SESSION TITLE: Cardiovascular Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM
INTRODUCTION: Platypnea-orthodeoxia (PO) is a relatively uncommon syndrome characterized by dyspnea and deoxygenation accompanying a change to a sitting from a recumbent position.1 There have been few reports of PO related to PE.2
CASE PRESENTATION: A 73 year old female with a history of ulcerative colitis and recurrent pulmonary emboli (PE) was admitted with hypoxemia requiring 10-15 L of O2. Her SpO2 dropped by > 5% when she moved from recumbent to sitting position. A CTPE showed no evidence of an acute PE or parenchymal disease. A V/Q scan showed chronic PE. Spirometry was normal and a shunt study calculated a 27.86% shunt, with a drop of PO2 from 80 mmHg to 65 mmHg with change from supine to seated position. TTE showed a normal EF with RVSP of 40 and trivial shunting. RHC with pulmonary angiography did not show any evidence of AVM, and selective saturations in RML and LUL pulmonary vein were > 95%,whereas LLL pulmonary vein sat was 77%. Bubble study demonstrated right to left shunting through a fossa ovalis defect which was closed with a Cribriform Atrial Septal Occluder. The patient was weaned off 10 L of O2 within 48 hours and discharged home. She remained on RA at a 6 week follow up visit.
DISCUSSION: PO is a rare, often-unrecognized, and under-reported clinical entity. There have been less than 100 case reports describing the syndrome. Few reports relate PO to PE.In patients with intracardiac communications and PE, right-to-left shunting is likely related to an acute elevation in PA pressure . Bilateral PE may result in V/Q mismatching, which worsen on upright position 2.Of the few reports of PO related to PE, two patients had resolution of their symptoms with correction of an ASD.3.
CONCLUSIONS: ASD should be considered in patients presenting with PE and PO Syndrome. Peripheral contrast tilt-table TEE should be considered for diagnosis. Long term effects of ASD closure on pulmonary HTN in patients with recurrent PE are unknown.
Reference #1: Mechanisms of Platypnea-Orthodeoxia: What Causes Water to Flow Uphill. Tsung O, Cheng MD, Circulation 2002
Reference #2: Platypnea-orthodeoxia: bilateral lower-lobe pulmonaryemboli and review of associated pathophysiology and management. Brunner M, Tapson V. South Med J2011
Reference #3: Platypnea and orthodeoxia in a patient with pulmonary embolism.Salvetti M, etal, Am J Emerg Med. 2013 Feb 1.
DISCLOSURE: The following authors have nothing to disclose: Mohamed Ali, Amy Pope-Harman, Nitin Bhatt
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