49. Case Report: Platypnea-Orthodeoxia secondary to a PFO Allegheny Health Network
CardioNerds\xa0(Amit Goyal\xa0&\xa0Daniel Ambinder)\xa0 join Allegheny Health Network cardiology fellows (Adnan Khalif, Mahathi\xa0Indaram, Kushani Gajjar, and Michael\xa0Nestasie) for a lovely Pittsburgh hike and discuss a fascinating case of platypnea-orthodeoxia secondary to a PFO. Dr. Farhan Katchi provides the E-CPR and Program director\xa0Dr. Craig Alpert\xa0provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.\xa0\n\n\n\n\n\nJump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team\n\n\n\nEpisode graphic by Dr. Carine Hamo\n\n\n\n\n\n\n\nThe\xa0CardioNerds Cardiology Case Reports\xa0series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an\xa0\u201cExpert CardioNerd Perspectives & Review\u201d (E-CPR)\xa0for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.\n\n\n\nWe are teaming up with the\xa0ACC FIT Section\xa0to use the\xa0#CNCR episodes\xa0to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an\xa0E-CPR\xa0segment and a message from the program director.\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza\n\n\n\n\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nA 64 y/o female with a\xa0history of venous and arterial embolism on anticoagulation, known\xa0PFO, and obesity presented after a fall. There was no loss consciousness, pre-syncopal symptoms, chest pain, aura, weakness, or palpitations. She had no recent preceding illness. When she arrived in the ED she was hypoxic to 87% on ambulation on room air and required 4L of nasal cannula O2 supplementation. The AGH\xa0CardioNerds\xa0were consulted!\xa0\xa0\n\n\n\nOn examination, the team noted that upon sitting up the patient would desaturate to the mid 80%\xa0but when lying down oxygen saturation would improve to 95%! Her ECG demonstrated a RBBB and no acute ST-T changes. TTE was obtained and showed normal LV and RV function and size, no valvular disease, and a likely PFO\xa0on an agitated saline study.\xa0Cardiac\xa0MRI revealed mild RV hypertrophy and\xa0Qp:Qs\xa0of 0.8\xa0(right/pulm\xa0cardiac output < left/systemic cardiac output, indicating right to left shunting).\xa0\xa0RHC showed normal right-sided pressures.\xa0A right\xa0femoral vein\xa0bubble study\xa0 was done showing\xa0torrential\xa0right to left shunting! She underwent PFO closure and her\xa0platypnea-orthodexia\xa0resolved;\xa0she was discharged on room air.\xa0\n\n\n\n\n\n\n\n\nCase Media\n\n\n\n\n\n\n\n\n\n\n\n\nEpisode Schematics & Teaching\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nThe CardioNerds 5! \u2013 5 major takeaways from the #CNCR case\n\n\n\nPlatypnea-orthodeoxia syndrome\xa0(POS)\xa0is when dyspnea (Platypnea) and hypoxia (Orthodeoxia) are present in the upright position, but improve upon lying flat.\xa0One cause is ARLIAS, or Acute Right-to-Left Inter-Atrial Shunting, which\xa0requires an anatomic component (I.e., ASD or PFO)\xa0and\xa0a functional component (I.e., PH, PE, RV failure) for Right-to-Left shunting to occur\xa0A PFO, or patent foramen ovale\xa0is a\xa0common congenital defect and typically will not lead to hypoxia unless there is right to left shunting. Typically flow is left to right due to an LA to RA pressure gradient and lower compliance of the RV.\xa0\xa0Remember when evaluating for a PFO with\xa0agitated saline, the timing of the appearance of bubbles is important!\xa0\xa0Early appearance of bubbles (seen in less than...