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• W4387249780 abstract "SESSION TITLE: Cardiovascular Disease Case Report Posters 5 SESSION TYPE: Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Right-to-left shunt (RLS) is an important cause of refractory hypoxemia as it allows the passage of deoxygenated venous blood into the arterial system [1]. RLS can be anatomic (intracardiac and intrapulmonary) or physiologic. Intracardiac RLS can present with platypnea–orthodeoxia syndrome (POS) which is characterized by dyspnea and hypoxemia, accentuated by standing or sitting positions and minimized when supine [1]. We present a case of intracardiac RLS with POS manifesting during dialysis. CASE PRESENTATION: A 60-year-old woman with end-stage renal disease was hospitalized for syncope and acute hypoxemia during dialysis. She reported recent episodic oxygen desaturation at the home of 73-88% on room air. Bilateral pulmonary emboli (PE) were seen on CT scan and transthoracic echocardiogram (TTE) was normal. Discharged on apixaban and oxygen, she was readmitted the next month for self-limited dialysis-related hypoxemia, dyspnea, and altered mentation. Admitted again several weeks later with severe desaturation during dialysis, a PaO2 of 48 mm Hg was seen on 100% facemask oxygen. Resolving PE was seen on CT scan with no new findings. TTE showed a right atrial mass near the jugular Ash Split dialysis catheter tip without right ventricular strain. O2 saturation on 8 liters of nasal oxygen declined from 92% supine to 74% standing with marked platypnea and PaO2 42 mm/Hg. TTE with bubble contrast revealed a large atrial RLS (image 1). Transesophageal echocardiography found a 3x3 cm right atrial mass prolapsing across the tricuspid valve and impeding flow, with an aneurysmal interatrial septum (images 1 and 2). Surgical excision of the mass (image 3) from the atrial free wall and repair of a secundum atrial septal defect (ASD) eliminated the RLS. Pathology found the mass to be a large, organized thrombus. She was discharged with no supplemental oxygen. DISCUSSION: Intracardiac RLS can be seen in patients with patent foramen ovale (PFO) and less often with ASD2. RLS typically occurs when the right atrial pressure is higher than the left atrial pressure as in Eisenmenger's physiology. RLS with normal atrial pressures can occur by altered venous flow directed at a PFO after pneumonectomy or in similar conditions of altered atrial anatomy [2]. Also, a case of RLS attributed to venous flow changes caused by right atrial thrombus was described [3]. However, in our case, we believe that decreased preload in the right atrium caused by standing or during dialysis resulted in worsening obstruction of the tricuspid valve by thrombus, causing accentuated RLS through the ASD. This variable obstruction explains many of the transient phenomena seen in this case as well as the prominent role dialysis played in the patient's presentation. CONCLUSIONS: Anatomical shunt should be considered in refractory hypoxemia cases, with TTE with contrast as the best initial test. RLS can occur in the setting of normal atrial pressures by several mechanisms. REFERENCE #1: De Vecchis R, Baldi C, Ariano C. Platypnea-Orthodeoxia Syndrome: Multiple Pathophysiological Interpretations of a Clinical Picture Primarily Consisting of Orthostatic Dyspnea. J Clin Med. 2016 Sep 23;5(10):85. doi: 10.3390/jcm5100085. Retraction in: J Clin Med. 2021 Feb 22;10(4): PMID: 27669319; PMCID: PMC5086587. REFERENCE #2: Ghamande S, Ramsey R, Rhodes JF, Stoller JK. Right hemidiaphragmatic elevation with a right-to-left interatrial shunt through a patent foramen ovale: a case report and literature review. Chest. 2001 Dec;120(6):2094-6. doi: 10.1378/chest.120.6.2094. PMID: 11742944. REFERENCE #3: Vargas-Beal F, Coulter SA, Yendamuri S, Contreras A, Duncan JM. Right-to-left interatrial shunt with hypoxemia caused by a right atrial thrombus. Tex Heart Inst J. 2007;34(2):225-9. PMID: 17622375; PMCID: PMC1894698. DISCLOSURES: No relevant relationships by Rami Dalbah No relevant relationships by Jack Malone III No relevant relationships by Roger McSharry" @default.
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• W4387249780 date "2023-10-01" @default.
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• W4387249780 title "AN UNUSUAL CAUSE OF HYPOXEMIA DURING DIALYSIS" @default.
• W4387249780 doi "https://doi.org/10.1016/j.chest.2023.07.406" @default.
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