Platypnea-Orthodeoxia Syndrome and COVID-19 Successfully Treated With Percutaneous Patent Foramen Ovale Closure: A Report of Two Cases and Literature Review

Platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by positional dyspnea and/or hypoxia. We report two cases of patients with COVID-19 bronchopneumonia with a torpid evolution. Due to clinical suspicion of POS, a diagnostic workup was performed, including a bubble echocardiography, which revealed a patent foramen ovale (PFO) with early and massive passage of bubbles to the left cavities. Both patients underwent percutaneous PFO closure with a resolution of POS. Here, we present the second and third cases of POS associated with PFO successfully closed during the acute phase of COVID-19. This suggests that PFO closure could be a potential treatment option for this condition.

Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature

Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.

Managing Congenital Heart Defects in Elderly: The Platypnea-Orthodeoxia Syndrome in Underestimated Patent Foramen Ovale

The platypnea-orthodeoxia syndrome (POS) is a rare and often suboptimally managed condition with a complex diagnostic workup, conversely displaying an easy treatment and a good recovery of symptoms, especially if consequent to an intracardiac shunt. However, its identification is challenging, due to the several clinical manifestations, the multiple etiologies, representing often the delayed presentation of a congenital heart disease. We present a case report and review of available literature on patients with the POS secondary to a patent foramen ovale successfully treated with its closure.

Cardiac Platypnea-Orthodeoxia Syndrome: A Rare Case of Flow-Directed, Right-to-Left Shunt via a Patent Foramen Ovale Exacerbated by Aortic Root Enlargement

Cardiac platypnea-orthodeoxia is a unique clinical syndrome characterized by dyspnea and deoxygenation when moving from a supine to an upright position. In this case report, we detail the experience of a 78-year-old male with persistent hypoxemia following a paradoxical embolic ischemic stroke. Despite proper management of his respiratory symptoms, the patient continued to be affected by marked dyspnea and hypoxemia, particularly when upright or in a right-sided decubitus position. Subsequent investigation revealed that his hypoxemia was a result of cardiac platypnea-orthodeoxia syndrome (POS). This condition was attributed to the enlargement of his aortic root and ascending aorta, coupled with a counterclockwise rotation of the heart axis. These factors facilitated a flow-directed, right-to-left interatrial shunt through a patent foramen ovale, even in the absence of elevated right heart pressures.

An Unusual Cause of Acute Right-Sided Heart Failure Presenting With Refractory Hypoxia

Atrial septal aneurysm (ASA) formation is due to a deformity at the fossa ovalis. While previously considered a rare cardiac anomaly found postmortem, it can now be diagnosed at the bedside with ultrasound. Unrepaired ASA can lead to right-sided heart failure and pulmonary hypertension. The case we describe is complicated by the patient's code status, limiting our ability to perform potential life-sustaining interventions. We also encountered a complication of rebound pulmonary hypertension with the use of inhaled nitric oxide. We detail the critical course of profound hemodynamic and respiratory instability responsive to salvage therapy.

Percutaneous closure of patent foramen ovale for treatment of hypoxemia: A case series and physiology review

Intracardiac right-to-left shunt (RTLS) mediated hypoxemia is a rare complication of patent foramen ovale (PFO). The process may be potentiated by reversal of the usual trans-atrial pressure gradient, or from alteration of intracardiac geometry such that venous flow is preferentially directed toward the PFO. We describe a series of four patients who presented with hypoxemia, detailing the diagnostic evaluation which led to the ascertainment of intracardiac RTLS across PFO as the culprit pathology. All underwent successful percutaneous closure with rapid resolution of hypoxemia. Particular attention is given to the underlying anatomic and physiologic derangements facilitating the intracardiac RTLS.

No effect of patent foramen ovale on acute mountain sickness and pulmonary pressure in normobaric hypoxia

What is the central question to this study? Is there a relationship between a patent foramen ovale and the development of acute mountain sickness and an exaggerated increase in pulmonary pressure in response to 7-10 hours of normobaric hypoxia? What is the main finding and its importance? Patent foramen ovale presence did not increase susceptibility to acute mountain sickness or result in an exaggerated increase in pulmonary artery systolic pressure with normobaric hypoxia. This data suggest hypobaric hypoxia is integral to the increased susceptibility to acute mountain sickness previously reported in those with patent foramen ovale, and patent foramen ovale presence alone does not contribute to the hypoxic pulmonary pressor response. ABSTRACT: Acute mountain sickness (AMS) develops following rapid ascent to altitude, but its exact causes remain unknown. A patent foramen ovale (PFO) is a right-to-left intracardiac shunt present in ∼30% of the population that has been shown to increase AMS susceptibility with high altitude hypoxia. Additionally, high altitude pulmonary edema (HAPE), is a severe type of altitude illness characterized by an exaggerated pulmonary pressure response, and there is a greater prevalence of PFO in those with a history of HAPE. However, whether hypoxia, per se, is causing the increased incidence of AMS in those with a PFO and whether a PFO is associated with an exaggerated increase in pulmonary pressure in those without a history of HAPE is unknown. Participants (n = 36) matched for biological sex (18 female) and the presence or absence of a PFO (18 PFO+) were exposed to 7-10 hours of normobaric hypoxia equivalent to 4755 m. Presence and severity of AMS was determined using the Lake Louise AMS scoring system. Pulmonary artery systolic pressure, cardiac output, and total pulmonary resistance were measured using ultrasound. We found no significant association of PFO with incidence or severity of AMS and no association of PFO with arterial oxygen saturation. Additionally, there was no effect of a PFO on pulmonary pressure, cardiac output, or total pulmonary resistance. These data suggest that hypobaric hypoxia is necessary for those with a PFO to have increased incidence of AMS and that presence of PFO is not associated with an exaggerated pulmonary pressor response. This article is protected by copyright. All rights reserved.

Percutaneous repair of post-myocardial infarction ventricular septal rupture presenting with cardiogenic shock

Ventricular septal rupture (VSR) is an uncommon and devastating complication with a high mortality rate due to limited available interventions required by expert hands in a small window of opportunity. Most commonly seen following delayed myocardial infarctions (MI), the rate of VSR has decreased partly from protocol driven reperfusion therapy; however, cases are still present, particularly when diagnosis is delayed. We present a case of a critically ill patient in cardiogenic shock following a large anterolateral wall ST-elevation MI complicated by a large VSR whom was transferred to our academic institution for percutaneous repair. Of note, such intervention was initially performed by Lock in 1988 and a comprehensive review published in 2016 noted only 273 such cases. This review noted patient cases since that initial percutaneous closure by Lock with a majority of cases utilizing an Amplatzer system; others being Clamshell and CardioSEAL. Our patient underwent the percutaneous VSR closure utilizing an Amplatzer Occluder delivery system with successful insertion of an 18 mm muscular VSD Amplatzer closure device. Although the rarely performed procedure was successful and provided invaluable insights into the treatment and management of VSR, the patient succumbed to multiple critical disease processes in the following days post intervention. Patient consent and ethics committee approval for publication, as per Saint Louis University case publication guidelines, were confirmed and approved.

Impaired pulmonary gas exchange efficiency, but normal pulmonary artery pressure increases, with hypoxia in men and women with a patent foramen ovale

NEW FINDINGS

What is the central question of this study? Do individuals with a patent foramen ovale (PFO⁺ ) have a larger alveolar-to-arterial difference in P O 2 ( A - a D O 2 ) than those without (PFO^- ) and/or an exaggerated increase in pulmonary artery systolic pressure (PASP) in response to hypoxia? What is the main finding and its importance? PFO⁺ had a greater A - a D O 2 while breathing air, 16% and 14% O₂ , but not 12% or 10% O₂ . PASP increased equally in hypoxia between PFO⁺ and PFO^- . These data suggest that PFO⁺ may not have an exaggerated acute increase in PASP in response to hypoxia.

ABSTRACT

Patent foramen ovale (PFO) is present in 30-40% of the population and is a potential source of right-to-left shunt. Accordingly, those with a PFO (PFO⁺ ) may have a larger alveolar-to-arterial difference in P O 2 ( A - a D O 2 ) than those without (PFO^- ) in normoxia and with mild hypoxia. Likewise, PFO is associated with high-altitude pulmonary oedema, a condition known to have an exaggerated pulmonary pressure response to hypoxia. Thus, PFO⁺ may also have exaggerated pulmonary pressure increases in response to hypoxia. Therefore, the purposes of the present study were to systematically determine whether or not: (1) the A - a D O 2 was greater in PFO⁺ than in PFO^- in normoxia and mild to severe hypoxia and (2) the increase in pulmonary artery systolic pressure (PASP) in response to hypoxia was greater in PFO⁺ than in PFO^- . We measured arterial blood gases and PASP via ultrasound in healthy PFO⁺ (n = 15) and PFO^- (n = 15) humans breathing air and 30 min after breathing four levels of hypoxia (16%, 14%, 12%, 10% O₂ , randomized and balanced order) at rest. The A - a D O 2 was significantly greater in PFO⁺ compared to PFO^- while breathing air (2.1 ± 0.7 vs. 0.4 ± 0.3 Torr), 16% O₂ (1.8 ± 1.2 vs. 0.7 ± 0.8 Torr) and 14% O₂ (2.3 ± 1.2 vs. 0.7 ± 0.6 Torr), but not 12% or 10% O₂ . We found no effect of PFO on PASP at any level of hypoxia. We conclude that PFO influences pulmonary gas exchange efficiency with mild hypoxia, but not the acute increase in PASP in response to hypoxia.

A Rare Complication of Transcatheter Aortic Valve Replacement: Aortic Root-Left Atrium Fistulization

The authors report the case of an 87-year-old man undergoing transcatheter aortic valve replacement via transfemoral approach who developed a life-threatening complication, i.e., fistulization between the aortic root and the left atrium, which was successfully treated by surgery. At 6-month follow-up, the clinical course was uneventful. (Level of Difficulty: Beginner.)

Quantification of pulmonary/systemic shunt ratio by single-acquisition phase-contrast cardiovascular magnetic resonance

PURPOSE

Phase-contrast cardiovascular magnetic resonance (PC-CMR) quantification of intracardiac shunt (measuring the pulmonary to systemic flow ratio, Qp/Qs) is typically determined by measuring flow through planes perpendicular the pulmonary trunk (PA) and ascending aorta (Ao). This method is subject to error from presence of background velocity offsets and requires two scan acquisitions. We evaluated an alternate PC-CMR technique for quantifying Qp/Qs using a single modified plane that encompasses both the PA and Ao.

MATERIAL AND METHODS

In 53 patients evaluated for intracardiac shunting, PC-CMR measurement in the individual Ao and PA planes and also in a single-acquisition plane was obtained and Qp/Qs calculated by each method. Bland-Altman analysis was performed to evaluate the agreement between the two methods.

RESULTS

The 95% confidence limits of agreement ranged from -0.52 to +0.34 indicating good agreement between the two methods. There was excellent agreement on the clinically relevant threshold value of Qp/Qs ratio of 1.5 (representing criteria for surgical correction of shunt).

CONCLUSIONS

Qp/Qs determined from the single-acquisition approach agrees well with that of the individual PA and Ao method and offers potential improved accuracy (due to background velocity offset).

Ventilatory responses to acute hypoxia and hypercapnia in humans with a patent foramen ovale

Subjects with a patent foramen ovale (PFO) have blunted ventilatory acclimatization to high altitude compared with subjects without PFO. The blunted response observed could be because of differences in central and/or peripheral respiratory chemoreflexes. We hypothesized that compared with subjects without a PFO (PFO-), subjects with a PFO (PFO+) would have blunted ventilatory responses to acute hypoxia and hypercapnia. Sixteen PFO+ subjects (9 female) and 15 PFO- subjects (8 female) completed four 20-min trials on the same day: 1) normoxic hypercapnia (NH), 2) hyperoxic hypercapnia (HH), 3) isocapnic hypoxia (IH), and 4) poikilocapnic hypoxia (PH). Hypercapnic trials were completed before the hypoxic trials, the order of the hypercapnic (NH & HH) and hypoxic (IH & PH) trials were randomized, and trials were separated by ≥40 min. During the NH trials but not the HH trials subjects who were PFO+ had a blunted hypercapnic ventilatory response compared with subjects who were PFO- (1.41 ± 0.46 l·min^-1·mmHg^-1 vs. 1.98 ± 0.71 l·min^-1·mmHg^-1, P = 0.02). There were no differences between the PFO+ and PFO- subjects with respect to the acute hypoxic ventilatory response during IH and PH trials. Hypoxic ventilatory depression was similar between subjects who were PFO+ and PFO- during IH. These data suggest that compared with subjects who were PFO-, subjects who were PFO+ have normal ventilatory chemosensitivity to acute hypoxia but blunted ventilatory chemosensitivity to carbon dioxide, possibly because of reduced carbon dioxide sensitivity of either the central and/or the peripheral chemoreceptors. NEW & NOTEWORTHY Patent foramen ovale (PFO) is found in ~25%-40% of the population. The presence of a PFO appears to be associated with blunted ventilatory responses during acute exposure to normoxic hypercapnia. The reason for this blunted ventilatory response during acute exposure to normoxic hypercapnia is unknown but may suggest differences in either central and/or peripheral chemoreflex contribution to hypercapnia.

A Review of Transcatheter Closure of Patent Foramen Ovale

A patent foramen ovale (PFO) is a common variant in cardiac anatomy found in 25% to 30% of U.S. adults. While PFOs are a normal part of fetal development and commonly seen in asymptomatic adults, they have been implicated in a variety of pathophysiologic conditions. The most clinically important of these is paradoxical embolization of venous thrombus resulting in stroke or systemic embolism. Various devices can be used to close PFOs via a transcatheter approach to prevent recurrent stroke. Data regarding the safety and effectiveness of these devices is rapidly evolving, with recent long-term results suggesting efficacy in preventing secondary stroke in carefully selected patients. This review discusses historical data on PFO occurrence and treatment, a risk score that can assess the likelihood of a stroke being attributable to a PFO, a variety of other conditions that may be linked to PFOs, and current research regarding the role transcatheter closure plays in their treatment.

Effect of a patent foramen ovale in humans on thermal responses to passive cooling and heating

Humans with a patent foramen ovale (PFO) have a higher esophageal temperature (T_esoph) than humans without a PFO (PFO-). Thus the presence of a PFO might also be associated with differences in thermal responsiveness to passive cooling and heating such as shivering and hyperpnea, respectively. The purpose of this study was to determine whether thermal responses to passive cooling and heating are different between PFO- subjects and subjects with a PFO (PFO+). We hypothesized that compared with PFO- subjects PFO+ subjects would cool down more rapidly and heat up slower and that PFO+ subjects who experienced thermal hyperpnea would have a blunted increase in ventilation. Twenty-seven men (13 PFO+) completed two trials separated by >48 h: 1) 60 min of cold water immersion (19.5 ± 0.9°C) and 2) 30 min of hot water immersion (40.5 ± 0.2°C). PFO+ subjects had a higher T_esoph before and during cold water and hot water immersion (P < 0.05). However, the rate of temperature change was similar between groups for each condition. Within a subset of 18 subjects (8 PFO+) who experienced thermal hyperpnea, PFO+ subjects experienced thermal hyperpnea at a higher absolute T_esoph but with a blunted magnitude compared with PFO- subjects. These data suggest that PFO+ subjects have a higher T_esoph at rest and have blunted thermal hyperpnea during passive heating.NEW & NOTEWORTHY Patent foramen ovale (PFO) is found in ~25-40% of the population. The presence of a PFO appears to be associated with a greater core body temperature and blunted ventilatory responses during passive heating. The reason for this blunted ventilatory response to passive heating is unknown but may suggest differences in thermal sensitivity in PFO+ subjects compared with PFO- subjects.

Platypnea-Orthodeoxia Syndrome: A Case of Chronic Paroxysmal Hypoxemia

A 75-year-old man with chronic (30-year) unexplained paroxysmal hypoxemia presented with postural hypoxemia and desaturation consistent with a clinical manifestation of platypnea-orthodeoxia syndrome. His history included a lack of significant past pulmonary disease, yet with intermittent need for oxygen supplementation. On admission he was found to have an interatrial shunt through a patent foramen ovale. Device closure by percutaneous catheterization led to sustained resolution of symptoms. Platypnea-orthodeoxia syndrome is a rare but important consideration in the differential diagnosis of hypoxemia, as it represents a potentially curable cause of hypoxemia, with missed diagnosis leading to possible patient morbidity if untreated. Even more importantly, an astute and careful history and physical examination are integral to the diagnosis of this rare but likely under-recognized syndrome.

Right coronary sinus of valsalva aneurysm with rupture into the right ventricle

We report a case of right coronary sinus of Valsalva aneurysm (SVA) with rupture into the right ventricle in a 23-year-old man. The problem was successfully managed with surgical closure of both ruptured SVA and the ventricular defect with cardiopulmonary bypass through median sternotomy.