The use of point-of-care ultrasound to diagnose patent foramen ovale in elective hip and knee arthroplasty patients and its association with postoperative delirium

Can J Anaesth. 2018 Jun;65(6):619-626. doi: 10.1007/s12630-018-1073-7. Epub 2018 Jan 24.


Purpose: Hip and knee arthroplasty surgeries are associated with embolism of materials such as air, cement, and fat. Patent foramen ovale (PFO) is a common congenital cardiac condition that has been reported to lead to paradoxical embolism. This observational study aimed to investigate if the presence of a PFO was associated with an increased risk of postoperative delirium in patients undergoing primary elective hip or knee arthroplasties.

Method: This was a prospective cohort study at a tertiary teaching hospital. We enrolled patients undergoing primary elective hip or knee arthroplasty who did not have any risk factors for embolism or delirium. Bedside transthoracic echocardiography (TTE) with a bubble study was performed on all patients to detect the presence of PFO. The primary outcome was postoperative delirium as assessed by the standardized Confusion Assessment Method. Secondary outcomes included the ease of performing a TTE bubble study in the perioperative setting, the quality of the TTE images, length of stay, major cardiovascular and neurologic complications, and effects of anesthetic or analgesic management techniques on delirium.

Results: Two hundred two patients completed the study. The median [interquartile range] duration of stay was 2 [2-3] days. Only 16 patients (8%) had a positive bubble study. Postoperative delirium was observed in only one patient. Major adverse events were not seen. The inter-rater reliability for the TTE image quality scores was fair (kappa statistic = 0.22).

Conclusion: Given the very low incidence of PFO and postoperative delirium in this study, we could not form any conclusions regarding the impact of a PFO on important outcomes including delirium or other major adverse events. No recommendation can be made regarding screening for PFO in patients scheduled for lower extremity arthroplasty surgery.

Trial registration: (NCT02400892). Registered 27 March 2015.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Arthroplasty, Replacement, Hip / methods*
  • Arthroplasty, Replacement, Knee / methods*
  • Cohort Studies
  • Confusion / epidemiology
  • Confusion / etiology
  • Confusion / psychology
  • Delirium / epidemiology
  • Delirium / etiology*
  • Delirium / psychology
  • Echocardiography / methods*
  • Elective Surgical Procedures / methods*
  • Female
  • Foramen Ovale, Patent / complications*
  • Foramen Ovale, Patent / diagnostic imaging*
  • Foramen Ovale, Patent / epidemiology
  • Humans
  • Male
  • Middle Aged
  • Observer Variation
  • Point-of-Care Systems*
  • Postoperative Complications / epidemiology
  • Prospective Studies
  • Reproducibility of Results

Associated data