Hypoxia, platypnea orthodeoxia and transient ischemic attacks in a patient

1. Valleggi A, Poletti R, Gabutti A, Barison A, Mammini C, Chiappino S,
Spadoni L, Passino C, Emdin M.
Cardiovascular Medicine Div., Fondazione G. Monasterio CNR – Regione Toscana, Pisa; Scuola
Superiore Sant'Anna, Pisa, Italy
Hypoxia, platypnea-orthodeoxia and transient ischemic
attack in a patient with carcinoid heart disease and patent
foramen ovale corrected by closure
Authors have no conflict of interest to disclose

2. At Admission:
43 y.o. Man, no CV risk factors
Dyspnoea (NYHA II), fatigue, flushing,
diaphoresis and diarrhoea (symptoms
begun 4 months before)
A chest CT before admission did not
demonstrate any thoracic or pulmonary
disease
ECG
Phisical examination:
- Jugular venous distension
- 3/6 L holosystolic murmur at the lift
sternal border, radiating to the right sternal
border
- Hepatomegaly
Chest X-ray
Enlargement of right sections. No signs
of intraparenchimal lesions

3. Routine blood analyses:
eGFR 73 ml/min/2.15m2
TnI 0.01 ng/ml
NT-proBNP 997 ng/L
PRA < 0.20 ng/ml/h
LDH 630 IU/L
GOT (67 UI/L) GPT (160 UI/L)
Echo 4-chambers view
- Massive tricuspid
regurgitation (TR)
- RV enlargement and
systolic dysfunction
- Signal void due to
massive TR
- D-shaped LV
Cardiac MRI cine sequences
Carcinoid syndrome ?

4. Medical therapy with BB (bisoprolol) and diuretics
(furosemide) to obtain stable hemodinamic balance
Specific assays:
Serum serotonin 6250 ng/ml
Urinary serotonin 2367 mcg/24h
Serum chromogranin A 2752 ng/ml
15-fold increased serum serotonin
9-fold increased urinary serotonin
27-fold increased in chromogranin A
Primitive lesion located at ileum and with
metastatic diffusions at liver
Octreoscan: SPECT/CT
Diagnosis of carcinoid
syndrome confirmed
- Oncologist evaluation
- 5 weeks after discharge surgical resection of
ileum and hepatic metastasis

5. After Surgery...
- Left hemiparesis with recent brain
ischemic lesions at CT scan
- Worsening dyspnoea
- Platypnea-orthodeoxia with severe
hypoxemia not corrected by O2
Readmission
to our Institute
Arterial gasanalysis
pH 7.42, pO2 53 mmHg
pCO2 20 mmHg, O2 Sat 85%
Diagnosis of Patent Foramen
Ovale (PFO) at TT and TE
echocardiography with significant
right to left shunt confirmed by
CMR imaging
Septal occluder Amplatzer
- Normalization of arterial gasanalysis
- Improvement of dyspnoea and exercise tollerance
- NT-proBNP values
FOLLOW-UP
- No readmission in hospital for worsening dyspnoea
or TIA
- Good exercise tolerance
- Periodic follow-up of hepatic lesions

6. Thank you for attention
valleggi@ftgm.it