Patent foramen ovale diagnosis: The importance of provocative maneuvers

Silvia Mongodi, Gabriele Via, Mariachiara Riccardi, Guido Tavazzi, Andrea Maria D'Armini, Marco Maurelli, Antonio Braschi, Francesco 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.

Original languageEnglish
JournalJournal of Clinical Ultrasound
Publication statusAccepted/In press - 2016


  • Echocardiography
  • Paradoxical response to positive end-expiratory pressure
  • Patent foramen ovale
  • Provocative maneuvers
  • Right-to-left shunt

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging


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