Copyright © 2000 by the European Society of Cardiology.
Atrial right-to-left shunting causing severe hypoxaemia despite normal right-sided pressures. Report of 11 consecutive cases corrected by percutaneous closure
a Hôpital Cardiologique, Centre Hospitalier Régional et Universitaire, Lille, France
b Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France
revised September 25, 1999; accepted September 8, 1999
Abstract
Background Hypoxaemia resulting from a right-to-left shunt occurs in patients with atrial septal defects and high pulmonary vascular resistance, but it is uncommon without pulmonary hypertension.
Methods We report on 11 consecutive patients (age: 59–78 years) in whom a patent foramen ovale or a small atrial septal defect with normal right-sided pressures led to significant cyanosis with clinical symptoms. Six of them had associated platypnoea and orthodeoxia. The diagnosis was confirmed by contrast transoesophageal echocardiography showing an atrial right-to-left shunt.
Results All but one were successfully treated by percutaneous closure of the inter-atrial defect. In one patient, delivery of the occluder failed due to kinking of the introducing sheath. Four complications were observed following the procedure: two supraventricular arrhythmias and a cerebrovascular accident, all resolved without sequelae; one patient died from a septic shock unrelated to the procedure. During follow-up (up to 30 months), no patient experienced any episode of desaturation due to inter-atrial shunting.
Conclusion Cyanosis without pulmonary arterial hypertension in the adult should prompt the performance of contrast transoesophageal echocardiography to identify a possible atrial right-to-left shunt. Percutaneous closure of the defect allows efficient and rapid correction of the hypoxaemia and avoids the need for surgical closure.
Key Words: Hypoxaemia, atrial R-to-L shunt, patent foramen ovale, percutaneous closure
f1 Correspondence: Dr François Godart, Service des Maladies Cardiovasculaires Infantiles et Congénitales, Hôpital Cardiologique, Centre Hospitalier Régional et Universitaire, 59037 Lille, France.
References
- Lloyd TR, Rao PS, Beekman RH, Mendelsohn AM, Sideris EB. Atrial septal defect occlusion with the buttoned device (a multi-institutional U.S. trial). Am J Cardiol. 1994;73:286–291[CrossRef][Web of Science][Medline]
- Tofeig M, Walsh KP, Chan C, Ladusans E, Gladman G, Arnold R. Occlusion of Fontan fenestrations using the Amplatzer septal occluder. Heart. 1998;79:368–370
[Abstract/Free Full Text] - Dubourg O, Bourdarias JP, Farcot JC. Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale. J Am Coll Cardiol. 1984;4:587–594[Abstract]
- de Belder MA, Tourikis L, Leech G, Camm AJ. Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol. 1992;69:1316–1320[CrossRef][Web of Science][Medline]
- Hausmann D, Mügge A, Becht I, Daniel WG. Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral embolic events. Am J Cardiol. 1992;70:668–672[CrossRef][Web of Science][Medline]
- Nazzal SB, Bansal RC, Fitzmorris SJ, Schmidt CA. Platypnea-orthodeoxia as a cause of unexplained hypoxemia in an 82-yr-old female. Cathet Cardiovasc Diagn. 1990;19:242–245[Web of Science][Medline]
- Coates EO, Drake EH. Myxoma of the right atrium, with variable right-to-left shunt. Clinical and physiologic observations and report of a case with successful operative removal. N Engl J Med. 1958;259:165–169[Web of Science][Medline]
- Ciafone RA, Aroesty JM, Weintraub RM, LaRaia PJ, Paulin S. Cyanosis in uncomplicated atrial septal defect with normal cardiac and pulmonary arterial pressures. Chest. 1978;74:596–599
[Abstract/Free Full Text] - Pitcher D, Fletcher P, Laszlo G, Keen G, Rees JR. Onset of right-to-left shunting through a foramen ovale in a 70-year-old woman: successful surgical treatment. Eur Heart J. 1986;7:541–544
[Abstract/Free Full Text] - Winters WL, Cortes F, McDonough M. Venoarterial shunting from inferior vena cava to left atrium in atrial septal defects with normal right pressures. Report of two cases. Am J Cardiol. 1967;19:293–300[CrossRef][Web of Science][Medline]
- Haworth SG, Shinebourne EA, Miller GAH. Right-to-left interatrial shunting with normal right ventricular presssure. A puzzling haemodynamic picture associated with some rare congenital malformations of the right ventricle or tricuspide valve. Br Heart J. 1975;37:386–391
[Abstract/Free Full Text] - Gallaher ME, Sperling DR, Gwinn JL, Meyer BW, Fyler DC. Functional drainage of the inferior vena cava into the left atrium—three cases. Am J Cardiol. 1963;12:561–566[CrossRef][Web of Science][Medline]
- Thomas JD, Tabakin BS, Ittleman FP. Atrial septal defect with right to left shunt despite normal pulmonary artery pressure. J Am Coll Cardiol. 1987;9:221–224[Abstract]
- Laybourn KA, Martin ET, Cooper RAS, Holman WL. Platypnea and orthodeoxia: shunting associated with an aortic aneurysm. J Thorac Cardiovasc Surg. 1997;113:955–956
[Free Full Text] - Landzberg MJ, Sloss LJ, Faherty CE. Orthodeoxia-platypnea due to intracardiac shunting. Relief with transcatheter double umbrella closure. Cathet Cardiovasc Diagn. 1995;36:247–250[Web of Science][Medline]
- Roman MJ, Devereux RB, Kramer-Fox R, O'Loughlin J, Spitzer M, Robins J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol. 1989;64:507–512[CrossRef][Web of Science][Medline]
- Schnabel TG, Ratto O, Kirby CK, Johnson J, Comroe JH. Postural cyanosis and angina pectoris following pneumonectomy: relief by closure of an interatrial septal defect. J Thorac Surg. 1956;32:246–250[Medline]
- Seward JB, Hayes DL, Smith HC. Platypnea-orthodeoxia: clinical profile, diagnostic workup, management, and report of seven cases. Mayo Clin Proc. 1984;59:221–231[Web of Science][Medline]
- Smeenk FW, Postmus PE. Interatrial right-to-left shunting developing after pulmonary resection in the absence of elevated right-sided heart pressures. Review of literature. Chest. 1993;105:528–531
- Bakris NC, Siddiqi AJ, Fraser CD, Mehta AC. Right-to-left interatrial shunt after pneumonectomy. Ann Thorac Surg. 1997;63:198–201
[Abstract/Free Full Text] - Godart F, Porte H, Rey C, Lablanche JM, Wurtz A. Post-pneumonectomy interatrial right-to-left shunt: successful percutaneous treatment. Ann Thorac Surg. 1997;64:834–836
[Abstract/Free Full Text] - Mercho N, Stoller JK, White RD, Mehta AC. Right-to-left interatrial shunt causing platypnea after pneumonectomy. A recent experience and diagnostic value of dynamic magnetic resonance imaging. Chest. 1994;105:931–933
[Abstract/Free Full Text] - Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life. An autopsy study in 956 normal hearts. Mayo Clin Proc. 1984;59:17–20[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M.-P. Revel, J.-B. Faivre, T. Letourneau, H. Henon, D. Leys, V. Delannoy-Deken, M. Remy-Jardin, and J. Remy Patent Foramen Ovale: Detection with Nongated Multidetector CT Radiology, October 1, 2008; 249(1): 338 - 345. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. C. Johansson, P. Eriksson, Y. Peker, J. Hedner, L. Rastam, and U. Lindblad The influence of patent foramen ovale on oxygen desaturation in obstructive sleep apnoea Eur. Respir. J., January 1, 2007; 29(1): 149 - 155. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Townsend, D.H. MacIver, and R. Bilku Platypnoea-orthodeoxia syndrome in association with an ascending aortic aneurysm Eur J Echocardiogr, January 1, 2007; 8(1): 50 - 52. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Allemann, D. Hutter, E. Lipp, C. Sartori, H. Duplain, M. Egli, S. Cook, U. Scherrer, and C. Seiler Patent Foramen Ovale and High-Altitude Pulmonary Edema JAMA, December 27, 2006; 296(24): 2954 - 2958. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Marini, M. Miniati, N. Ambrosino, B. Formichi, L. Tonelli, G. Di Ricco, C. Michelassi, S. Giusti, and I. Spadoni Dyspnoea and hypoxaemia after lung surgery: the role of interatrial right-to-left shunt. Eur. Respir. J., July 1, 2006; 28(1): 174 - 181. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Wallaert, B. Cavestri, C. Fournier, R. Neviere, and B. Aguilaniu Positional hyperventilation-induced hypoxaemia in pectus excavatum. Eur. Respir. J., July 1, 2006; 28(1): 243 - 247. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G Agnoletti, Y Boudjemline, P Ou, D Bonnet, and D Sidi Right to left shunt through interatrial septal defects in patients with congenital heart disease: results of interventional closure Heart, June 1, 2006; 92(6): 827 - 831. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. P. Anzola, G. B. Frisoni, F. Casilli, V. Pestrichella, and E. Onorato Response to Letter by Magrini et al Stroke, June 1, 2006; 37(6): 1362 - 1362. [Full Text] [PDF]
|
|
|
|
 |
|
 D. D. Hegland, G. A. Kunz, J. K. Harrison, and A. Wang Clinical problem-solving. A hole in the argument. N. Engl. J. Med., December 1, 2005; 353(22): 2385 - 2390. [Full Text] [PDF]
|
|
|
|
 |
|
 I. D. Bella, S. Pasquino, U. D. Col, and T. Ragni Cyanosis in atrial septal defect without pulmonary hypertension: a case of Platypnea-orthodeoxya syndrome Interactive CardioVascular and Thoracic Surgery, February 1, 2005; 4(1): 15 - 17. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H Shnaider, A Shiran, and A Lorber Right ventricular diastolic dysfunction and patent foramen ovale causing profound cyanosis Heart, June 1, 2004; 90(6): e31 - e31. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M Schwerzmann, S Windecker, A Wahl, H Mehta, K Nedeltchev, H Mattle, C Seiler, and B Meier Percutaneous closure of patent foramen ovale: impact of device design on safety and efficacy Heart, February 1, 2004; 90(2): 186 - 190. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Ghamande, R. Ramsey, J. F. Rhodes, and J. K. Stoller Right Hemidiaphragmatic Elevation With a Right-to-Left Interatrial Shunt Through a Patent Foramen Ovale : A Case Report and Literature Review Chest, December 1, 2001; 120(6): 2094 - 2096. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. R. Sukernik, B. Mets, and E. Bennett-Guerrero Patent Foramen Ovale and its Significance in the Perioperative Period Anesth. Analg., November 1, 2001; 93(5): 1137 - 1146. [Full Text] [PDF]
|
|
|
|
 |
|
 E. K. Kerut, W. T. Norfleet, G. D. Plotnick, and T. D. Giles Patent foramen ovale: a review of associated conditions and the impact of physiological size J. Am. Coll. Cardiol., September 1, 2001; 38(3): 613 - 623. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Caleb, S. Shankar, and T. Agasthian Tricuspid Endocarditis and Paradoxical Embolism Asian Cardiovasc Thorac Ann, June 1, 2001; 9(2): 132 - 134. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Godart and C. Rey Platypnea-Orthodeoxia Syndrome : A Probably Underestimated Syndrome? Chest, May 1, 2001; 119(5): 1624 - 1625. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||