Pulmonary Vascular Disease: Student/Resident Case Report Poster - Pulmonary Vascular Disease II |

Refractory Hypoxemia From Intra-Cardiac Shunting Through Patent Foramen Ovale: A Case Report and Review of Literature FREE TO VIEW

Bankim Patel, MD; Puneet Singh, MD; Stella Ogake, MD; Samuel Durrett, MD; Frank Lodeserto, MD
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Brody School of Medicine/East Carolina University, Greenville, NC

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1224A. doi:10.1016/j.chest.2016.08.1333
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: We describe a case of refractory hypoxemia due to acute elevation in pulmonary vascular resistance (PVR) secondary to a pulmonary embolism(PE) with resulting right to left intra-cardiac shunt through a patent foramen ovale (PFO).

CASE PRESENTATION: We describe a case of a 44-year-old female COPD, Systolic Heart Failure, and Asthma presenting with sudden onset hypoxemic respiratory failure requiring emergent endotracheal intubation. On arrival, hypoxemia persisted with oxygen saturations 69-73% despite maximal supplemental oxygen and airway pressure release ventilation with a positive end expiratory pressure of 20. The admission vital signs included a blood pressure of 90/54, pulse 87, and temperature of 100.3 degrees F. The cardiopulmonary examination encompassed a sedated female with bilateral rhonchi without wheezing/rales and s1/s2 without additional mummers. The rest of the examination was unremarkable. A computed tomography angiogram revealed a submissive PE to the left lower lobe anterobasal and medial-basal segments with diffuse ground glass opacities throughout the lungs due to infarction. Given her refractory hypoxia and hypotension requiring norepinephrine, a bedside echocardiogram was performed and revealed evidence of right ventricular failure and transesophageal echocardiogram demonstrated a PFO (9mm) with right to left intra-cardiac shunting. Initiating Inhaled NO (INO), epoprostenol, and milrinone facilitated shunt reversal by reducing the PVR. Ultimately, the patient was extubated and discharged with closure of the PFO.

DISCUSSION: We present a rare case of an acute right to left intra-cardiac shunt through a PFO secondary to a pulmonary embolism. The acute management of this scenario is not widely reported, yet the death rate of patients with a PFO with right to left shunting has been shown to be twice as high. Nitrous Oxide was used to help reduce right-sided pressures with studies demonstrating decreased right-to-left intra-cardiac shunting in the setting of pulmonary embolism. Due to minimal improvement in patient’s condition on INO, Milrinone and Flolan were initiated. Animal models have shown that INO and Milrinone can provide additional pulmonary vasodilation and inotropic support. Flolan, prostacyclin vasodilator, has a significant survival benefit in people with chronic severe pulmonary hypertension.

CONCLUSIONS: Our case suggests the importance of heightened suspicion for significant shunt physiology in the setting of refractory hypoxemia with the benefit of performing a bedside echocardiogram to aid in diagnosis. Thus, a combination of agents from different classes may provide the most benefit in managing the complex physiology of an acute right to left intra-cardiac shunt with hemodynamic instability.

Reference #1: De Backer D, Moures JM, Vachiery JL, Leclerc JL, Kahn RJ, Vincent JL: Oxygenation improvement with nitric oxide in right-to-left shunt without significant effects on pulmonary arterial pressure. Chest 1996;110:1361-3.

DISCLOSURE: The following authors have nothing to disclose: Bankim Patel, Puneet Singh, Stella Ogake, Samuel Durrett, Frank Lodeserto

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