Paroxysmal supine hypoxaemia with hyperthyroidism and atrial fibrillation: a case report of a diagnostic challenge.

Autor: Liu LY; Mayo Clinic Alix School of Medicine, Rochester, MN, USA., Reddy YNV; Mayo Clinic Rochester, Department of Cardiovascular Medicine, USA., Niven AS; Mayo Clinic Rochester, Department of Pulmonary and Critical Care Medicine, USA., Hu TY; Mayo Clinic Rochester, Department of Cardiovascular Medicine, USA., Larson KF; Mayo Clinic Rochester, Department of Cardiovascular Medicine, USA., Mulpuru SK; Mayo Clinic Rochester, Department of Cardiovascular Medicine, USA., Cullen MW; Mayo Clinic Rochester, Department of Cardiovascular Medicine, USA.
Jazyk: angličtina
Zdroj: European heart journal. Case reports [Eur Heart J Case Rep] 2022 May 24; Vol. 6 (6), pp. ytac214. Date of Electronic Publication: 2022 May 24 (Print Publication: 2022).
DOI: 10.1093/ehjcr/ytac214
Abstrakt: Background: A patent foramen ovale (PFO) is a persistent embryonic defect in the interatrial septum. Platypnoea-orthodeoxia syndrome is characterized by positional hypoxaemia that is most commonly due to right-to-left shunting through a PFO. Dynamic right-to-left shunting through a PFO can also exacerbate positional hypoxaemia without platypnea-orthodeoxia syndrome.
Case Summary: A 78-year-old woman with hyperthyroidism and paroxysmal atrial fibrillation (AF) presented with positional hypoxaemia exacerbated by supine positioning. Diagnostic testing revealed intermittent right-to-left shunting through a PFO triggered by worsening atrial functional tricuspid regurgitation and elevated right atrial pressures. Diuresis, rate control, and thyroidectomy initially led to resolution of positional hypoxaemia, but recurrent AF episodes triggered right-to-left shunting with recurrent desaturation. Left atrial and cavo-tricuspid isthmus ablation led to restoration of normal sinus rhythm and resolution of positional hypoxaemia without PFO closure.
Discussion: The clinical presentation of intermittent intracardiac right-to-left shunting can mimic decompensated heart failure with pulmonary oedema. Persistent hypoxaemia out of proportion to the degree of pulmonary oedema and minimally responsive to supplemental O 2 should raise suspicion for right-to-left shunt aetiology. Positional arterial blood gases can facilitate the diagnostic evaluation of refractory hypoxaemia in cases of suspected shunting. Diagnostic imaging for PFO detection includes both transthoracic and transesophageal echocardiography with Valsalva manoeuver and agitated saline injection. Closure of a PFO for management of arterial deoxygenation syndromes should not be performed before treating other causes of arterial deoxygenation and optimizing factors that may exacerbate shunting across the PFO.
(© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)
Databáze: MEDLINE
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