Cardiovascular Disease |

A ‘Laid-back’ Approach to an Out-‘Standing’ Diagnosis FREE TO VIEW

Tanmay Panchabhai, MD; Mohannad Dugum, MD; Jafar Abunasser, MD; Gustavo Heresi, MD; Aanchal Kapoor, MD
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Respiratory Institute, Department of Pulmonary, Allergy and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH

Chest. 2013;144(4_MeetingAbstracts):122A. doi:10.1378/chest.1703876
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SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Platypnea-orthodeoxia is a symptom complex caused by shunts which can be intra-cardiac, pulmonary parenchymal or from ventilation-perfusion mismatch.1 We describe the diagnostic workup and management of a patient presenting with hypoxemia and orthodeoxia of insidious onset post right pneumonectomy.

CASE PRESENTATION: A 66 year-old Caucasian female with history of Squamous cell cancer of the right hilar region, post right pneumonectomy 7 months earlier; presented with worsening shortness of breath. Pre-operative PFTs showed FEV1 of 1.69 (79% predicted) and DLCO 66% predicted. Post-pneumonectomy, she did notice gradual onset of dyspnea more pronounced on standing upright and with activity. She never used home oxygen prior to surgery but required 3 L of oxygen in the late post-operative period. She had an extensive 80 pack year history of smoking. On admission, the patient required 80% high-flow oxygen to maintain saturations between 88 and 92%. CT Chest with contrast showed no evidence of pulmonary emboli. Oxygen saturations were noted to be significantly different in supine (98%) versus sitting up (85%) position on the same high flow oxygen. Trans-thoracic echocardiogram with agitated saline contrast was non-diagnostic for intra-cardiac shunt. Trans-esophageal echocardiogram was pursued due to high clinical suspicion and showed a fenestrated patent foramen ovale (PFO) with bidirectional shunt flow on color and agitated saline contrast images (Figures I and II). Right and left heart catheterization revealed normal coronaries, normal atrial pressures (RA = 10 mm Hg, LA = 8 mm Hg) and intra-cardiac echo probe showed positive agitated saline contrast study across inter-atrial septum. The PFO was closed with a 25 mm amplatzer cribriform device. Post-procedure, the patient’s oxygen saturations improved to 96% on room air. Follow-up trans-thoracic echocardiogram showed no residual shunting. She was discharged home on 2 L oxygen with exertion, plavix and aspirin.

DISCUSSION: ‘Postural cyanosis’ was aptly the original description of Platypnea-orthodeoxia symptom complex. Post right pneumonectomy, mediastinal shift causes the inter-atrial septum to stretch and hence, opening up of a previously silent atrial septal defect.2 In upright position, the weight of the heart pulls the inter-atrial septum causing the PFO/ASD to widen leading to hypoxemia.

CONCLUSIONS: Prompt recognition of this postural hypoxemia is important as closure of the inter-atrial communication frequently leads to cure, as described in our patient.

Reference #1: Rodrigue P, Palma P, Sousa-Pereira L. Platypnea-orthodeoxia syndrome in review - defining a new disease? Cardiology 2012; 123:15-23.

Reference #2: Bhattacharya K, Birla R, Northridge D, Zamvar V. Platypnea-orthodeoxia syndrome: A rare complication after right pneumonectomy. Ann Thor Surg 2009; 88: 2018-2019.

DISCLOSURE: The following authors have nothing to disclose: Tanmay Panchabhai, Mohannad Dugum, Jafar Abunasser, Gustavo Heresi, Aanchal Kapoor

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