Platypnea-Orthodeoxia Syndrome After Complicated Cholecystectomy: An Unsuspected Diagnosis

Abstract

RESUMODoente do sexo feminino, 65 anos de idade, sem antecedentes pessoais relevantes, apresentou no pós-operatório de uma colecistectomia complicada diversos episódios de dessaturação arterial. Suspeitou-se repetidamente de tromboembolismo pulmonar, no entanto as diversas angio-tomografias computorizadas obtidas nunca revelaram a presença de trombos no leito vascular pulmonar. Atendendo a que os episódios de dessaturação eram maioritariamente despoletados por alterações posturais, foi levantada a hipótese de se tratar de uma síndrome de platipneia-ortodeoxia. Foi realizado ecocardiograma transtorácico, que revelou um foramen oval patente; o ecocardiograma transesofágico confirmou a presença de um shunt direito-esquerdo significativo, exacerbado pela manobra de Valsalva. O defeito foi reparado através de uma técnica transcatéter, com resolução completa do quadro clínico. Palavras-chave: Colecistectomia; Dispneia; Forame Oval Patente; Hipoxia; Síndrome ABSTRACT A 65-year-old woman with no significant prior medical history presented, in the postoperative course of a complicated cholecystectomy, several episodes of arterial desaturation. Pulmonary embolism was repeatedly suspected, but there was no evidence of pulmonary thrombus on the chest computed tomography angiographies obtained. As these episodes were mainly induced by postural changes, a platypnea-orthodeoxia syndrome was suspected. A transthoracic echocardiogram was performed and revealed a patent foramen ovale. A transesophageal echocardiography confirmed the presence of a significant right-to-left shunt exacerbated by the Valsalva manouver. The defect was repaired using a percutaneous transcatheter technique with complete resolution of the condition.

A case of platypnoea orthodeoxia following Laproscopic Cholecystectomy

“…A previous case of POS following laparoscopy was attributed to right diaphragmatic palsy 9. However, this was not evident in this case, with a chest radiograph demonstrating normal diaphragmatic position.…”

Platypnea-orthodeoxia syndrome after open prostatectomy and cystolithotomy: Coincidence or unknown pathophysiology?

“…Acute POS cases are usually associated with acute anatomical thoracic changes due to trauma 5,6 or surgery. 7,9,10 In this case report, we highlight the sudden and disproportional degree of hypoxemia in relation to the degree of symptoms. We do not know which factors led to the acute onset of frequent episodes of hypoxemia.…”

“…1,2 The most common pathophysiology of POS involves an intermittent and dynamic right-toleft cardiac shunt triggered by anatomical changes in the position of the atria in the presence of a patent foramen ovale (PFO) and usually in the absence of pulmonary hypertension. These anatomical changes may include a progressive dilation of the ascending aorta 3,4 or can be induced more acutely by thoracic trauma 5,6 and thoracic 7 or upper abdominal surgeries, [8][9][10] among others. In this report, we describe a case of acute-onset hypoxemia due to POS in a patient before a surgical urologic intervention that became severe after surgery with no obvious cause.…”

Platypnoea-Orthodeoxia Syndrome: An Intriguing Diagnosis

“…In parallel with imaging, serial positional oxygen measurements should be taken to estimate shunt magnitude. The gold standard for the diagnosis of POS related to intracardiac shunting remains cardiac catheterization with direct measurement of oxygen saturation in the left atrium and pulmonary veins; however, in our daily clinical practice, non-invasive work-up is usually enough [4, 5] . In the present case we found a clear anatomical defect, that is, a PFO confirmed by transoesophageal echocardiography with a bubble test.…”

“…Percutaneous closure has been shown to be effective in patients of all ages, avoids the mortality and morbidity associated with open-heart surgery, and is associated with total resolution of the shunt, as was the case in our patient. The decision to treat should be guided by patient disability rather than shunt magnitude [1, 5] .…”