Combined Interatrial and Intrapulmonary Shunting in Orthodeoxia Detected by Transesophageal Echocardiography

[Platypnea: оne more type position shortness of breath]

The article presents modern data on the causes of platypnea, methods of its diagnosis and treatment. The data on the development of platypnea syndrome are given not only in cardiac pathology, but also in severe liver diseases with the development of hepatopulmonary syndrome and chronic obstructive pulmonary disease of a severe course.

Platypnoea-orthodeoxia syndrome: novel cause for a known condition

A 50-year-old man presented with dyspnoea while sitting, standing and walking but resolved completely in supine position. On cardiorespiratory examinations, fine crackles were noted over bibasal area. Chest X-ray showed bilateral reticulonodular shadows, restrictive pattern on spirometry, elevated alveolar arterial O2 gradient on arterial blood gas. High-resolution CT of the thorax revealed pattern as 'confident' or 'certain' radiographic diagnosis of idiopathic pulmonary fibrosis (IPF). Bubble-contrast echocardiography in recumbent, sitting and upright positions revealed no intracardiac (right to left shunt) or intrapulmonary shunts. This case highlights the necessity of awareness of this syndrome in cases of interstitial lung diseases (ILDs) also. Although 188 cases have been described thus far of platypnoea-orthodeoxia syndrome (P-OS) of various aetiologies, to the best of our knowledge, it is the first ever case of P-OS in ILD/IPF. Both lung bases were predominantly affected in this patient, platypnoea and orthodeoxia were attributed to areas of low/zero ventilation/perfusion (V/Q) ratio (zone 1 phenomena) as no other obvious explanation was found.

Platypnea and orthodeoxia associated with Pneumocystis jiroveci and Cytomegalovirus pneumonia: a case report

Introduction

Platypnea-orthodeoxia is an uncommon syndrome characterized by dyspnea and deoxygenation accompanying a change to a sitting or standing posture from a recumbent position. It is usually related to interatrial communications, although several other disorders associated with platypnea-orthodeoxia syndrome have been reported. However, the precise mechanisms are unknown.

Case presentation

We present the case of a 75-year-old Caucasian woman with chronic renal failure due to vasculitis who was admitted with fever and respiratory failure. She was found to have both Pneumocystis jiroveci and Cytomegalovirus pneumonia. She was HIV negative. Severe platypnea and orthodeoxia were major features of her illness with no history of respiratory, liver or cardiac disease. Further investigation with contrast echocardiography revealed no intracardiac or intrapulmonary shunts. Although one case involving Pneumocystis jiroveci pneumonia and platypnea has been previously reported, to the best of our knowledge, this is the first time that two opportunistic pathogens have been accompanied by platypnea and orthodeoxia. As both lung bases were predominantly affected and no obvious explanation was found, platypnea and orthodeoxia were attributed to significant areas of low or zero ventilation/perfusion (V/Q) ratio.

Conclusion

Platypnea-orthodeoxia is a rare and usually underestimated syndrome. Intracardiac shunts and anatomic pulmonary vascular shunts are the most common etiologic associations. However, if a detailed examination reveals no obvious intracardiac or intrapulmonary shunting combined with extensive pulmonary lesions, then severe V/Q mismatching should be considered as the probable explanation.

Echocardiographic detection of intrapulmonary shunting in a patient with hepatopulmonary syndrome: case report and review of the literature

Transthoracic echocardiography is a useful tool in the evaluation of patients with intrapulmonary and intracardiac shunts. We describe a case of a 49-year-old female with severe hypoxemia in the setting of aortic stenosis and cirrhosis of the liver. The use of agitated saline contrast during an echocardiography study helped to establish the diagnosis of intrapulmonary arteriovenous shunting consistent with the hepatopulmonary syndrome, thereby confirming the etiology of her symptoms and laboratory findings. This case report highlights the utility of echocardiography in diagnosing intrapulmonary shunts and assists in the understanding of the pathophysiology of hypoxemia in such patients.

Contrast transesophageal echocardiographic detection of a pulmonary arteriovenous malformation draining into left lower pulmonary vein

We report the identification of a pulmonary arteriovenous malformation draining into the left lower pulmonary vein by contrast two-dimensional transesophageal echocardiography in an adult with no evidence of hereditary hemorrhagic telangiectasia. To our knowledge, this has not been reported previously. This study also emphasizes the importance of transesophageal echocardiographic examination of the left lower pulmonary vein in the detection of a pulmonary arteriovenous malformation.

Platypnea-orthodeoxia in a patient with ostium primum atrial septal defect with normal right heart pressures

We describe an adult patient with an ostium primum atrial septal defect (ASD) and a patent foramen ovale (PFO) with normal right heart pressures who presented with platypnea and orthodeoxia. A dilated aortic root encroaching into the region of the ASD and PFO, along with a tricuspid regurgitant jet moving into the left atrium through the ASD found on the transesophageal echocardiogram may have been responsible for orthodeoxia. Surgical closure of these defects resulted in the disappearance of both platypnea and orthodeoxia.