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Dyspnea, worse when upright than when recumbent
    Differential Diagnosis[Top] [Nav]
shunting of blood (as seen in pulmonary, cardiac, or hepatic disease)
    Discussion -- not available online[Top] [Nav]
    Update Comments[Top] [Nav]
  • After cardiac surgery, a 73 year old man developed cardiac tamponade localized to the right atrium, probably due to localized pericardial inflammation. This raised right atrial pressure and caused right-to-left shunting across a patent foramen ovale.
       Such cases may be hard to detect clinically without a detailed physical examination. In this case report, for example, the patient had a mean right atrial pressure of 12 cm H2O in the cath lab, yet had "no jugular venous distension." These findings are at odds with each other. Please remember to examine carefully the neck veins. [101]
  • This case report doesn't even include a description of the physical examination! With that caveat, this paper describes a 64 year old man who developed orthodeoxia and platypnea after cardiac surgery. Echocardiogram showed extrinsic compression of the right atrium and ventricle by a loculated pericardial effusion, plus right-to-left flow across the inter-atrial septum. Of note, however, the mean right atrial pressure was 10 and the mean left atrial pressure was 9 (as measured by the pulmonary capillary wedge pressure). In the absence of a right-to-left pressure gradient, the authors hypothesize that distortion of the right heart effectively aimed the effluent of the inferior vena cava directly at the foramen ovale when the patient was upright, causing shunting only in that position. The shunting stopped after the effusion resolved. [102]
  • Another case of distorted cardiac anatomy leading, probably, to redirection of atrial inflow across a patent foramen ovale. [103]
  • A persistent eustachian valve in the right atrium can cause right-to-left inter-atrial shunting in the presence of normal atrial pressures. [104]
  • Found, in one patient, that a single bolus of methylene blue reduces pulmonary shunting in liver disease. Methylene blue blocks the vasodilatory effect of nitric oxide. [107]
    Footnotes in Print Edition[Top] [Nav]
    (1a) Platypnea-orthodeoxia: clinical profile, diagnostic workup, management, and report of seven cases.
  Seward JB, Hayes DL, et al.   Mayo Clin Proc 1984 Apr;59(4):221-31.  Pubmed+Abstract  Similars
    (1b) Gravity, posture, and cardiopulmonary function [editorial].
  Rehder K, Marsh HM.   Mayo Clin Proc 1984 Apr;59(4):280-1.  Pubmed  Similars
    (2) Pulmonary arteriovenous fistulas.
  Dines DE, Seward JB, et al.   Mayo Clin Proc 1983 Mar;58(3):176-81.  Pubmed+Abstract  Similars
    (3) Severe hypoxemia associated with liver disease: Mayo Clinic experience and the experimental use of almitrine bismesylate.
  Krowka MJ, Cortese DA.   Mayo Clin Proc 1987 Mar;62(3):164-73.  Pubmed+Abstract  Similars
    (-) Heart Disease. 3rd ed.
  Braunwald E, et al. Philadelphia: Saunders, 1988: 3, 1877.   Amazon.com
    New References[Top] [Nav]

Intracardiac shunting
    101.Intracardiac right-to-left shunting following cardiac surgery.
  Klepper JI, Seifert F, et al.   Am Heart J 1988 Jul;116(1 Pt 1):189-92.  Pubmed  Similars
    102.Reversible orthodeoxia and platypnea due to right-to-left intracardiac shunting related to pericardial effusion [see comments].
  Adolph EA, Lacy WO, et al.   Ann Intern Med 1992 Jan 15;116(2):138-9.  Pubmed  Similars
    103.Eosinophilic endomyocardial disease presenting as cyanosis, platypnea, and orthodeoxia [see comments].
  Wright RS, Simari RD, et al.   Ann Intern Med 1992 Sep 15;117(6):482-3.  Pubmed  Similars
    104.Persistent Eustachian valve causing severe cyanosis in atrial septal defect with normal right heart pressures.
  Bashour T, Kabbani S, et al.   Angiology 1983 Feb;34(2):79-83.  Pubmed  Similars

Heaptopulmonary syndrome
    105.Hepatopulmonary syndrome with progressive hypoxemia as an indication for liver transplantation: case reports and literature review.
  Krowka MJ, Porayko MK, et al.   Mayo Clin Proc 1997 Jan;72(1):44-53.  Pubmed+Abstract  Similars
    106.The hepatopulmonary syndrome [see comments].
  Lange PA, Stoller JK.   Ann Intern Med 1995 Apr 1;122(7):521-9.  Pubmed+Abstract  Similars
    107.Methylene blue in the hepatopulmonary syndrome [letter].
  Rolla G, Bucca C, et al.   N Engl J Med 1994 Oct 20;331(16):1098.  Pubmed  Similars

Older references
    108.Orthodeoxia: a new finding in interstitial fibrosis.
  Tenholder MF, Russell MD, et al.   Am Rev Respir Dis 1987 Jul;136(1):170-3.  Pubmed+Abstract  Similars
    109.Platypnea related to orthodeoxia caused by true vascular lung shunts.
  Robin ED, Laman D, et al.   N Engl J Med 1976 Apr 22;294(17):941-3.  Pubmed  Similars
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    ©1986-2000 John Sotos, MD. All rights reserved.  Last updated 16:34 PDT on July 4, 2000.[Top]

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