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Platypnea-orthodeoxia syndrome: a rare cause of unexplained hypoxemia
Session:
Sessão Speaker’s Corner - Casos clínicos desafiantes… em Cardiologia - 1
Speaker:
Joana Guimarães
Congress:
CPC 2022
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
---
Authors:
Joana Guimarães; Diogo Fernandes; Patrícia Costa; Joana Ferreira; Graça Castro; Lino Gonçalves
Abstract
<p>CASE PRESENTATION: A 59-year-old woman presented with severe hypoxemia during a mastectomy procedure. After surgery, it was not possible to wean the patient from the ventilator due to a peripheral O<sub>2</sub> saturation of 77%. In this context, she was transferred to an intensive care unit and successfully extubated a few hours later. However, the patient maintained significant variations of the peripheral O<sub>2</sub> saturation (between 78-97%) even on maximum tolerated high-flow nasal cannula (HFNC) oxygen therapy (60L/min and FiO<sub>2</sub> 100%). Hypoxemia worsened when she was sitting or in an upright position and improved in decubitus position, specially right lateral decubitus. The patient had a history of hypertension and breast cancer. Cardiac and pulmonary exam were normal. Pulmonary CT angiography showed a very small subsegmental pulmonary embolism that didn’t appear to explain the severe hypoxemia. When the possibility of a right-to-left shunt was suggested, a transesophageal echocardiography (TEE) was performed. The exam showed an aneurysm of the ascending aorta (48-49 mm) with an angled course to the right compressing the right atrium close to the tricuspid valve, distorting the atrial septum and resulting in a "stretched patent foramen ovale (PFO)“ with large right-to-left shunt visualized by color Doppler and bubble study. Right heart catheterization was also performed, which ruled out pulmonary arterial hypertension. Based on the clinical and echocardiographic findings, a diagnosis of platypnea-orthodeoxia syndrome (POS) was made. Thereafter, the patient underwent percutaneous PFO closure with a 18-mm Amplatzer ASD Occluder device. Immediately after the procedure, the patient’s peripheral O<sub>2</sub> saturation raised to 99% in room air. Postprocedure transthoracic echocardiogram showed no residual shunt and the patient was discharged next day without the need of oxygen supply.</p> <p> </p> <p>DISCUSSION: The most characteristic finding in POS is the onset of hypoxia with postural changes. This syndrome is caused by the existence of either intracardiac or intrapulmonary pathologies. Anatomical cardiac abnormalities such as a PFO are present in many cases of this entity. In addition, an aortic aneurysm may cause increased pressure in the right atria and a right-to-left shunt may occur. Percutaneous closure of PFO usually leads to immediate improvement of dyspnea and systemic blood saturation.</p>
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