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Dynamic right-to-left interatrial shunt may complicate severe COVID-19
  1. Rajkumar Rajendram1,2,
  2. Arif Hussain3,
  3. Naveed Mahmood1,2 and
  4. Gabriele Via4
  1. 1Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
  2. 2College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  3. 3Department of Cardiovascular Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
  4. 4Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
  1. Correspondence to Dr Rajkumar Rajendram; rajkumarrajendram{at}


Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.

  • adult intensive care
  • mechanical ventilation
  • pneumonia (respiratory medicine)
  • COVID-19

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  • Contributors RR, AH and NM were involved in the management of the case. They were also involved in the conceptualisation, data collection for, and preparation of the manuscript, as well as editing and approval of the final manuscript for publication. GV was involved in conceptualisation and preparation of the manuscript, as well as in editing and approval of the final manuscript for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.