Ann Thorac Surg 2009;88:2018-2019. doi:10.1016/j.athoracsur.2009.01.047
© 2009 The Society of Thoracic Surgeons
Case Reports
Platypnea-Orthodeoxia Syndrome: A Rare Complication After Right Pneumonectomy
Kausik Bhattacharya, FRCS, CTha,*,
Rashmi Birla, MBBSa,
David Northridge, FRCPb,
Vipin Zamvar, FRCS, CTha
a Department of Cardiothoracic Surgery, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
b Department of Cardiology, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
Accepted for publication January 20, 2009.
* Address correspondence to Dr Bhattacharya, Department of Cardiothoracic Surgery, Edinburgh Royal Infirmary, Dalkeith Rd, Edinburgh, EH16 4SA, United Kingdom (Email: k.bhattacharya{at}ed.ac.uk).
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Abstract
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Platypnea is characterized by breathlessness in the upright position. Orthodeoxia is defined by arterial desaturation on standing. Herein we describe a case of platypnea-orthodeoxia syndrome in a patient who underwent a right pneumonectomy for adenocarcinoma of the lung. Closure of a patent foramen ovale, causing a right-to-left shunt, with an Amplatzer device, produced immediate symptomatic relief.
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Introduction
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Platypnea-orthodeoxia syndrome is a rare physiological consequence of anatomical changes between the caval orifices and the atrial septum. This alteration of alignment typically occurs after a right pneumonectomy, and the net effect causes shunting through the patent foramen ovale. This results in preferential blood flow from the right-to-left atrium, despite similar atrial pressures.
A 55-year-old man underwent a right pneumonectomy for T1N1 poorly differentiated adenocarcinoma of the lung. Past medical history included a left hemicolectomy for a Duke's C moderately differentiated adenocarcinoma of sigmoid colon. He recovered well from his pneumonectomy and was discharged on postoperative day 8 with saturations of 95% on air. Outpatient follow-up 5 weeks after surgery was satisfactory. He did not complain of dyspnea on exertion. However, he was readmitted to hospital 5 weeks later. His primary complaint was marked breathlessness on standing (platypnea). This was relieved by lying in the supine position. There was no association with chest pain. His oxygen saturations were found to drop from 84% in supine position to 73% in the erect position. Subsequent transesophageal echocardiogram revealed a patent foramen ovale, 7 mm in diameter, with right-to-left shunt. Right heart catheterization confirmed the shunt with a pulmonary systemic flow ratio of 0.6:1. The patent foramen ovale was then closed using 25-mm Amplatzer device (AGA Medical Corp, Plymouth, MN) (Fig 1) with an immediate substantial reduction in the right to left shunting. His oxygen saturations on air increased to 96% in supine position and 93% in the erect position. Simultaneously, it afforded him symptomatic relief.
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Fig 1. The deployed 25-mm Amplatzer device (demonstrated by the white arrow), closing the patent foramen ovale.
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Comment
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The platypnea-orthodeoxia syndrome was first described as a late complication of pneumonectomy in 1956 [1]. Since then there have been isolated case reports in the literature. All case reports occurred after a right pneumonectomy except three that occurred after a single lobectomy [2]. Nearly all shunts were due to a patent foramen ovale, except in four cases [3, 4]. Common characteristics are present in the cases cited. They tend to present at 2 months after surgery, and the atrial pressures are equal [1–6]. The time lag may be attributable to the residual lung shifting the mediastinum to change the anatomical relationship of the caval orifices and the atrial septum. Correction of the shunt either by surgery [2] or by a percutaneous route [7] affords immediate symptomatic relief. In assessing a patient with hypoxia a few weeks after right lung resection, right-to-left atrial shunting should be considered in the differential diagnosis.
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References
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- 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;32:246-250.[Medline]
- Spinger RM, Gheorghiade M, Chakko CS, et al. Platypnea and intra atrial right to left shunting after lobectomy Am J Cardiol 1983;51:1802-1803.[Medline]
- Smeenk FW, Postmus PE. Interatrial right-to-left shunting developing after pulmonary resection in the absence of elevated right-sided heart pressures Chest 1993;103:528-531.[Abstract/Free Full Text]
- Zueger O, Soler M, Stulz P, et al. Dyspnea after pneumonectomy: the result of an atrial septal defect Ann Thorac Surg 1997;63:1451-1452.[Abstract/Free Full Text]
- Rossum van P, Plokker HW, Ascoop CA. Breathlessness and hypoxaemia in the upright position after right pneumonectomy Eur Heart J 1988;9:1230-1233.[Abstract/Free Full Text]
- Berry L, Braude S, Hogan J. Refractory hypoxaemia after pneumonectomy: diagnosis by transoesophageal echocardiography Thorax 1992;47:60-61.[Abstract/Free Full Text]
- Crosbie P, Cooper A, Ray S, O'Driscoll R. A rare complication of pneumonectomy: diagnosis made by a literature search Respir Med 2005;99:1198-1200.[Medline]
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Abstract
Introduction
