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BMJ Case Reports 2013; doi:10.1136/bcr-2012-008398
  • CASE REPORT

Transient right-to-left intracardiac shunt following a right ventricular myocardial infarction

  1. Rizwan Ahmed3
  1. 1Department of Cardiology, Chesterfield Royal Hospital, Chesterfield, UK
  2. 2Department of Cardiology, Pinderfields General Hospital, Wakefield, UK
  3. 3Department of Respiratory Medicine, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK
  1. Correspondence to Dr Arvindra Krishnamurthy, arvindra{at}doctors.org.uk

Summary

A 56-year-old smoker presented with a 3-day history of intermittent chest pain. Cardiovascular examination on admission was normal. ECG showed minimal (<1 mm) ST elevation in lead III, and right-sided leads revealed similar mild ST-elevation. Troponin I was elevated at 10.91. He was managed as a delayed-presentation ST-elevation myocardial infarction case. 12 h following admission, he developed oxygen-resistant hypoxia and hypotension. There were no clinical or radiological signs of pulmonary congestion. CT pulmonary angiogram revealed no pulmonary embolus. A bubble-contrast echocardiogram confirmed an active interatrial right-to-left shunt without Valsalva provocation. His hypoxia steadily improved over the following 24 h and he did not require any shunt closure. A repeat bubble contrast echocardiogram showed that the shunt was now only active following a Valsalva manoeuvre. Transoesophageal echocardiography confirmed a patent foramen ovale. This is a rare but important cause of resistant hypoxia following a right-heart infarct.

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