When PEEP Becomes a Balancing Act: Ventilatory Challenges in a Patient with PFO Undergoing Laparoscopic Surgery in Trendelenburg Position

When PEEP Becomes a Balancing Act: Ventilatory Challenges in a Patient with PFO Undergoing Laparoscopic Surgery in Trendelenburg Position | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report When PEEP Becomes a Balancing Act: Ventilatory Challenges in a Patient with PFO Undergoing Laparoscopic Surgery in Trendelenburg Position Evelyn Martin, Karl Meggiolaro, Felix Schmitt, Christine Gaik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9204392/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Advances in cardiology and perioperative care have markedly improved survival rates in patients with congenital heart disease, including atrial septum defect (ASD) and persistent foramen ovale (PFO). Consequently, an increasing number of these patients reach present for non-cardiac surgery in adulthood. With advancing age, 97concomitant comorbidities, such as chronic obstructive pulmonary disease (COPD), become more prevalent. Although laparoscopic surgery offers potential benefits over open procedures, pneumoperitoneum and Trendelenburg positioning may adversely affect cardiopulmonary physiology, particularly in patients with intracardiac shunts or obstructive airway disease Case presentation : We present the case of a 53-year-old man with a history of embolic stroke and presumed PFO undergoing robotic-assisted laparoscopic surgery. Intraoperatively, previously undiagnosed obstructive airway disease caused severe dynamic hyperinflation with intrinsic PEEP. Escalation of ventilatory pressures was restricted due to concern for right-to-left shunt exacerbation under pneumoperitoneum and Trendelenburg positioning, and persistent ventilatory compromise required conversion to mini-laparotomy. After relief of pneumoperitoneum and individualized PEEP adjustment, respiratory mechanics improved. Postoperative transthoracic echocardiography unexpectedly demonstrated an ASD with left-to-right shunt instead of the presumed PFO. Conclusion This case highlights the complex interplay between ventilatory mechanics and intracardiac shunt physiology during laparoscopic surgery. It underscores the importance of comprehensive preoperative evaluation, critical reassessment of historical diagnoses, and dynamic intraoperative echocardiographic assessment. Individualized anesthetic and ventilatory strategies are essential to minimize perioperative risk in patients with congenital heart disease and concomitant obstructive lung pathology . Intrinsic PEEP Patent foramen ovale Atrial septal defect Ventilatory compromise Right heart strain Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9204392","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":614042688,"identity":"6a81012c-d9a8-4ad2-a335-9390443ac4a1","order_by":0,"name":"Evelyn Martin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYLCCBAYGOSBlAMQSID4bRPgATg2MDUAtxiRqARKJDRAtDIS16Lafff7g4Q6b9LXtzRuYeXdYgESePebdU8vAd7wBqxazM+mGDYln0nK3nTlWwMx7RgIkYm7M8+w4g+QZ7NaYHUhjbEhsO5y77UaOATNvm0T9tgNpbNI8B44xGNxIwK7l/DOQlv/pZvffgLWARKBa7j/AruUG2JYDCWY3eKBaboBtqQHagt37ZjeeMc5IbEs23HYmreDgXLCWZ+yGcw4c4JE8g8thaQwff7bZyZsdP7zxwdu2OpAI24M3B+rk+I5j9z4KQFZymIewejRQR7KOUTAKRsEoGLYAAHqPZLiv1gvkAAAAAElFTkSuQmCC","orcid":"","institution":"Marburg University","correspondingAuthor":true,"prefix":"","firstName":"Evelyn","middleName":"","lastName":"Martin","suffix":""},{"id":614042689,"identity":"834326ad-49eb-43e3-aa2a-7a6d785b7a23","order_by":1,"name":"Karl Meggiolaro","email":"","orcid":"","institution":"Marburg University","correspondingAuthor":false,"prefix":"","firstName":"Karl","middleName":"","lastName":"Meggiolaro","suffix":""},{"id":614042690,"identity":"ce58a939-2ecb-44d1-b98d-e73d1c3602bf","order_by":2,"name":"Felix Schmitt","email":"","orcid":"","institution":"Marburg University","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Schmitt","suffix":""},{"id":614042691,"identity":"833a99f4-50ec-40ed-82b8-29939ca00f39","order_by":3,"name":"Christine Gaik","email":"","orcid":"","institution":"Marburg University","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Gaik","suffix":""}],"badges":[],"createdAt":"2026-03-23 20:38:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9204392/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9204392/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108491324,"identity":"334b8d5e-6a48-4737-b481-342b5cbc0f70","added_by":"auto","created_at":"2026-05-05 09:53:18","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":937325,"visible":true,"origin":"","legend":"","description":"","filename":"WhenPEEPBecomesaBalancingActVersuchCG020326No.3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9204392/v1_covered_75bbf9c8-b0b4-4e12-8c2f-2ac7238fe2ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"When PEEP Becomes a Balancing Act: Ventilatory Challenges in a Patient with PFO Undergoing Laparoscopic Surgery in Trendelenburg Position","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intrinsic PEEP, Patent foramen ovale, Atrial septal defect, Ventilatory compromise, Right heart strain","lastPublishedDoi":"10.21203/rs.3.rs-9204392/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9204392/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdvances in cardiology and perioperative care have markedly improved survival rates in patients with congenital heart disease, including atrial septum defect (ASD) and persistent foramen ovale (PFO). Consequently, an increasing number of these patients reach present for non-cardiac surgery in adulthood. With advancing age, 97concomitant comorbidities, such as chronic obstructive pulmonary disease (COPD), become more prevalent. Although laparoscopic surgery offers potential benefits over open procedures, pneumoperitoneum and Trendelenburg positioning may adversely affect cardiopulmonary physiology, particularly in patients with intracardiac shunts or obstructive airway disease\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003e: We present the case of a 53-year-old man with a history of embolic stroke and presumed PFO undergoing robotic-assisted laparoscopic surgery. Intraoperatively, previously undiagnosed obstructive airway disease caused severe dynamic hyperinflation with intrinsic PEEP. Escalation of ventilatory pressures was restricted due to concern for right-to-left shunt exacerbation under pneumoperitoneum and Trendelenburg positioning, and persistent ventilatory compromise required conversion to mini-laparotomy. After relief of pneumoperitoneum and individualized PEEP adjustment, respiratory mechanics improved. Postoperative transthoracic echocardiography unexpectedly demonstrated an ASD with left-to-right shunt instead of the presumed PFO.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights the complex interplay between ventilatory mechanics and intracardiac shunt physiology during laparoscopic surgery. It underscores the importance of comprehensive preoperative evaluation, critical reassessment of historical diagnoses, and dynamic intraoperative echocardiographic assessment. 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