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An unusual case of hypoxemia after orthopaedic surgery on an elderly patient
Session:
Casos Clinicos
Speaker:
Pedro Teixeira Carvalho
Congress:
CPC 2020
Topic:
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Theme:
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Subtheme:
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Session Type:
Comunicações Orais
FP Number:
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Authors:
Pedro Teixeira Carvalho; José Luís Costa Martins; Marco Costa; Diana Vale Carvalho; Lisa Maria Ferraz; Daniela Meireles; Manuela Vieira; Ana Maria Briosa Neves
Abstract
<p><strong>Introduction</strong></p> <p>Various complications can cause post-operative hypoxemia, but new symptomatic intracardiac shunt is very rare. We report a case of refractory hypoxemia after orthopaedic surgery due to right-to-left (R-L) shunt via a patent foramen ovale (PFO).</p> <p><strong>Clinical Case</strong></p> <p>A 71-year-old male underwent elective left hip replacement surgery. His medical history included hypertension, diabetes mellitus and a stroke. He had no history of cardiopulmonary disease. </p> <p>The first postoperative day was complicated by postoperative ileus (Fig. 1). Diet was restarted four days later, but abdominal distention and reduced bowel movements persisted. On postoperative day 15 the patient presented severe refractory hypoxemia, with O2 saturation (O2sat) 75%, improving to 86% on high-flow oxygen therapy. Blood pressure was 110/75 mmHg, heart rate was 76 bpm. Pulmonary auscultation was normal and electrocardiogram was unremarkable. The patient underwent chest computed tomographic (CT) angiography, negative for pulmonary embolism or parenchymal lung disease. The following days he maintained O2sat 85-90% despite high-flow oxygen nasal canula.</p> <p>A ventilation/perfusion (VQ) lung scan was performed, demonstrating absence of VQ imbalance, but revealing brain and kidney uptake of tracer, suggesting R-L shunt. Transesophageal echocardiography revealed an interatrial septal aneurysm and a PFO with a large resting R-L shunt visible by colour Doppler and agitated saline injection (Fig. 2). Upon review of CT images, bowel distention was verified to have caused left hemidiaphragm elevation, changing the the supra-hepatic inferior vena cava (IVC) axis and the heart position horizontally (Fig. 3).</p> <p>On postoperative day 32 the patient underwent right heart catheterization. Pulmonary artery pressures (PAP) were normal. Chamber saturations were compatible with R-L shunt, which resolved upon inflation of sizing balloon on the PFO – systemic O2sat increased 77% to 96%, while maintaining normal PAP. Closure was performed with a 14 mm Amplatzer ASD occluding device (Fig. 4). No residual leak was noted (Fig. 5). The patient was discharged two weeks later, with O2sat 98% on room air.</p> <p><strong>Discussion</strong></p> <p>Hypoxemia due to R-L shunt is a rare complication of PFO, usually associated with platipnea-orthodeoxia syndrome. This has also been described in patients with normal intracardiac pressures, due to anatomical distortion of the interatrial septum and inferior vena cava leading to streaming of venous flow to the PFO. Our patient however had severe hypoxemia irrespective of body position, possibly due to irreversible deformation of cardiac anatomy caused by diaphragm elevation.</p> <p><strong>Conclusion</strong></p> <p>The present case illustrates one of the many causes of hypoxemia and highlights the mechanisms causing abnormal intracardiac flow and impaired oxygenation with intracardiac shunts, which in rare cases can occur despite normal chamber pressures. </p>
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