Platypnea-orthodeoxia syndrome following left pneumonectomy for early stage non-small cell lung cancer

Introduction

Lobectomy or pneumonectomy represents the treatment of choice for resectable early stage non-small cell lung cancer (NSCLC). The location of heart and great vessels, liver and spleen changes considerably following pneumonectomy as a consequence of mediastinal shift and elevation of the hemidiaphragm.

Presentation of case

A 70 years old gentleman developed acute shortness of breath two months after undergoing a left pneumonectomy for a pT2pN1M0 NSCLC, squamous cell carcinoma. His dyspnea and oxygen saturation worsened when sitting upright and immediately improved when he assumed the supine position, consistent with platypnea-orthodeoxia syndrome, and suggesting a potential inter-atrial right-to-left shunt. The presence of a patent foramen ovale (PFO) was documented by transoesophageal echocardiography. The patient underwent percutaneous closure of the PFO which markedly reduced the shunt, and led to resolution of symptoms.

Discussion

PFO is a common anomaly, found in approximately 25% of adults. Its presence is associated with increased risk of stroke from paradoxical emboli. Inter-atrial shunting after major thoracic surgery is a rare but clinically significant event. The case here reported was diagnosed following left pneumonectomy and to our knowledge, only two other single cases of PFO after left pneumonectomy have been reported in the literature so far.

Conclusion

A PFO should always be considered in the differentials for patients presenting with platypnea-orthodeoxia syndrome after lung surgery. Given the high risk of embolic stroke and high success rate of transcatheter percutaneous closure, these patients should be promptly referred for cardiac investigations and appropriate management.