Ventricular fibrillation occurring two hours after successful angioplasty in non-ST-segment elevation acute coronary syndrome.

Rev Esp Cardiol. 2009;62(9):1068-81 1069 these patients is complex. The hypoxaemia does not respond to increases in positive end-expiratory pressure (PEEP) which has even been related to the shunt increase.4 Also, patient maladjustment during weaning which involves a manoeuvre similar to that of Valsalva increases the shunt and consequently the hypoxaemia, which hinders extubation.3 In our patient, the decompression of the left cavities due to massive intraoperative arterial blood loss, mechanical ventilation and PEEP, and diaphragmatic elevation were probable mechanisms of hypoxaemia in the intraoperative and immediate postoperative periods. It is essential to keep this manifestation of the PFO in mind in cases of intraoperative or perioperative hypoxaemia. With these clinical symptoms, the transoesophageal echocardiogram can exclude, without having to move the patient, a significative pulmonary embolism or a PFO. The position faced with a PFO shunt in the perioperative stage should be the correction of the precipitant situation if possible. Nitric oxide decreases the shunt3 by reducing pressure in the pulmonary tree and PEEP should be avoided.4 Percutaneous closing is a disputable subject.3 Besides the indications of paradoxical embolism, cases of closing in patients with chronic5 or acute refractory6 hypoxaemia have been described. The evolution of our patient was favourable without percutaneous closing and there is currently no indication of its use to avoid similar occurrences.