SHM Converge Scientific Abstract ePoster Gallery-Platypnea-Orthodeoxia Syndrome Due to Patent Foramen Ovale

Pdf Summary

This case report describes platypnea-orthodeoxia syndrome (POS) caused by a patent foramen ovale (PFO) in an 86-year-old man with stroke history and metastatic renal cell carcinoma. He presented with severe hypoxemia that worsened when upright and improved when supine, along with orthostatic hypotension. Imaging and echocardiography confirmed a right-to-left intracardiac shunt through a PFO, likely associated with an atrial septal aneurysm.<br /><br />Because the patient had active bleeding from metastatic disease, percutaneous PFO closure was considered too risky. Instead, clinicians treated him with oral midodrine, a vasoconstrictor thought to increase left atrial pressure and reduce shunting. Midodrine at 5 mg three times daily partially helped, and increasing it to 10 mg three times daily resolved orthodeoxia. His oxygen saturation improved significantly when upright.<br /><br />Later, cancer treatment with cabozantinib caused severe hypertension, forcing midodrine to be stopped. As a result, the patient’s orthodeoxia returned. Symptoms improved again when midodrine was restarted, but controlling blood pressure became difficult. Eight months after the initial presentation, the patient underwent percutaneous PFO closure to allow continued cancer therapy. The procedure was successful, with only trivial residual shunting, and his orthodeoxia resolved. Midodrine was discontinued five weeks later.<br /><br />The authors note that POS due to PFO is rare and usually treated with closure, which is generally the standard of care. This is only the second reported case using midodrine for this condition. The report suggests midodrine may be a useful temporary or alternative treatment for patients who are not good candidates for closure, though more research is needed to assess long-term safety and effectiveness.

Asset Subtitle

Philip Speigel

Meta Tag

Author List Gavin M. Sowa, Katherine McGee, Nausheen Akhter, Philip Speigel, Remy Bremner

Category Clinical Vignettes

Concept Platypnea-Orthodeoxia Syndrome

Concept Patent Foramen Ovale

Concept Right-to-Left Shunt

Concept Positional Hypoxemia

Concept Echocardiography

Distinguished Finalist

Presenter Organization Division of Hospital Medicine, Northwestern University Feinberg School of Medicine

Presenting Author Philip Speigel

Track Adult

Keywords

platypnea-orthodeoxia syndrome

patent foramen ovale

right-to-left shunt

orthodeoxia

midodrine

hypoxemia

atrial septal aneurysm

percutaneous PFO closure

metastatic renal cell carcinoma

orthostatic hypotension

Platypnea-Orthodeoxia Syndrome

Patent Foramen Ovale

Right-to-Left Shunt

Positional Hypoxemia

Echocardiography