What is the pre-operative evaluation for a 45-year-old woman undergoing breast augmentation with a history of retinal artery occlusion and patent foramen ovale (PFO) in her 20s?

From the Guidelines

For a 45-year-old woman with a history of retinal artery clot and patent foramen ovale (PFO) undergoing breast augmentation, I strongly recommend a comprehensive preoperative evaluation including a cardiology consultation to assess her current risk of paradoxical embolism and guide management. The patient's history of retinal artery clot in her 20s suggests a possible previous paradoxical embolic event, which increases her risk of future events, particularly in the setting of surgery and potential venous thromboembolism [ 1 ].

Key Considerations:

• A recent echocardiogram is essential to assess the current status of the PFO and cardiac function, as this will guide decisions regarding anticoagulation management and the need for any interventions [ 1 ].
• Anticoagulation management is critical; if the patient is on anticoagulants, they should be bridged appropriately with low molecular weight heparin (e.g., enoxaparin 1mg/kg twice daily) with the last dose 24 hours before surgery and resumption 24-48 hours postoperatively based on bleeding risk.
• Aspirin 81mg daily should be continued perioperatively if already prescribed, as it may help reduce the risk of thrombotic events.
• Intraoperative precautions should include adequate hydration, avoiding air in IV lines, and possibly intraoperative transesophageal echocardiography monitoring to minimize the risk of paradoxical embolism.
• Postoperatively, early mobilization is essential, with the use of pneumatic compression devices until the patient is fully mobile, to reduce the risk of venous thromboembolism.
• The anesthesiologist should be informed about the patient's history to consider modifications to the anesthetic technique that may reduce the risk of paradoxical embolism.

Rationale:

The approach outlined above is based on the understanding that the combination of PFO and a previous thrombotic event increases the patient's risk of paradoxical embolism, where venous clots can cross through the PFO into the arterial circulation, potentially causing stroke or other arterial occlusions during surgery [ 1 ]. While the current evidence does not strongly support PFO closure for primary prevention in patients with a history of stroke or transient ischemic attack [ 1 ], the patient's specific situation, including her history of retinal artery clot and upcoming surgery, necessitates a cautious approach to minimize her risk of adverse outcomes.

From the Research

Pre-operative Evaluation for Breast Augmentation

Given the patient's history of retinal artery clot with PFO in her 20s, the following factors should be considered in the pre-operative evaluation:

• The patient's history of PFO, a congenital heart anomaly, which can lead to paradoxical embolism and cryptogenic strokes 2, 3
• The association between PFO and retinal artery occlusion, although rare, has been reported in several cases 4, 5
• The patient's age and lack of history of miscarriages are notable, as most cases of retinal artery occlusion associated with PFO occur in individuals under 50 years of age 4
• The importance of considering paradoxical embolism as a cause of retinal artery occlusion, especially in the absence of known cardiovascular risk factors, young age, migraine, recent immobility, vigorous exercise, and pregnancy 4

Diagnostic Considerations

The following diagnostic tests may be relevant in the pre-operative evaluation:

• Transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) to visualize the PFO 4, 5
• Laboratory testing and imaging to uncover possible systemic etiologies of the artery occlusion 6
• Stroke workup and hypercoagulability evaluations to rule out other potential causes of retinal artery occlusion 2, 3

Management Considerations

The following management considerations should be taken into account:

• The potential benefits and risks of percutaneous closure of the PFO, which may be considered to prevent future paradoxical embolic events 4, 5
• The importance of timely diagnosis, acute management, and ensuring urgent initiation of stroke workup in cases with retinal artery occlusion or transient monocular vision loss 4