Ann Thorac Surg 2010;90:2087. doi:10.1016/j.athoracsur.2010.02.116
© 2010 The Society of Thoracic Surgeons
A Rare Complication Indeed
Willem N. Welvaart, MDa,
Koen J. Hartemink, MDb,
Marinus A. Paul, MD, PhDb,
Jan W.A. Oosterhuis, MD, PhDb
a Department of Surgery, Rivierenland Hospital, Pr. Kennedylaan 1, 4002 WP Tiel, The Netherlands
b Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
To the Editor:
We read with interest the article "Platypnea-Orthodeoxia Syndrome: A Rare Complication After Right Pneumonectomy" by Bhattacharya and colleagues  in which they described a patient with platypnea-orthodeoxia syndrome after right-sided pneumonectomy. They treated the patient with an Amplatzer device to close the patent foramen ovale (PFO). With this device they achieved good symptomatic relief. Figure 1 in their article shows the device, but also an elevated right hemidiaphragm, in our opinion the source of the problem.
Platypnea-orthodeoxia syndrome is indeed rare; however, a PFO can occur in patients with right ventricular compression by an elevated right hemidiaphragm. Autopsy series have shown that the foramen can be opened in up to 30% of patients. The actual reopening of the foramen ovale in patients can be explained as follows: After resection of the right lung, a mediastinal shift occurs. The paralysed diaphragm opposes this shift, resulting in of a rotation of the heart around the caval axis and an increased right atrial pressure. In one of our patients, during dynamic magnetic resonance imaging investigation, straining resulted in an increased rotation and increased shunting!
Closure of the PFO with a device stops the shunting, but not the atrial compression. Plication of the diaphragm resolves the interatrial pressure gradient and subsequently stops the blood flow through the PFO, and we have used this technique with good result.
In literature, treatment of interatrial shunting is still done by open heart surgery or, preferably, by percutaneous transcatheter closure [2–4]. We postulate that plication of the diaphragm corrects the cause and obviates the need for a cardiac operation. Spontaneous closure of the PFO after plication of the hemidiaphragm occurred in all patients .
- Bhattacharya K, Birla R, Northridge D, Zamvar V. Platypnea-orthodeoxia syndrome: a rare complication following right pneumonectomy Ann Thorac Surg 2009;88:2018-2019.[Abstract/Free Full Text]
- Bellato V, Brusa S, Balazova J, Marescotti S, De Caria D, Bordone G. Platypnea-orthodeoxia syndrome in interatrial right to left shunt postpneumonectomy Minerva Anestesiol 2008;74:271-275.[Medline]
- Marini C, Miniati M, Ambrosino N, et al. Dyspnoea and hypoxaemia after lung surgery: the role of interatrial right-to-left shunt Eur Respir J 2006;28:174-181.[Abstract/Free Full Text]
- Godart F, Porte HL, Rey C, Lablanche JM, Wurtz A. Postpneumonectomy interatrial right-to-left shunt: successful percutaneous treatment Ann Thorac Surg 1997;64:834-836.[Abstract/Free Full Text]
- Welvaart WN, Becker A, Marcus JT, Vonk-Noordegraaf A, Oosterhuis JW, Paul MA. Unusual treatment of patent foramen ovale after pneumonectomy Eur Respir J 2010;35:929-931.[Free Full Text]