SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Platypnea orthodeoxia is a rare disorder characterized by both dyspnea and arterial desaturation in the upright position with improvement in the supine position. We describe an unusual case of platypnea - orthodeoxia in a 64 year old male who was subsequently diagmosed to have large aneurysm of ascending aorta that required surgical intervention.
CASE PRESENTATION: A 64 year old Caucasian male with no previous known illness presented with 2 week history of difficulty in breathing present only in upright position, that got relieved on lying down. On physical examination: B.P 142/75, heart rate 102, respiratory rate 28 and oxygen saturation 75% on room air in upright position, improved to 92% on room air on supine position. On auscultation, there was soft systolic murmur of 3/6 in left parasternal region and normal heart sounds were heard. Chest was clear to auscultation. ECG showed sinus tachycardia, otherwise normal. Blood counts and chemistry was unremarkable. Chest radiograph was unremarkable, VQ scan showed low probability for pulmonary embolism. Transthoracic echocardiogram showed 5.5 cm ascending aortic aneurysm. Transesophageal echo (TEE) confirmed aneurysm, as well as a large patent foramen ovale (PFO) with right to left intracardiac shunt. Tilt table TEE confirmed orthodeoxia, with predominant right to left shunt. Patient underwent surgical correction of aneurysm and recovered well.
DISCUSSION: Platypnea-orthodeoxia syndrome is characterized by dyspnea and deoxygenation associated with change of position from a recumbent to a sitting or standing. This is due to positional variation of abnormal shunting. It requires both an anatomical component (Atrial septal defect / PFO) and a functional component (Prominent Eustachian valve, localized pericardial effusion or aortic aneurysm) that causes redirection of shunt flow from right atria to left atria with assuming upright position. It is suggested that the aneurysm produces an anatomical distortion of the inter-atrial septum leading to widening of the preexisting PFO. Another mechanism involves the aneurysm causing a “spinnaker effect”, potentiating a right to left shunt via a PFO. This clinical scenario could present a diagnostic and therapeutic dilemma. Early recognition and prompt management is life saving.
CONCLUSIONS: Approach to a case of platypnea - orthodeoxia requires comprehensive work up as it could be due to myriad of conditions including various cardiovascular and respiratory causes. High index of suspicion with a good understanding of basic physioanatomical correlation is required.
Reference #1: Tsung O. Mechanisms of Platypnea-Orthodeoxia: What Causes Water to Flow Uphill? Circulation, 2002;105:e47
DISCLOSURE: The following authors have nothing to disclose: Gunjan Choudhary, Deepshika Sudhakar, Vijay Das, Umashankar Lakshmanadoss
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