Shimizu Masato, Suzuki Makoto, Hashiyama Naoki, Sasano Tetsuo
Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan.
Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan.
J Cardiol Cases. 2024 May 3;30(2):43-46. doi: 10.1016/j.jccase.2024.04.009. eCollection 2024 Aug.
A 73-year-old female patient was diagnosed with lumbar spinal stenosis by an orthopedic surgeon. During admission for further evaluation, she was found to have hypoxemia. Contrast-enhanced computed tomography revealed a 43-mm ascending aortic aneurysm, but there were no signs of pulmonary embolism, and no abnormalities were detected in the lung fields. Upon initiating rehabilitation in the standing position, respiratory distress and hypoxemia worsened. Careful observation revealed that hypoxemia worsened in the seated position but normalized while lying down. We considered the possibility of platypnea-orthodeoxia syndrome (POS), in which hypoxemia worsens in the seated position. Transesophageal echocardiography revealed that a patent foramen ovale (PFO), which was hardly noticeable while lying down, worsened in the seated position. A pulmonary perfusion scan showed a 27 % right-to-left shunt. Cardiac catheterization confirmed the presence of right-to-left shunting during right atrial injection. Consequently, it was diagnosed that the ascending aortic aneurysm aggravated the PFO in the seated position, leading to POS. The PFO was unsuitable for transcatheter treatment. Consequently, the patient underwent direct closure surgery in the cardiac surgery department. Postoperatively, the patient's hypoxemia and respiratory distress in the seated position improved, and subsequent progress has been favorable.
Diagnosing platypnea-orthodeoxia syndrome in patients with poor activities of daily living (ADL) is challenging. Careful observation of the percutaneous oxygen saturation in both supine and seated positions is crucial, and a transesophageal echocardiogram in the supine and seated positions is inevitable. Lung perfusion scintigraphy is often used to evaluate the cause of hypoxemia; however, whole-body scans are important for detecting the presence and number of right-left shunts. This case report highlights the pitfalls of diagnosis in patients with poor ADL.
一名73岁女性患者被骨科医生诊断为腰椎管狭窄症。在入院进一步评估期间，发现她有低氧血症。增强计算机断层扫描显示升主动脉瘤直径为43毫米，但没有肺栓塞迹象，肺野未检测到异常。开始站立位康复训练后，呼吸窘迫和低氧血症加重。仔细观察发现，坐位时低氧血症加重，而卧位时恢复正常。我们考虑了平卧位呼吸困难 - 直立位低氧血症综合征（POS）的可能性，即坐位时低氧血症加重。经食管超声心动图显示，卧位时几乎不明显的卵圆孔未闭（PFO）在坐位时加重。肺灌注扫描显示右向左分流为27%。心导管检查证实右心房注射时存在右向左分流。因此，诊断为升主动脉瘤在坐位时加重了PFO，导致POS。该PFO不适合经导管治疗。因此，患者在心脏外科接受了直接闭合手术。术后，患者坐位时的低氧血症和呼吸窘迫得到改善，随后病情进展良好。
诊断日常生活活动能力（ADL）差的患者的平卧位呼吸困难 - 直立位低氧血症综合征具有挑战性。仔细观察仰卧位和坐位时的经皮血氧饱和度至关重要，仰卧位和坐位时的经食管超声心动图检查不可避免。肺灌注闪烁扫描常用于评估低氧血症的原因；然而，全身扫描对于检测左右分流的存在和数量很重要。本病例报告强调了ADL差的患者诊断中的陷阱。
