Right-to-Left Shunt via a Patent Foramen Ovale Triggered by Constrictive Pericarditis With Right Heart Compression - A Case Report

Sep 28, 2026

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A rare case documents a right-to-left shunt through a patent foramen ovale (PFO) triggered by constrictive pericarditis secondary to an organized pericardial hematoma. A 72-year-old woman developed persistent hypoxemia after idiopathic pericarditis despite anti-inflammatory and antimicrobial therapy. On day 50, she suffered cerebral embolism involving the right middle cerebral artery territory. Imaging showed pericardial effusion compressing the right heart; intraoperative transesophageal echocardiography confirmed the PFO shunt. Surgical evacuation normalized pressures and resolved the shunt without recurrence.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

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Abstract

Introduction

Case Presentation

Patient presentation

Diagnostic findings

Treatment and outcome

Review began 10/26/2025 Review ended 11/26/2025 Published 11/29/2025 © Copyright 2025 Yamashita et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98123 Open Access Case Report Right-to-Left Shunt via a Patent Foramen Ovale Triggered by Constrictive Pericarditis With Right Heart Compression: A Case Report Takeshi Yamashita 1, Hanako Yoshihara Kurihara 1 , Tamami Watanabe 1, Kenichi Sugisaki 2, Takahiko Fukuchi 1 1. Division of General Medicine, Department of Comprehensive Medicine, Jichi Medical University Saitama Medical Center, Saitama, JPN 2. Division of Radiology, Department of Comprehensive Medicine, Jichi Medical University Saitama Medical Center, Saitama, JPN Corresponding author: Takeshi Yamashita, [t.yamashita@jichi.ac.jp](t.yamashita@jichi.ac.jp) Abstract We report a rare case of a right-to-left shunt through a patent foramen ovale (PFO) triggered by constrictive pericarditis secondary to an organized pericardial hematoma. A 72-year-old woman presented with thoracic back pain and subsequently developed persistent hypoxemia following idiopathic pericarditis. Despite appropriate anti-inflammatory and antimicrobial therapy, she experienced a cerebral embolism involving the right middle cerebral artery territory on hospital day 50. Imaging studies revealed a pericardial effusion compressing the right heart. Intraoperative transesophageal echocardiography confirmed a right-to-left shunt through a PFO. Surgical evacuation of the organized pericardial hematoma relieved right heart compression, normalized intracardiac pressures, and resolved the shunt. The pericardium was markedly thickened and adherent to the right ventricle with a fibrotic hematoma, and histopathology revealed fibrotic thickening with inflammatory infiltration and hemosiderin deposition. The patient 's respiratory status gradually improved, and she was discharged home without the recurrence of paradoxical cerebral embolism. This case highlights a rare pathophysiological mechanism in which constrictive pericarditis elevates right atrial pressure, unmasking a previously silent PFO and resulting in paradoxical embolism and refractory hypoxemia. Constrictive pericarditis should be considered a potential trigger for right-to-left shunting inpatients with unexplained hypoxemia or cryptogenic stroke. Categories: Neurology, Cardiology, Internal Medicine Keywords: constrictive pericarditis, hypoxemia, paradoxical cerebral embolism, patent foramen ovale (pfo), right-toleft cardiac shunt Introduction Patent foramen ovale (PFO) is a common congenital interatrial communication present in approximately 15-35% of the adult population [1] . Although often asymptomatic, a PFO can serve as a conduit for paradoxical embolism, particularly when right atrial pressure is elevated, such as in the setting of pulmonary embolism or right heart failure or during the Valsalva maneuver [1,2] . Paradoxical embolism through a PFO can lead to ischemic stroke, systemic embolization, or unexplained hypoxemia [3-6]. PFO results from the incomplete fusion of the septum primum and secundum [7] . Although it typically remains closed in function due to higher left atrial pressure [8], any condition that reverses this gradient can cause right-to-left shunting. The degree of shunting is influenced by defect size and pressure differential [7,9] . Constrictive pericarditis, a chronic inflammatory disorder characterized by the fibrotic thickening of the pericardium and impaired diastolic filling, can lead to elevated right-sided cardiac pressures [10]. Recent expert consensus from the American College of Cardiology has also emphasized early recognition and multimodal imaging for the diagnosis and management of pericardial diseases [11]. Asymm

FAQs

What condition triggered the right-to-left shunt in this case?

Constrictive pericarditis secondary to an organized pericardial hematoma triggered right-to-left shunting through a patent foramen ovale (PFO).

How was the PFO-related shunt confirmed?

Intraoperative transesophageal echocardiography confirmed a right-to-left shunt through the PFO.

What was the clinical outcome after treatment?

Surgical evacuation relieved right heart compression, normalized intracardiac pressures, resolved the shunt, improved respiratory status, and prevented recurrence of paradoxical cerebral embolism.

Sep 28, 2026

Uploaded by Aldword