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Intracardiac Shunts

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.

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Intracardiac Shunts

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  1. Intracardiac Shunts

  2. 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

  3. 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

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

  5. 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

  6. 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

  7. 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

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

  9. 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

  10. 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

  11. 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

  12. Intracardiac Shunts • Incidence • Diagnosis

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

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