A case of platypnoea orthodeoxia following Laproscopic Cholecystectomy

Abstract

Platypnoea Orthodeoxia syndrome is defined by dyspnoea and hypoxaemia exacerbated by orthostatic positioning and alleviated in recumbency. This condition has been reported in association with pulmonary, hepatic and cardiac disease. We describe a case herein of a 79 year old female who developed severe hypoxaemia and dyspnoea post laparoscopic cholecystectomy. A difference in arterial blood gas oxygen tension was demonstrated in the supine and erect positions on arterial blood gas analysis. A Patent Foramen Ovale (PFO) with a right to left shunt was evident on echocardiogram employing colour doppler and agitated normal saline studies. Definitive management, with closure of the patent foramen ovale lead to a complete resolution of symptoms and normalisation of arterial blood gas parameters in both the supine and erect positions.

Platypnoea–orthodeoxia after left total knee replacement

“…PFO is thought to be present in 25% of the population; however, clinically significant right-to-left shunting is rare and requires raised right atrial pressure 3. Riddles et al 4 reported a case of POS following laparoscopic cholecystectomy. Other case studies also indicate that surgery is a common precipitant for the development of POS 5–8.…”

“…Possible explanations for mechanisms that maintain postoperative right-to-left shunting remain speculative. Riddles et al 4 suggested that ‘a common postoperative complication of atelectasis may increase pulmonary vascular resistance and cause a V/Q mismatch’. While the patient in the present case study had left lower lobe atelectasis, it is unlikely to be the only explanation.…”

“…While the patient in the present case study had left lower lobe atelectasis, it is unlikely to be the only explanation. Literature describing POS is scarce outside the realm of intra-abdominal or intrathoracic surgery where surgery has been deemed the precipitant 4 8. The proposed mechanism in abdominal laparoscopic surgeries involved stretching of the interatrial septum, resulting from the dilated aortic root; upright positioning accentuated this stretching, with possible compression on the right atrium 7.…”

“…Our patient had a stable 4.5 cm ascending aorta aneurysm and an aortic root of 35 mm, with the presence of PFO, which represented the anatomical component. Advanced age represents an added risk factor7 which may be due to a decline in connective tissue compliance, leading to postoperative anatomical distortion, as well as a change in the cardiac axis leading to a change in shunting 4…”

Persistent pathology of the patent foramen ovale: a review of the literature

“…There have been multiple case reports of hypoxaemia due to acquired right-to-left shunts in patients with a PFO following thoracic or laparoscopic abdominal surgery. 43,44 While not completely understood, patients who develop unexplained hypoxaemia after the operation should be considered for a transthoracic echocardiogram and bubble study to assess for PFOs.…”