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Episodic Desaturation

J D Fl h t MDJames D. Flaherty, MDAssistant Professor of Medicine

Northwestern University, Feinberg School of MedicineMedical Director, Coronary Care Unit

Northwestern Memorial Hospital, Chicago

April 27, 2012

The Bluhm Cardiovascular InstituteNorthwestern

DisclosuresDisclosures

NoneNone


PresentationPresentation

• 75 year-old woman presents with shortness of b th

• 75 year-old woman presents with shortness of b thbreath

• Episodic, worse when getting up in the morningbreath

• Episodic, worse when getting up in the morning

• Review of Systems: no chest pain, cough, edema• Review of Systems: no chest pain, cough, edemaReview of Systems: no chest pain, cough, edema OR other associated symptomsReview of Systems: no chest pain, cough, edema OR other associated symptoms


P t M di l Hi tP t M di l Hi tPast Medical History• Crypogenic strokes (1993

and 1997) residual ataxia

Past Medical History• Crypogenic strokes (1993

and 1997) residual ataxia

• Allergies – Iodinated Contrast Dye

• Allergies – Iodinated Contrast Dye

and 1997) residual ataxia• HTN• D i

and 1997) residual ataxia• HTN• D i

• MedicationsCoumadin 6mg daily

• MedicationsCoumadin 6mg daily• Depression• Depression - Coumadin 6mg daily

- Pravastatin 40 qd- HCTZ 25mg daily

- Coumadin 6mg daily- Pravastatin 40 qd- HCTZ 25mg daily

Social Historyno tobacco/alcholol/drug useSocial Historyno tobacco/alcholol/drug use

- Verapamil 180 qd- Bupropion 300mg qd- Nexium 40 qd

- Verapamil 180 qd- Bupropion 300mg qd- Nexium 40 qd

Family HistoryFamily History

Nexium 40 qd- Valium 5mg bid prn- Premarin .3mg daily

Nexium 40 qd- Valium 5mg bid prn- Premarin .3mg daily

Family HistoryNo cardiac or pulmonary

conditions

Family HistoryNo cardiac or pulmonary

conditions


conditionsconditions

Physical Exam:Physical Exam:Physical Exam:Physical Exam:

• Gen: Elderly Caucasian female in moderate distress• Gen: Elderly Caucasian female in moderate distressGen: Elderly Caucasian female in moderate distress• Vitals: Afebrile, BP 146/70, HR 100, RR 21,

Pulse ox 88% on Room Air; 96% on 100% FM

Gen: Elderly Caucasian female in moderate distress• Vitals: Afebrile, BP 146/70, HR 100, RR 21,

Pulse ox 88% on Room Air; 96% on 100% FMPulse ox 88% on Room Air; 96% on 100% FM• Neck: No jugular venous pressure elevation• CV: tachy normal S1 nl S2 no S3 no S4 no murmurs

Pulse ox 88% on Room Air; 96% on 100% FM• Neck: No jugular venous pressure elevation• CV: tachy normal S1 nl S2 no S3 no S4 no murmurs• CV: tachy, normal S1, nl S2, no S3, no S4, no murmurs• Lungs: clear• Abd: soft nontender

• CV: tachy, normal S1, nl S2, no S3, no S4, no murmurs• Lungs: clear• Abd: soft nontender• Abd: soft, nontender• Ext: no edema• Abd: soft, nontender• Ext: no edema

• Lab Values – all normal• Lab Values – all normal


ElectrocardiogramElectrocardiogram

The Bluhm Cardiovascular InstituteNorthwestern 6

Ch tCh tChest X-rayChest X-ray


CT Chest: no PNA or PE, ascending thoracic aortamildly dilated (4cm) and ectatic. + thoracic kyphosisCT Chest: no PNA or PE, ascending thoracic aortamildly dilated (4cm) and ectatic. + thoracic kyphosisy ( ) ypy ( ) yp

Transthoracic Echocardiogram: grossly normal


Hospital CourseHospital Course

• Recurrent episodes of symptomatic hypoxia • 50% Facemask ith p lse o 92%• Recurrent episodes of symptomatic hypoxia • 50% Facemask ith p lse o 92%• 50% Facemask with pulse ox 92%• 50% Facemask with pulse ox 92%

• Pulse Ox supine: 98%• Pulse Ox sitting up: 90%• Pulse Ox supine: 98%• Pulse Ox sitting up: 90%g pg p


Episodic Hypoxia:Episodic Hypoxia:Episodic Hypoxia:Episodic Hypoxia:


Transesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal Echocardiogram


TEE: Bubble Contrast Study TEE: Bubble Contrast Study


Transesophageal EchocardiogramTransesophageal Echocardiogram

• Normal Left and Right Ventricular function

• L P t t F O l t l 6

• Normal Left and Right Ventricular function

• L P t t F O l t l 6• Large Patent Foramen Ovale, tunnel 6 mm • Color doppler and bubble contrast consistent with right to

left shunt

• Large Patent Foramen Ovale, tunnel 6 mm • Color doppler and bubble contrast consistent with right to

left shuntleft shunt

• Entry of IVC into RA is rotated; most likely due to

left shunt

• Entry of IVC into RA is rotated; most likely due to y ; yabnormal aorta

• Prominent eustachian valve

y ; yabnormal aorta

• Prominent eustachian valve• Above 2 findings maybe directing IVC flow into

IAS/PFO• Above 2 findings maybe directing IVC flow into

IAS/PFO


Pl t O th d i S dPl t O th d i S dPlatypnea-Orthodeoxia Syndrome:Platypnea-Orthodeoxia Syndrome:

• Rare pattern of orthostatic dyspnea and arterial hypoxemia• Rare pattern of orthostatic dyspnea and arterial hypoxemiaRare pattern of orthostatic dyspnea and arterial hypoxemia

• Platypnea:

Rare pattern of orthostatic dyspnea and arterial hypoxemia

• Platypnea:Platypnea:- Dyspnea induced by upright posture; relieved by supine

position

Platypnea:- Dyspnea induced by upright posture; relieved by supine

positionposition

• Orthodeoxia:

position

• Orthodeoxia:Orthodeoxia:- Arterial desaturation resulting from assuming an erect or

upright position

Orthodeoxia:- Arterial desaturation resulting from assuming an erect or

upright positionp g pp g p


Clinical States Associated with the Platypnea-Orthodeoxia SyndromeClinical States Associated with the Platypnea-Orthodeoxia SyndromePlatypnea-Orthodeoxia SyndromePlatypnea-Orthodeoxia Syndrome


Bellato et al. Minerva Anesth 2008;74:271-5

Platypnea Orthodeoxia SyndromePlatypnea Orthodeoxia SyndromePlatypnea-Orthodeoxia SyndromePlatypnea-Orthodeoxia Syndrome

2 conditions must coexist:2 conditions must coexist:2 conditions must coexist:

• A t i l t

2 conditions must coexist:

• A t i l t• Anatomical component - ASD/PFO/Fenestrated Septum

• Anatomical component - ASD/PFO/Fenestrated Septum- Pulmonary Vascular AVM- Pulmonary Parenchymal Shunt (severe V/Q mismatch)- Pulmonary Vascular AVM- Pulmonary Parenchymal Shunt (severe V/Q mismatch)

• Functional component • Functional component - results in redirection of blood flow through anatomical

component with upright posture- results in redirection of blood flow through anatomical

component with upright posture


Pl t O th d i S dPl t O th d i S dPlatypnea-Orthodeoxia Syndrome:Platypnea-Orthodeoxia Syndrome:• Most common anatomical component is intra-cardiac • Most common anatomical component is intra-cardiac ost co o a ato ca co po e t s t a ca d ac

right to left shunt (most often PFO)ost co o a ato ca co po e t s t a ca d ac

right to left shunt (most often PFO)

• Most common functional component is thoracic or abdominal s rger :

• Most common functional component is thoracic or abdominal s rger :abdominal surgery:- Pneumonectomy (usually right)

L b ( ll i h )

abdominal surgery:- Pneumonectomy (usually right)

L b ( ll i h )- Lobectomy (usually right)- Abdominal surgery with R hemidiaphragm paralysis- Lobectomy (usually right)- Abdominal surgery with R hemidiaphragm paralysis

Sorrentino et al. Chest 1991; 100:1157-8Begin et al N Engl J Med 1987 2941:941 3


Begin et al. N Engl J Med 1987. 2941:941-3Toffart et al. Heart Lung 2008; 37:385

Referred to Cardiac Cath LabReferred to Cardiac Cath Lab


Positioning the DevicePositioning the Device


Releasing the DeviceReleasing the Device


Summary of ProcedureSummary of Procedure

• Guided by Intra-cardiac echocardiography (ICE) –A N S t (Bi W b t )

• Guided by Intra-cardiac echocardiography (ICE) –A N S t (Bi W b t )AcuNav System (Biosense Webster)AcuNav System (Biosense Webster)

• PFO closed with 25 mm Cribiform ASD-closure Device – Amplatzer (AGA Medical)

• PFO closed with 25 mm Cribiform ASD-closure Device – Amplatzer (AGA Medical)p ( )p ( )


Post-Device Deployment:Post-Device Deployment:Post-Device Deployment:Post-Device Deployment:

Follow-up: Patient’s symptoms completely resolved,


p y p p y ,no further need to supplemental oxygen

AcknowledgementsAcknowledgements

• Arijit Dasgupta, MD• Arijit Dasgupta, MD• David Wax, MD• David Wax, MD


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