Author + information
- Received April 19, 2017
- Accepted April 28, 2017
- Published online November 6, 2017.
- Cory R. Trankle, MDa,
- Hem L. Bhardwaj, MDa,
- Walter H.J. Paulsen, MDa,
- John D. Grizzard, MDb,
- Rachit D. Shah, MDc and
- Zachary M. Gertz, MD, MBEa,∗ ()
- aDivision of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
- bDepartment of Radiology, Virginia Commonwealth University, Richmond, Virginia
- cDivision of Cardiothoracic Surgery, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
- ↵∗Address for correspondence:
Dr. Zachary M. Gertz, Structural Heart Disease, VCU Pauley Heart Center, 1200 East Broad Street, Box 980036, Richmond, Virginia 23298.
A 58-year old man without cardiac history presented with dyspnea and was found to be hypoxemic (oxygen saturation 88% on room air) with platypnea-orthodeoxia. The symptoms had started soon after a laparoscopic cholecystectomy 3 weeks before.
Imaging revealed new right hemidiaphragmatic paralysis (confirmed with sniff testing showing paradoxical motion) and no pulmonary embolism (Figures 1A and 1B). Transthoracic echocardiography with agitated saline demonstrated the early appearance of a large number of microbubbles in the left heart, consistent with a right-to-left interatrial shunt (Figure 1C, Online Video 1). Transesophageal echocardiography confirmed a patent foramen ovale (PFO) with near continuous right-to-left flow (Figures 1D and 1E).
The patient was referred for percutaneous PFO closure. Pulmonary vein oxygen saturation was 96% (arterial room air saturation 87%). A 25-mm Amplatzer cribriform septal occluder device (St. Jude Medical, St. Paul, Minnesota) was deployed, and the patient’s arterial saturation immediately improved to 96% (Figure 1F). His symptomatic shortness of breath was improved but not completely resolved, so he was referred for diaphragmatic plication. After successful plication, the patient’s dyspnea nearly completely resolved (Figures 1F to 1H, Online Videos 2 and 3).
Platypnea-orthodeoxia syndrome is a rare phenomenon that can be caused by a hemodynamically significant PFO. It has been reported several times as a complication after right pneumonectomy (1,2) and less frequently as a result of right hemidiaphragmatic elevation (3,4). Timely diagnosis and closure of the PFO can lead to rapid correction of hypoxemia.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 19, 2017.
- Accepted April 28, 2017.
- 2017 American College of Cardiology Foundation