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 PAO2 35
PCO 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 CI 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