Intracardiac Shunts

History 28 y female Non smoker was seen in HSC ER 3 days of SOB , Cough , Fever SOB on minimal exertion with orthopnea No CP , PND , Leg swelling or pain Cough productive of minimal yellow sputum No hemoptysis

History Was assessed up north transferred because of hypoxemia & abnormal CXR No contact with TB or a sick person No pets , travel No Rx & NKA

History Known to Pulmonary HTN team 2002 Mixed connective tissue disease Erosive arthritis with +ve RF & ANA Intermittently on steroid & methotrexate No previous VTE

History Investigation back in 2002: PFT  moderate restrictive disease VC 1.8 liter severe reduction DLCO 6MWT severe desaturation low 80s walking distance 250m CT chest  cystic broncheactiasis RML Echo 2002 RVSP 85-90

History Heart Cath  N PCWP PAP 35 ! Quantitative VQ  RML &RLL minimal contribution 2 small unmatched defects Was on Bosentan for a short period taken off when she became pregnant Missed few clinic visits

Examination Respiratory Distress RR 24 Sat 91% on 15 liters O2 desaturation with minimal effort 80% HR 120 BP 120/60 Temp 37.8 JVP 9cm ASA giant V wave

Examination Chest minimal coarse crackles Rt lower1/3 S1+S2+0 P2 loud TR murmur Abd N LL edema minimal No DVT signs

Investigation CBC WBC N mild Lt shift Hb & Plt N ABG on RA PH 7.42 PAO2 35 PCO2 30 HCO3 24 BUN Creat & Lytes N CXR & CT chest

Hospital Course Admitted under Medicine isolation Abx Cefotaxime & clinda Seen by Chest medicine Hypoxemia out of proportion to radiological finding  ? Intracardiac shunt Echo RVSP 90 severe RV dysfunction Rt to Lt shunt LV N

Hospital Course No improvement on Abx 3 Sputum AFB –ve Signs of respiratory fatigue Transferred to MICU  Rt Heart Cath PAP 90/40  20/50 in 2002 CO 4.2 CI 2.7 PVRI 550 IV Flolan started  PAP decreased 45 Patient improved Sent to H6

Intracardiac Shunts Incidence Diagnosis

Intracardiac Shunts Retrospective study 18863 Jan 1999  June 2002 430 with TIA or CVA , rest control PFO incidence 24% in CVA group 5% in control group Italian Heart Journal 2003

Intracardiac Shunts 126 patients for Lung Tx work up Different groups IPF , PPH , COPD & congenital heart disease Perfusion scan with macro-aggregated albumin Compared to heart catheterization Respiratory Med May 2003

Intracardiac Shunts with PAP <50 mm Hg No evidence of Rt Lt shunt With PAP >50 mm Hg 40% +ve shunt Renal images had false +ve uptake Brain images didn’t have

Intracardiac Shunts 81 patients were evaluated by transcranial doppler US TCD Transosophageal echo was gold standard Comparing 2 contrast in finding Rt Lt shunt Saline Vs echovist Stroke sep 2002

Intracardiac Shunts 31 patients had +ve RtLt shunt Echvist TCD had 100% sensitivity Saline TCD had 88% sensitivity ?TCD with echovist is an alternative to TEE