Patent foramen ovale causing position-dependent shunting in a patient, when laying down her corset

Grutters, Jan C.; Berg, Jürrien M. ten; Zeijden, J. van der; Jaarsma, Wybren; Ernst, J. M. P. G.; Westermann, C. J. J.

doi:10.1183/09031936.01.00200701

Cited by 8 publications

(8 citation statements)

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“…Alteration in the positional relationship of the inferior vena cava (IVC) to the PFO with postural change from supine to upright has been postulated to be the cause for reversal of the shunt. 6 Grutters et al 7 described a case in which the superior vena cava (SVC) was involved. They showed a change of blood flow direction from the SVC to the PFO when position changed from supine to upright position.…”

Section: Discussionmentioning

confidence: 99%

Orthodeoxia syndrome: a rare complication of ASD in spinal cord injury

Magimairaj

Hariharan

Thumbikat

2015

Spinal Cord Ser Cases

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STUDY DESIGN: This is a single-subject case report. OBJECTIVES: The objective is to describe and discuss a rare presentation of orthodeoxia after spinal cord injury in a previously healthy adult with an asymptomatic and undiagnosed atrial septal defect. SETTING: This study was conducted at the Tertiary Care Spinal Injuries Center in Sheffield, UK. METHODS: An 81-year-old woman who was otherwise healthy and active sustained a polytrauma following a road traffic collision. Her injuries were managed conservatively. As a complication of epidural analgesia, she developed a complete thoracic paraplegia secondary to an epidural hematoma. She was found to have repeated episodes of severe deoxemia, without any significant postural hypotension when attempts were made to sit her up in bed. Detailed investigations were done to ascertain the cause for this deoxemia. RESULTS: Echocardiography revealed an atrial septal defect; agitated saline contrast transesophageal ultrasound done in various positions revealed interatrial defect with reversal of shunting when the patient was made to sit up in bed. CONCLUSION: Orthodeoxia is an uncommon finding in spinal injury patients. Detailed investigations at an early stage of rehabilitation need to be done to rule out cardiac causes after ruling out the common medical complications seen in the acute and subacute phases following spinal cord injury.Spinal Cord Series and Cases (2015) , 15005; doi:10.1038/scsandc.2015.5; published online 9 July 2015An 81-year-old woman with controlled hypertension presented to the emergency department following a road traffic collision. She sustained a stable C2 and multiple rib fractures. On examination, she had no neurological deficits. As she was immobilized, she was placed on prophylactic anticoagulation with low-molecular-weight heparin. The pain was managed by epidural patient-controlled analgesia for 4 days. On the seventh day following injury, she developed complete flaccid paralysis of both lower limbs with bilateral sensory loss below T8 (ASIA Impairment Scale-A). An MRI confirmed an intradural extramedullary hematoma compressing the spinal cord between T6 and the conus with signs indicating a venous infarct. This was managed conservatively.After 6 weeks of immobilization, reimaging confirmed satisfactory union of her C2 fracture. She was mobilized and racked up in bed to 30 degrees, during which the oxygen saturation (SpO2) dropped to 76%.This was not associated with dyspnea, chest pain or dizziness. There were no changes to her blood pressure and heart rate to suggest postural hypotension. Oxygen saturation returned to normal with supine position. CBC, serum chemistry and chest X-ray were normal. D-dimer was within normal range. CT pulmonary angiogram ruled out pulmonary embolism. ECG ruled out ST-elevation myocardial infarction. The echocardiogram done in supine position showed an atrial septal defect (ASD) measuring 12 mm (Figure 1). Estimated pulmonary artery pressures were within normal limits. Pulmonary function tests were not done.Saline...

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Section: Discussionmentioning

confidence: 99%

Orthodeoxia syndrome: a rare complication of ASD in spinal cord injury

Magimairaj

Hariharan

Thumbikat

2015

Spinal Cord Ser Cases

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“…[5][6][7][8][9][10][11][12] Intravenous injection of saline mixed with microbubbles of air greatly enhances the diagnosis yield of right-to-left shunts by TTE or TEE by permitting visualization of the shunt between atria. 4,9,12 The sensitivity of this technique may be augmented by having the patient cough or perform a Valsalva manoeuvre, thereby increasing intrathoracic pressure and right-to-left shunting. 5 This technique was performed in different positions, such as in the upright position.…”

Section: Discussionmentioning

confidence: 98%

“…7 A third mechanism may consist of the development of abnormal anatomic relationships between the vena cava and the atrial septum, increasing in the upright position, directing preferentially the venous blood flow from the inferior vena cava through a PFO or a small atrial defect into the left atrium. [7][8][9] It is called the "flow phenomenon" (eg, a preferential blood flow streaming from the inferior vena cava toward the atrial septum as a part of the remnant prenatal circulatory pattern). 2 After surgery (pneumonectomy and intra-abdominal surgery), the interatrial stretching can be conspicuous, and right-to-left shunting through a PFO may develop (mainly in the upright position) despite normal right atrial pressure.…”

Section: Discussionmentioning

confidence: 99%

Hypoxemia-orthodeoxia related to patent foramen ovale without pulmonary hypertension

et al. 2008

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“…The cause of the right to left shunt with normal intracardiac pressures through an interatrial communication has not yet been completely clarified and, although very complex diagnostic tools are available, a series of questions remain unanswered as to the physiopathology and the anatomical and physiological substrate that can explain this picture [1][2][3] .…”

Section: Case Reportmentioning

confidence: 99%

“…Case reports 1,2,8,9 , as well as the largest series available 10 reporting on the treatment of these patients include the percutaneous or surgical repair of the interatrial communication as a key point. We decided to perform the surgical repair of our patient's defect, and obtained an excellent result.…”

Section: Although the Mechanisms Involved In Its Pathogenesismentioning

confidence: 99%

Shunt direita-esquerda através de forame oval patente sem hipertensão pulmonar

Lisboa¹,

Costa²,

Furian³

et al. 2007

Arq. Bras. Cardiol.

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ECG without ischemic alterations; chest X-ray showing pleural calcifications; and chest angiotomography with no evidence of pulmonary thromboembolism.He had progressive worsening of hypoxemia, and had to be admitted into the intensive care unit (ICU), at first with non-invasive mechanical ventilation and later with invasive mechanical ventilation, with two unsuccessful extubation attempts.The investigation also included the following: pulmonary perfusion scintilography, with low probability of pulmonary thromboembolism; Doppler of lower limbs with no evidence of deep venous thrombosis; high resolution chest tomography showing no alterations that justified his degree of hypoxemia; transthoracic echocardiogram with air contrast, showing interatrial septal aneurysm, with intense and early passage of contrast to the left cavities, which is compatible with a patent foramen ovale, with no evidence of pulmonary arterial hypertension; enlarged left ventricle, with a relaxation deficit, and preserved global and segmental systolic function and with ejection fraction (EF) = 66%; transesophageal echocardiogram with Doppler, with evidences of a patent foramen ovale, with a predominant right to left flow, without intracavity thrombus; pulmonary arteriography with absence of intrapulmonary shunt.With the presumptive diagnosis of hypoxemia secondary to the right to left shunt through the patent foramen ovale, we installed a pulmonary artery catheter and performed blood gas analysis. Later we performed cardiac catheterization and measured oxygen saturation in the heart chambers (Tab. 1).As the patient continued to present desaturation when in a seated position and therefore required mechanical ventilation despite the absence of a right left pressure gradient, he underwent surgical repair of the patent foramen ovale (atrioseptoplasty) (Fig. 1). In addition to the patent foramen ovale, no other alteration was identified in the interatrial septum. The patient progressed with substantial improvement in hypoxemia. He was extubated in the first postoperative period, and discharged from the ICU and from hospital without symptoms; his condition has been stable for six months.Cases of hypoxemia secondary to right to left shunt through a patent foramen ovale in the absence of pulmonary hypertension are rarely described in the literature and may constitute a picture of platypnea-orthodeoxia syndrome 1 . In this paper we will describe the case of a patient with this rare condition. Case ReportA 71-year old white male patient, married, was admitted to the Emergency Room of HCPA due to major dyspnea at rest, with no associated symptoms. He reported having progressive dyspnea for ten months, which became more intense ten days before admission.His previous medical history included: smoking from 31 to 35 years of age; thoracic bruise with no sequela 25 years ago; systemic arterial hypertension since 1985, treated with Amlodipine, Hydrochlorothiazide and Enalapril; dyslipidemia since 1996, treated with Sinvastatin and gastroesophageal reflux dise...

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Patent foramen ovale causing position-dependent shunting in a patient, when laying down her corset

Cited by 8 publications

References 5 publications

Orthodeoxia syndrome: a rare complication of ASD in spinal cord injury

Orthodeoxia syndrome: a rare complication of ASD in spinal cord injury

Hypoxemia-orthodeoxia related to patent foramen ovale without pulmonary hypertension

Shunt direita-esquerda através de forame oval patente sem hipertensão pulmonar

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