A 47-year-old man admitted to intensive care unit (ICU) for acute respiratory distress syndrome remained severely hypoxemic despite mechanical ventilation and proning. Under transesophageal echocardiography (TEE) guidance, a bubble study was performed through an upper-body venous access to rule out a patent foramen ovale (PFO). However, a large Eustachian valve (Fig. 1a and video 1) prevented the bubbles from reaching the inter-atrial septum (IAS) (Fig. 1b and video 2). Colour Doppler did not show flow through the IAS (Fig. 1c and video 3).
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