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A 57-year-old man presented with breathlessness that worsened on sitting up and was relieved by lying down. He had undergone a right pneumonectomy for lung carcinoma three months previously. His exercise capacity was limited to 10 yards (3 m) and he preferred to eat lying flat to minimise the symptom of dyspnoea. Orthodeoxia was confirmed by measuring oxygen saturations on room air in the supine (89%) and sitting (77%) positions. The hypoxia was not corrected by high flow oxygen. A transoesophageal echocardiogram delineated a patent foramen ovale (PFO) with a fixed 7 mm defect and colour flow imaging (upper panel) demonstrated continuous right to left shunting. At cardiac catheterisation right-sided pressures were normal (right ventricle 22/0 mm Hg) and there was a substantial right to left atrial shunt (Qp/Qs = 0.54) with oxygen saturations (on 40% inspired oxygen) falling from 97% in the pulmonary vein to 72% in the left atrium. Percutaneous closure of the PFO was performed using a 25 mm Amplatzer PFO occluder (lower panel). The patient experienced immediate symptomatic relief with improvement in oxygen saturations to 97% (supine) and 94% (sitting). The syndrome of breathlessness on standing relieved by lying down (platypnoea) accompanied by orthodeoxia caused by shunting through a PFO is a recognised complication of pneumonectomy and lobectomy. The shunting occurs despite normal right-sided pressures and may result from atrial septal displacement allowing preferential streaming of blood from the inferior vena cava across the PFO into the left atrium. Percutaneous PFO closure is, as illustrated above, an effective treatment.
This article has been adapted from Henriksen P A, Strachan K, Selby C, Northridge D B. Percutaneous patent foramen ovale closure in a patient with platypnoea-orthodeoxia syndrome Heart 2007;93:892