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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
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DisclosuresDisclosures
NoneNone
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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
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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
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conditionsconditions
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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
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ElectrocardiogramElectrocardiogram
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Ch tCh tChest X-rayChest X-ray
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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
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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
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Episodic Hypoxia:Episodic Hypoxia:Episodic Hypoxia:Episodic Hypoxia:
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Transesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal Echocardiogram
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Transesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal EchocardiogramTransesophageal Echocardiogram
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TEE: Bubble Contrast Study TEE: Bubble Contrast Study
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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
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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
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Clinical States Associated with the Platypnea-Orthodeoxia SyndromeClinical States Associated with the Platypnea-Orthodeoxia SyndromePlatypnea-Orthodeoxia SyndromePlatypnea-Orthodeoxia Syndrome
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Bellato et al. Minerva Anesth 2008;74:271-5
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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
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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
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Begin et al. N Engl J Med 1987. 2941:941-3Toffart et al. Heart Lung 2008; 37:385
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Referred to Cardiac Cath LabReferred to Cardiac Cath Lab
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Positioning the DevicePositioning the Device
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Releasing the DeviceReleasing the Device
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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 ( )
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Post-Device Deployment:Post-Device Deployment:Post-Device Deployment:Post-Device Deployment:
Follow-up: Patient’s symptoms completely resolved,
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p y p p y ,no further need to supplemental oxygen
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AcknowledgementsAcknowledgements
• Arijit Dasgupta, MD• Arijit Dasgupta, MD• David Wax, MD• David Wax, MD
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