673115c57d15358240112c3fd2
doc_id: 760169
cord_uid: p52ikn3u

nan

Reply to the Editor:

We read with great interest the article form Rajendram and colleagues (1), with regard to our previous publication of a young patient, presenting with a severe pulmonary embolism as an initial symptom of a COVID-19 infection (2) . We reported our clinical experience and insisted on the facts that at the initial work-up the patient had a patent foramen ovale with clot into it (which made us chose the surgical treatment rather than an intravenous thrombolytic therapy) and that after the surgical embolectomy, mechanical ventilation of our patient was difficult with refractory hypoxemia. Although this was somehow improved by prone position, the patient was put under extracorporeal membrane oxygenation and died of multiorgan failure soon after.

Rajendram and colleagues (1) very interestingly hypothesized that platypnea-orthodeoxia syndrome with a right-to-left interatrial shunt, in relation with the initial patent foramen ovale, may have play a crucial role. We think that this was not possible in our case as the patent foramen ovale was closed during the cardiac surgery with a polypropylene running suture.

Moreover, no interatrial shunt was seen in the various echocardiographies done in the postoperative period. In our opinion, improvement of blood gas exchange in prone decubitus was mostly due to the release of posterior atelectasis in an obese patient as in "classic" acute respiratory distress syndrome (3) . We think that in our patient parenchymal severe inflammatory aggression was per se the main mechanism of lung failure.

Also, it is important to underline that unlike the initial period, when we published our article, in the last three weeks there have been almost 65 publications showing the link and the high frequency between Covid-19 and pulmonary embolism. These proximal or distal lung 2 vessels thromboses may also present a preponderant factor in impairment of pulmonary 

Covid-19 may be exacerbated by right-to-left interatrial shunt

Severe acute proximal pulmonary embolism and COVID-19: a word of caution

Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis