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Ann Thorac Surg 1996;62:582-583
© 1996 The Society of Thoracic Surgeons

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Case Report

Intermittant Hypoxia Due to Right Atrial Compression by an Ascending Aortic Aneurysm

Divisions of Thoracic Surgery and Cardiology, Allegheny General Hospital, The Medical College of Pennsylvania/ Hahnemann University, Pittsburgh, Pennsylvania

Accepted for publication March 12, 1996.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment Reference

 
Two cases are described wherein right atrial compression from a dilated and elongated ascending aorta caused intermittent positional hypoxia. Extrinsic compression of the right atrium caused shunting though a patent foramen ovale.

	Introduction

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Twenty-seven percent of the adult population has a patent foramen ovale [1]. These rarely, if ever, become symptomatic because normal hemodynamics keep the foramen closed. Reported complications of a patent foramen ovale include paradoxical embolus and the development of a right-to-left shunt in the presence of pulmonary hypertension. We recently treated 2 patients with an unusually symptomatic patent foramen ovale. Compression of the right atrium by a large ascending aortic aneurysm caused right-to-left shunting through the foramen ovale.

	Case Reports

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Patient 1
Patient 1 is an 82-year-old woman previously in good health who presented with symptoms of progressive shortness of breath. Evaluation demonstrated a large (7.8-cm in diameter) ascending aortic aneurysm with extension into the base of the aortic arch. When placed supine for cardiac catheterization she abruptly desaturated and did not resaturate with supplemental oxygen. Further investigation demonstrated that she was normally saturated sitting up and desaturated when lying flat. When she was placed in the left lateral decubitus position her right atrial saturation increased from 84% to 92%. An intermittent, positional right-to-left shunt at the atrial level and extrinsic compression of the right atrium were demonstrated by echocardiography. Coronary angiography demonstrated no evidence of coronary artery disease. There was no valvular disease, and the pulmonary artery pressures at catheterization were normal. At operation she had a markedly dilated, but of more importance, a markedly elongated ascending aorta. When the pericardium was opened the only identifiable structure was the aneurysm; the heart had rotated counterclockwise such that the apex was displaced to the left and the right atrium toward the diaphragm. The aneurysm was resected and replaced with a tube graft. The right atrium was opened and inspected. There was no evidence of a true atrial septal defect, and the foramen ovale was closed with a single mattress suture. Her postoperative course was uneventful. Her arterial blood oxygen saturation was normal.

Patient 2
Patient 2 is a 74-year-old woman who presented with progressive shortness of breath over several months. Evaluation included a computed tomographic scan, which demonstrated a large (8.6 x 8.7-cm), elongated ascending aortic aneurysm. Echocardiography demonstrated moderate aortic insufficiency. On presentation she was noted to have an oxygen tension of 42 mm Hg. This did not increase with supplemental oxygen. On right heart catherization, dye opacification of the right atrium demonstrated shunting across the patent foramen ovale with extrinsic compression. Pulmonary artery pressures were normal, and there was no incremental increase in oxygen saturation from the right atrium to the pulmonary artery. A Cabrol composite replacement of the aortic valve and ascending aorta and closure of the patent foramen ovale were performed. Her symptoms resolved.

	Comment

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This is an unusual mode of presentation for an ascending aortic aneurysm. The two contributing mechanisms are (1) compression of the right atrium by the aneurysm causing an elevation in right atrial pressure and subsequent opening of the foramen ovale and (2) deformation of the right atrium by the aneurysm causing preferential flow of blood from the inferior vena cava toward and through the foramen ovale. In both cases aneurysm resection with closure of the foramen ovale was successful. In a high-risk patient symptomatic relief should be expected from elimination of the right-to-left shunt by catheter closure of the patent foramen ovale.

	Footnotes

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Address reprint requests to Dr Savage, Allegheny Professional Building, Suite 302, 490 E North Ave, Pittsburgh, PA 15212.

	Reference

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1. Kopf GS, Laks H. Atrial septal defects and cor triatriatum. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn's thoracic and cardiovascular surgery. 5th ed. East Norwalk: Appleton & Lange, 1991:995-1006.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Edward B. Savage Daniel H. Benckart Yong D. Cho Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Savage, E. B. Articles by Cho, Y. D. Search for Related Content PubMed PubMed Citation Articles by Savage, E. B. Articles by Cho, Y. D.