Signs and Symptoms of Chest Diseases: Student/Resident Case Report Poster - Signs and Symptoms of Chest Disease |

Constriction-Created Catastrophe FREE TO VIEW

Emily Schuiteman, DO; Eva Otoupalova, MD; Shaiva Meka, DO; Thomas Verrill, MD; Nader Mina, MD; Bhavinkumar Dalal, MD
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William Beaumont Hospital, Department of Internal Medicine, Royal Oak, MI

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

Chest. 2016;150(4_S):1251A. doi:10.1016/j.chest.2016.08.1364
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SESSION TITLE: Student/Resident Case Report Poster - Signs and Symptoms of Chest Disease

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: A patent foramen ovale (PFO) is found in 25-30% of patients. The discovery is often made only on autopsy, as most PFOs are clinically silent and any inter-atrial blood exchange usually shunts from the left to right heart. Thus, when a patient presents with hypoxic respiratory failure, concern for presence of a PFO is rarely at the top of the differential. However, in the setting of elevated right heart pressures, PFOs can become of great hemodynamic importance and can lead to deadly complications, including right to left shunting and refractory hypoxic respiratory failure. We present an unusual case of constrictive pericarditis leading to significant shunting through a PFO.

CASE PRESENTATION: A 75-year-old male presented with progressive dyspnea for one month. Upon presentation, he was found to have hypoxia with oxygen saturation of 80%. His lung and cardiac exams were normal. Arterial blood gas showed pure hypoxia without hypercarbia. CXR was normal. CT scan with IV contrast was negative for pulmonary embolism and other lung pathology; however, it showed a small amount of pericardial fluid and calcifications. Transthoracic echocardiography with agitated saline was obtained and showed moderate shunting through a PFO. Right heart catheterization (RHC) was performed and showed equalization of diastolic pressures consistent with constrictive physiology (Fig. 1). Autoimmune markers and tuberculosis testing were negative. Cardiac MRI showed thickened pericardium with a small circumferential effusion and ventricular interdependence, confirming pericardial constriction. He underwent pericardiectomy for which he was electively intubated. Despite pericardiectomy, the patient remained hypoxic on the ventilator requiring FiO2 of 100%. This indicated that his hypoxia was primarily due to the PFO. Transesophageal echo was done showing a moderate PFO with significant right-left shunting (Fig 2). The patient underwent another RHC with successful transcatheter closure. He was quickly weaned from the ventilator and was successfully extubated three days post-procedure, and was discharged home several days later on room air.

DISCUSSION: PFOs are typically asymptomatic. Rarely, they can cause catastrophic clinical manifestations including refractory hypoxemia. In this case, other causes of hypoxia were first ruled out, including V/Q mismatch, hypoventilation, and diffusion limitation. The patient was found to have significant constrictive physiology, which caused right to left shunting and refractory hypoxia which improved only after closure of PFO.

CONCLUSIONS: This case illustrates that PFOs are not always clinically silent, and should be a serious clinical consideration in cases of hypoxic respiratory failure when the source is unclear.

Reference #1: Hagen, PT, DG Scholz, and WD Edwards. “Incidence and Size of Patent Foramen Ovale During the First 10 Decades of Life: An Autopsy Study of 965 Normal Hearts.” Mayo Clinic Proceedings 59.1 (1984): 17-20. Web. 31 Mar. 2016.

DISCLOSURE: The following authors have nothing to disclose: Emily Schuiteman, Eva Otoupalova, Shaiva Meka, Thomas Verrill, Nader Mina, Bhavinkumar Dalal

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