A rare post-lobectomy complication of right-to-left shunt via foramen ovale
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CASE REPORT
A rare post‑lobectomy complication of right‑to‑left shunt via foramen ovale Nobuaki Arai1 · Riken Kawachi2 · Yoko Nakazato1 · Keisei Tachibana1 · Yasushi Nagashima1 · Ryota Tanaka1 · Kazuma Okamoto3 · Haruhiko Kondo1 Received: 9 August 2019 / Accepted: 21 October 2019 © The Japanese Association for Thoracic Surgery 2019
Abstract Background Various complications can cause hypoxemia after pulmonary resection for lung cancer, but intracardiac shunt that becomes symptomatic and causes severe hypoxemia postoperatively is very rare. We report a case that presented platypnea-orthodeoxia syndrome (POS) due to right-to-left shunt via patent foramen ovale (PFO). Case A 71-year-old man with a lung cancer in the left upper lobe was referred to our hospital. Left upper lobectomy was performed. Dyspnea developed postoperatively, which was worsened by sitting or standing and relieved in a recumbent position. Contrast transesophageal echocardiogram (TEE) and right intracardiac catheterization revealed a right-to-left shunt via PFO. Open-heart closure of PFO was performed and the patient was free from POS. Conclusions Postoperative intracardiac shunt via PFO can cause severe hypoxemia after lung resection. POS suggests the possibility of intracardiac shunt and careful observation is needed. Keywords Platypnea-orthodeoxia syndrome · Lung cancer · Complication · Intracardiac shunt · Patent foramen ovale
Case A 71-year-old man with a lung cancer in the left upper lobe was referred to our hospital. His preoperative respiratory and circulatory conditions were normal. Left upper lobectomy and systematic lymph node dissection were performed under posterolateral thoracotomy. The histological diagnosis was adenocarcinoma (pT3N0M0, Stage IIB). Dyspnea developed on the second operative day (POD) and progressed. Dyspnea deteriorated in a sitting or standing position ( SpO2 80%) and was relieved in a recumbent position ( SpO2 98%), which suggested platypnea-orthodeoxia syndrome (POS). * Riken Kawachi kawachi.riken@nihon‑u.ac.jp 1
Department of General Thoracic Surgery, Kyorin University School of Medicine, 6‑20‑2 shinkawa, Mitaka, Tokyo 181‑8611, Japan
2
Department of Respiratory Surgery, Nihon University School of Medicine, 30‑1 Oyaguchi‑Kamicho, Itabashi, Tokyo 173‑8610, Japan
3
Department of Cardiovascular Surgery, Akashi Medical Center, 743‑33 okubocho‑yagi, Akashi, Hyogo 674‑0063, Japan
Eventually, he could not stand up even under oxygenation on 15 POD. Chest X-ray, enhanced chest CT scan and 99m Tc-perfusion lung scintigraphy did not detect any likely causes. The cardiac chambers were rotated clockwise and consequently the right ventricle was wide in contact with the anterior chest wall postoperatively in enhanced chest CT (Fig. 1). A contrast transesophageal echocardiogram (TEE) clearly showed an interatrial right-to-left shunt via PFO, and microbubbles in the left atrium increased with Valsalva maneuver during an agitated saline contrast imaging (Fig. 2). Right cardiac catheterization revealed O2 s
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