Platypnea Orthodeoxia Due to a Patent Foramen Ovale and Intrapulmonary Shunting After Severe COVID-19 Pneumonia

Abstract

Patient: Male, 85-year-old Final Diagnosis: Platypnea orthodeoxia Symptoms: Dyspnea • orthostatic intolerance Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Unusual clinical course Background: Platypnea orthodeoxia syndrome (POS) presents with positional dyspnea and hypoxemia defined as arterial desaturation of at least 5% or a drop in PaO2 of at least 4 mmHg. Causes of POS include a variety of cardiopulmonary etiologies and has been reported in patients recovering from severe COVID-19 pneumonia. However, clinical presentation and outcomes in a patient with multiple interrelated mechanisms of shunting has not been documented. Case Report: An 85-year-old man hospitalized for hypertensive emergency and severe COVID-19 pneumonia was diagnosed with platypnea orthodeoxia on day 28 of illness. During his disease course, the patient required supplemental oxygen by high-flow nasal cannula but never required invasive mechanical ventilation. Chest imaging revealed evolving mixed consolidation and ground-glass opacities with a patchy and diffuse distribution, involving most of the left lung. Echocardiography was ordered to evaluate for intracardiac shunt, which revealed a patent foramen ovale. Closure of the patent foramen ovale was not pursued. Management included graded progression to standing and supplemental oxygen increases when upright. The patient was discharged to a skilled nursing facility and his positional oxygen requirement resolved on approximately day 78. Conclusions: The present case highlights the multiple interrelated mechanisms of shunting in patients with COVID-related lung disease and a patent foramen ovale. Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known patent foramen ovale. In patients with persistent positional oxygen requirements at follow-up, quantifying shunt fraction over time through multiple modalities can guide treatment decisions.

Acute respiratory distress syndrome and shunt detection with bubble studies: a systematic review and meta-analysis

“…nitric oxide, epoprostenol) which would exacerbate hypoxemia; (2) careful titration of PEEP and ventilator settings to prevent dilation of pulmonary vessels, while preventing shunt from atelectasis from occurring; (3) reducing underlying cause of inflammation/infection, which led to the pulmonary vasodilation originally (e.g. corticosteroids in COVID-19 shunt) (7, 24, 34). Given these nuances, optimal conservative, non-procedural management of intra-cardiac vs. intra-pulmonary shunts is required.…”

Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study

“…In contrast, intracardiac shunt management should lower right-sided heart pressures to prevent further shunting through an intra-atrial septum defect (e.g., PFO or ASD). Treatments include: 1) pulmonary vasodilators (e.g., inhaled nitric oxide, epoprostenol) and/or inodilators (e.g., milrinone, dobutamine) through reducing RV afterload and improving RV function (23, 27, 28); 2) lowering ventilator settings (e.g., PEEP, plateau pressures) (23, 27, 28); 3) closure or repair of an intraseptal defects (PFO, ASD) to prevent further R-L shunting (23, 27, 28); and 4) diuresis to offload RV volume overload (23, 27, 28). Regardless, diagnosing shunt in ARDS patients starts with high suspicion and prompt diagnosis.…”

Platypnea-Orthodeoxia Syndrome in Coronavirus Disease 2019 Pneumonia: A Case Report and Literature Review

“…Ultimately, we found 17 reports on 22 patients with POS associated with COVID-19 (Table 1). Regarding the presence of cardiac shunting, foramen ovale patency was found in three cases [5][6][7] and absent in 13 cases, [8][9][10][11][12][13][14][15][16][17][18] while no echocardiographic results were mentioned in the remaining three reports. [19][20][21] Most cases required respiratory support with high-volume oxygen, noninvasive ventilation, or invasive mechanical ventilation.…”