Episodic Desaturation

JDFlhtMDJames D. Flaherty, MD Assistant Professor of Medicine Northwestern University, Feinberg School of Medicine Medical Director, Coronary Care Unit Northwestern Memorial Hospital, Chicago

April 27, 2012

The Bluhm Cardiovascular Institute Northwestern Disclosures

None

The Bluhm Cardiovascular Institute Northwestern Presentation

• 75 year-old woman presents with shortness of bthbreath • Episodic, worse when getting up in the morning

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

The Bluhm Cardiovascular Institute Northwestern PtMdilHitPast Medical History • Allergies – Iodinated • Crypogenic strokes (1993 Contrast Dye and 1997) residual ataxia • HTN • Medications • DiDepression - Coumadin 6mg daily - Pravastatin 40 qd - HCTZ 25mg daily Social History - Verapamil 180 qd - Bupropion 300mg qd no tobacco/alcholol/drug use - Nexium 40 qd - Valium 5mg bid prn - Premarin .3mg daily Family History No cardiac or pulmonary conditions

The Bluhm Cardiovascular Institute Northwestern 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:tachynormalS1nlS2noS3noS4nomurmursCV: tachy, normal S1, nl S2, no S3, no S4, no murmurs • Lungs: clear • Abd: soft, nontender • Ext: no edema

• Lab Values – all normal

The Bluhm Cardiovascular Institute Northwestern Electrocardiogram

The Bluhm Cardiovascular Institute Northwestern 6 Ches t X-ray

The Bluhm Cardiovascular Institute Northwestern CT Chest: no PNA or PE, ascending thoracic aorta mildlyy() dilated (4cm) and ectatic. + thoracic kyp hosis

Transthoracic Echocardiogram: grossly normal

The Bluhm Cardiovascular Institute Northwestern Hospital Course

• Recurrent episodes of symptomatic hypoxia • 50% Facemask with p ulse o x 92%

• Pulse Ox supine: 98% • Pulse Ox sittinggp up: 90%

The Bluhm Cardiovascular Institute Northwestern Episodic Hypoxia:

The Bluhm Cardiovascular Institute Northwestern Transesophageal Echocardiogram

The Bluhm Cardiovascular Institute Northwestern Transesophageal Echocardiogram

The Bluhm Cardiovascular Institute Northwestern TEE: Bubble Contrast Study

The Bluhm Cardiovascular Institute Northwestern Transesophageal Echocardiogram

• Normal Left and Right Ventricular function

• LPttFOltl6Large Patent Foramen Ovale, tunnel 6 mm • Color doppler and bubble contrast consistent with right to left shunt

• Entryy;y 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

The Bluhm Cardiovascular Institute Northwestern Platy t pnea-OthdOrthodeox ia SdSyndrome:

• 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 uppgright p osition

The Bluhm Cardiovascular Institute Northwestern Clinical States Associated with the Platypnea-Orthodeoxia Syndrome

Bellato et al. Minerva Anesth 2008;74:271-5 The Bluhm Cardiovascular Institute Northwestern Platypnea-Orthodeoxia Syndrome

2 conditions must coexist:

• AtAnatomi ilcal 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

The Bluhm Cardiovascular Institute Northwestern Platy t pnea-OthdOrthodeox ia SdSyndrome: • Most comm on an atomi cal co mpo n ent is int ra -card iac right to left shunt (most often PFO)

• Most common functional component is thoracic or abdominal s urger y: - Pneumonectomy (usually right) - LbLobectomy (llih)(usually right) - Abdominal surgery with R hemidiaphragm paralysis

Sorrentino et al. Chest 1991; 100:1157-8 Begin et al. N Engl J Med 1987. 2941:941 -3 Toffart et al. Heart Lung 2008; 37:385 The Bluhm Cardiovascular Institute Northwestern Referred to Cardiac Cath Lab

The Bluhm Cardiovascular Institute Northwestern 19 Positioning the Device

The Bluhm Cardiovascular Institute Northwestern 20 Releasing the Device

The Bluhm Cardiovascular Institute Northwestern 21 Summary of Procedure

• Guided by Intra-cardiac echocardiography (ICE) – ANAcuNav StSystem (Biosense Wbt)Webster)

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

The Bluhm Cardiovascular Institute Northwestern 22 Post-Device Deployment:

Follow-uppyppy,: Patient’s symptoms completely resolved, no further need to supplemental oxygen The Bluhm Cardiovascular Institute Northwestern Acknowledgements

• Arijit Dasgupta, MD • David Wax, MD

The Bluhm Cardiovascular Institute Northwestern 24