Episodic Desaturation

Transcription

1 Episodic Desaturation James D. Flaherty, MD Assistant Professor of Medicine University, Feinberg School of Medicine Medical Director, Coronary Care Unit Memorial Hospital, Chicago April 27, 2012

2 Disclosures None

3 Presentation 75 year-old woman presents with shortness of breath Episodic, worse when getting up in the morning Review of Systems: no chest pain, cough, edema OR other associated symptoms

4 Past tm Medical lhi History Crypogenic strokes (1993 and 1997) residual ataxia HTN Depression Social History no tobacco/alcholol/drug use Family History No cardiac or pulmonary conditions Allergies Iodinated Contrast Dye Medications - Coumadin 6mg daily - Pravastatin 40 qd - HCTZ 25mg daily - Verapamil 180 qd - Bupropion 300mg qd - Nexium 40 qd - Valium 5mg bid prn - Premarin.3mg daily

5 Physical Exam: 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% FM Neck: No jugular venous pressure elevation CV:tachy tachy, normals1 S1, nl S2, no S3, nos4 S4, no murmurs Lungs: clear Abd: soft, nontender Ext: no edema Lab Values all normal

6 Electrocardiogram 6

7 Chest X-ray

8 CT Chest: no PNA or PE, ascending thoracic aorta mildly dilated (4cm) and ectatic. + thoracic kyphosis Transthoracic Echocardiogram: grossly normal

9 Hospital Course Recurrent episodes of symptomatic hypoxia 50% Facemask with pulse ox 92% Pulse Ox supine: 98% Pulse Ox sitting up: 90%

10 Episodic Hypoxia:

11 Transesophageal Echocardiogram

12 Transesophageal Echocardiogram

13 TEE: Bubble Contrast Study

14 Transesophageal Echocardiogram Normal Left and Right Ventricular function Large Patent t Foramen Ovale, tunnel 6 mm Color doppler and bubble contrast consistent with right to left shunt Entry of IVC into RA is rotated; most likely due to abnormal aorta Prominent eustachian valve Above 2 findings maybe directing IVC flow into IAS/PFO

15 Platypnea-Orthodeoxia Othd Syndrome: Rare pattern of orthostatic dyspnea and arterial hypoxemia Platypnea: - Dyspnea induced by upright posture; relieved by supine position Orthodeoxia: - Arterial desaturation resulting from assuming an erect or upright position

16 Clinical States Associated with the Platypnea-Orthodeoxia Syndrome Bellato et al. Minerva Anesth 2008;74:271-5

17 Platypnea-Orthodeoxia Syndrome 2 conditions must coexist: Anatomical component - ASD/PFO/Fenestrated Septum - Pulmonary Vascular AVM - Pulmonary Parenchymal Shunt (severe V/Q mismatch) Functional component - results in redirection of blood flow through anatomical component with upright posture

18 Platypnea-Orthodeoxia Othd Syndrome: Most common o anatomical ato component is intra-cardiac ac right to left shunt (most often PFO) Most common functional component is thoracic or abdominal surgery: - Pneumonectomy (usually right) - Lb Lobectomy (usually right) - Abdominal surgery with R hemidiaphragm paralysis Sorrentino et al. Chest 1991; 100: Begin et al. N Engl J Med :941-3 Toffart et al. Heart Lung 2008; 37:385

19 Referred to Cardiac Cath Lab 19

20 Positioning the Device 20

21 Releasing the Device 21

22 Summary of Procedure Guided by Intra-cardiac echocardiography (ICE) AcuNav System (Biosense Webster) PFO closed with 25 mm Cribiform ASD-closure Device Amplatzer (AGA Medical) 22

23 Post-Device Deployment: Follow-up: Patient s symptoms completely resolved, no further need to supplemental oxygen

24 Acknowledgements Arijit Dasgupta, MD David Wax, MD 24