Author + information
- Received March 17, 2020
- Accepted March 24, 2020
- Published online June 10, 2020.
- Tetsuma Kawaji, MD, PhDa,b,∗ (, )@ttlapmk,
- Kazuhisa Kaneda, MDa,
- Masashi Kato, MDa and
- Takafumi Yokomatsu, MDa
- aDepartment of Cardiology, Ryorei Memorial Kyoto Hospital, Kyoto, Japan
- bDepartment of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- ↵∗Address for correspondence:
Dr. Tetsuma Kawaji, Department of Cardiology, Ryorei Memorial Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto 615-8087, Japan.
A 70-year-old woman, who had received mechanical aortic and mitral valve replacement for rheumatic valvular disease and implanted cardiac defibrillator (ICD) implantation for ventricular arrhythmia, underwent radiofrequency catheter ablation for symptomatic atrial fibrillation (AF). During the procedure, a single transseptal puncture with a radiofrequency needle (Bayliss Medical, Montreal, Quebec, Canada) was made, and we performed extensive encircling pulmonary vein isolation through the puncture site. After discharge, the patient began to feel dyspnea on exertion. A small iatrogenic atrial-septal defect (iASD) was detected, but there were no signs of lung congestion or other complications.
One year after procedure, she was admitted for heart failure exacerbation without recurrence of AF. Even after volume reduction by intravenous diuresis, oxygen saturation transiently decreased in the left lateral decubitus position and standing position, but not at rest. Echocardiography revealed main left-to-right flow during the diastolic phase from a small iASD (3.2 mm) and transient right-to-left flow consistent with a deviated severe tricuspid valve regurgitation (TR) jet during the systolic phase (Qp/Qs = 1.1) (Figures 1A and 1B, Video 1). We directly approached the left atrium though the iASD using a Swan-Ganz catheter and tried an occlusion test with the balloon (Figure 1C). Oxygen saturation was decreased under residual iASD in the left lateral decubitus position, and occlusion of the iASD prevented the decrease. Computed tomography image in the left lateral decubitus position demonstrated severe scoliosis and deviation of the atrium (Figure 1D). These facts indicate that residual iASD with transient right-to-left shunt caused the position-dependent hypoxemia. A surgical approach for the residual iASD and severe TR was considered, although the patient declined the redo surgery owing to frailty. She was alive without exacerbation of heart failure requiring admission, by close follow-up.
The majority of iASD spontaneously close, and residual iASD is also benign for the slight left-to-right shunt (1) However, this case report shows the iASD causing position-dependent hypoxemia by transient right-to-left shunt as platypnea-orthodeoxia syndrome in patients with intracardiac shunts (2). We should take care residual iASD with transient right-to-left shunt.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
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- Received March 17, 2020.
- Accepted March 24, 2020.
- 2020 American College of Cardiology Foundation