Abstract

We report a case of platypnea-orthodeoxia syndrome resulting from multiple inter-atrial communications with right-toleft
shunting in a 73 year old woman. Our patient presented with progressive shortness of breath over the last eighteen
months. She was on 10 liters of high flow oxygen at time of presentation to our hospital and was bed bound owing to
severe dyspnea. Her history of chronic pulmonary emboli despite therapeutic coumadin levels and ulcerative colitis
initially led to an exhaustive hepatopulmonary work-up. On clinical exam, she was noted to have normal oxygen
saturation with lying down, but with sitting up or walking she developed significant hypoxia and respiratory distress.
With no evidence of lung parenchymal or vascular diseases, right heart catheterization was performed and revealed
normal right sided pressures. Intracardiac echocardiography confirmed a typical appearing patent foramen ovale (PFO)
with atrial septal aneurysm and bidirectional shunting, and a small inferior secundum atrial septal defect (ASD).
Although the ASD was congenital, aortic dilation with ageing could have altered the location of the atrial septum
which facilitated laminar blood flow from the inferior vena cava to the left atrium. We proceeded to close both defects
with an Amplatzer Cribiform Occluder. Her symptoms dramatically improved 48 hours following closure and she was
ambulating on room air at time of discharge. One month follow-up was notable for no recurrence of symptoms. PFOs
and small ASDs are generally innocuous but could cause right to left shunting even in the absence of elevated right
sided pressures. Excluding other causes of platypnea-orthodeoxia, and closing the atrial communications can lead to
resolution of symptoms.

Key words: Multiple Atrial Communications, Platypnea-Orthodeoxia Syndrome.