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Ann Thorac Surg 1997;64:834-836
© 1997 The Society of Thoracic Surgeons

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Case Report

Postpneumonectomy Interatrial Right-to-Left Shunt: Successful Percutaneous Treatment

Hôpital Cardiologique and Clinique Chirurgicale, Hôpital Calmette. Centre Hospitalier Régional Universitaire de Lille, Lille, France

Accepted for publication April 2, 1997.

	Abstract

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This report describes the case of a 67-year-old man in whom atrial right-to-left shunt developed after a right pneumonectomy, leading to dyspnea with severe arterial desaturation. Transcatheter occlusion of the patent foramen ovale was successfully performed using a buttoned device. Review of literature and mechanisms of these atrial right-to-left shunts are discussed.

	Introduction

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Shortness of breath with severe hypoxemia after pneumonectomy is a common finding with multiple causes. The current report presents this complication after a right pneumonectomy due to a right-to-left shunt through a patent foramen ovale (PFO) successfully treated by transcatheter occlusion.

A 67-year-old man was referred to our hospital for a squamous cell carcinoma (classified T4 N0 M0) of the right main bronchus involving the trachea. After neoadjuvant chemotherapy, he underwent a right sleeve pneumonectomy and was immediately extubated.

Two days after the operation, acute dyspnea developed with variable hypoxemia requiring oxygen support with no postural changes. Physical examination revealed a pulse rate of 90 beats/min, a blood pressure of 130/80 mm Hg, and respiration rate of 25 per minute. The thorax examination revealed dullness over the right hemithorax and normal breath sounds. The heart sounds and the electrocardiogram were normal. Chest radiography showed a mediastinal shift to the right and a clear left-lung field. Severe hypoxemia was noticed on 8 L/min of oxygen delivered by nasal canula (oxygen partial pressure of 53 mm Hg, saturation 87%). Arterial blood gas determination on inspired oxygen concentration of 100% showed a mild increase (oxygen partial pressure of 85 mm Hg, saturation 96%). Spiral computed tomographic angiography of the pulmonary artery revealed an early aortic opacification but no evidence of left-pulmonary embolism. Thus, interatrial shunting was suspected and confirmed by transoesophageal echocardiography.

Cardiac catheterization was performed under local anesthesia on the ninth postoperative day with the patient receiving 6 L/min of oxygen. Contrast material injection in the inferior vena cava showed right atrial opacification with shunting of contrast material into the left atrium through a PFO 10 mm in diameter. The atrial septum was displaced horizontally (the angle with the horizontal axis was 23 degrees) (Fig 1). The pressures were as follows: right atrium, had a pressure of 6/3 (mean, 4 mm Hg); left atrium, 8/0 (mean, 4 mm Hg); and right ventricle, 28/0 mm Hg. The oxygen saturation was decreased in the left atrium (89%) whereas a normal value was noticed in the left-upper pulmonary vein (saturation of 97.4%). Transcatheter occlusion of the PFO was performed with a modified buttoned device initially fashioned to occlude secundum atrial septal defect [1]. This modification included two occluding devices. The first occluder is a squared foam of polyurethane supported by an X-shaped wire skeleton deployed in the left atrium, and a second similar occluder is deployed in the right atrium to prevent right-to-left shunt. Both occluding devices are then buttoned together (Fig 2). After deployment of the first occluder, the arterial oxygen saturation rose to 94% and then to 99% after deployment of the second occluder. Fifteen minutes later on room air, the arterial saturation was 94%. The patient was discharged from the hospital while receiving oral anticoagulant treatment. Six months later, he remains asymptomatic with normal oxygen saturation (arterial saturation of 93% on room air) and contrast echocardiography reveals no interatrial residual shunt.

View larger version (131K): [in this window] [in a new window]   Fig 1. . Right atrial angiogram showing opacification of the right atrium (RA) and shunting from RA to left atrium (LA) across the patent foramen ovale (arrow). Notice the displacement of atrial septum (dashed line) toward the diaphragm.

View larger version (96K): [in this window] [in a new window]   Fig 2. . Reversed buttoned device. The two occluders are radiopaque because of the X-shaped skeleton. One device is in the left atrium (LA) (arrows) and the second device is in the right atrium (RA) (arrowheads).

	Comment

Top Footnotes Abstract Introduction Comment References

The possible explanation for atrial right-to-left shunt is interatrial pressure gradient favoring right-to-left shunt either through a PFO or a small atrial septal defect. Due to increased right ventricle afterload after pulmonary resection, reversal of the normal mean interatrial pressure has been advocated. Such a gradient can be accentuated by inspiration, cough, and Valsalva maneuver. Nevertheless, reversal gradient is not always observed, but some reports show a mean right atrial pressure equal to or lower than the mean left atrial pressure, as observed in our patient. We believe that the modifications of anatomic relations between inferior vena cava and atrial septum are the determinant factor. The atrial septum was completely displaced toward the diaphragm. These modifications allow a complete streaming of the inferior vena caval blood flow through the PFO leading to cyanosis. This flow phenomenon seems essential in our experience and is clearly the consequence of lung resection with heart displacement.

Due to the prevalence of PFO in the general population (up to 25% to 27%), the interatrial right-to-left shunt may be underestimated in patients with dyspnea or hypoxemia after pneumonectomy. When it occurs, the first diagnosis to eliminate is pulmonary embolism. Then contrast two-dimensional echocardiography or transesophageal echocardiography is the most helpful procedure to detect PFO or atrial septal defect.

Most patients suffering from postpneumonectomy atrial right-to-left shunt are referred for surgical correction of the PFO. Transcatheter closure of the PFO or atrial septal defect appears as a good alternative to operation. It is an effective and safe method with a low procedural morbidity, especially in patients who recently underwent a pulmonary resection. Several devices are available for transcatheter occlusion of atrial septal defect. In our report, the buttoned device was employed successfully.

This case report illustrates that transcatheter therapy is the first-choice procedure in patients with dyspnea or hypoxemia due to interatrial right-to-left shunt after pneumonectomy.

	Footnotes

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Address reprint requests to Dr Godart, Service des Maladies Cardiovasculaires Infantiles et Congénitales, Hôpital Cardiologique, Centre Hospitalier Régional et Universitaire de Lille, 59037 Lille cedex, France.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Rao S, Sideris EB, Hausdorf G, et al. International experience with secundum atrial septal defect occlusion by the buttoned device. Am Heart J 1994;128:1022–35.[Medline]
2. Schnabel TG, Ratto O, Kirby CK, Johnson J, Comroe JH. Postural cyanosis and angina pectoris following pneumonectomy: relief by closure of an interatrial septum defect. J Thorac Surg 1956;32:246–50.
3. Vacek JL, Foster J, Quinton RR, Savage PJ. Right-to-left shunting after lobectomy through a patent foramen ovale. Ann Thorac Surg 1985;39:576–8.[Abstract/Free Full Text]
4. Smeenk FW, Postmus PE. Interatrial right-to-left shunting developing after pulmonary resection in the absence of elevated right-sided heart pressures. Review of literature. Chest 1993;105:528–31.
5. Mercho N, Stoller JK, White RD, Mehta AC. Right-to-left interatrial shunt causing platypnea after pneumonectomy. A recent experience and diagnostic value of dynamic magnetic resonance imaging. Chest 1994;105:931–3.[Abstract/Free Full Text]
6. Landzberg MJ, Sloss LJ, Faherty CE, et al. Orthodeoxia-platypnea due to intracardiac shunting. Relief with transcatheter double umbrella closure. Cathet Cardiovasc Diagn 1995;36:247–50.[Medline]
7. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life. An autopsy study in 956 normal hearts. Mayo Clin Proc 1984;59:17–20.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Henri L. Porte Alain Wurtz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Godart, F. Articles by Wurtz, A. Search for Related Content PubMed PubMed Citation Articles by Godart, F. Articles by Wurtz, A.