Brief Communications

Platypnea–orthodeoxia syndrome combined withconstrictive pericarditis after coronary artery bypass
surgery
Masaki Hashimoto, MD, PhD, Yasuhide Okawa, MD, Hiroshi Baba, MD,Yoshiyuki Nishimura, MD, and Masakazu Aoki, MD, Toyohashi, Japan

Clinical Summary
A 61-year-old man presented with dyspnea 3 years after coronary
artery bypass surgery. He had multiple cerebral infarctions 1 year
after the operation. Because pulse oximetry was 92% in room airat his physician’s consultation, he started home oxygen therapy.
After 3 years, his dyspnea got worse. Redo work-up, including
ventilation/perfusion (V/Q) scanning and computed tomographic
scanning, was done. The result of the V/Q scan was normal. Computed tomographic scanning showed an abnormal cyst above theheart. The cyst contained liquid and showed a compressed rightatrium and right ventricular outflow (Figure 1). He consulted with
our institution to perform an extensive work-up.
Physical examination revealed a regular pulse, a blood pressureof 103/81 mm Hg, and no murmur in cardiac auscultation. Arterial
blood gas analysis in a sitting posture showed a PaO2 of 53.8 mm
Hg and a PaCO2 of 24.6 mm Hg with 15 L of oxygen supplementation by means of a face mask and a PaO2 of 63.2 mm Hg and aPaCO2 of 25.1 mm Hg in the supine position. Common blood countshowed polycythemia, with a hematocrit value of 52.4%. Chest
radiographic film showed any apparent pulmonary disease that
could be a cause of the dyspnea.
Electrocardiography revealed sinus rhythm and left atrial load.
Echocardiography was performed and revealed right atrial compression. Transesophageal echocardiography revealed an atrial
septal aneurysm and patent foramen ovale and a right-to-left shunt
through the foramen ovale. These shunts increased in a sittingposture.
Cardiac catheterization was performed and revealed a small
right-to-left shunt (27.3%). A small portion of blood flowed fromthe superior vena cava influx directly into the inferior vena cava.
Blood flowed from the inferior vena cava influx into the left atrium
through the foramen ovale. The previous bypass graft (ie, the leftinternal thoracic artery to the left anterior descending artery) waspatent. All of the right-sided intracardiac pressure measurements
were normal (Table 1).
From the Division of Cardiovascular Surgery, Toyohashi Heart Center,Toyohashi, Aichi, Japan.
Received for publication May 24, 2006; revisions received June 21, 2006;
accepted for publication July 12, 2006.
Address for reprints: Masaki Hashimoto, MD, PhD, Division of Cardiovascular Surgery, Toyohashi Heart Center, 21-1 Gobudori, Oyama-cho, Toyohashi, 4418530, Japan (E-mail: hashimoto@heart-center.or.jp).
J Thorac Cardiovasc Surg 2006;132:1225-60022-5223/$32.00
Copyright © 2006 by The American Association for Thoracic Surgery
doi:10.1016/j.jtcvs.2006.07.021

Surgical removal of the cyst
was performed. There were polytetrafluoroethylene* sheets surrounding the heart. There was a
cyst surrounding the right atrium
Dr Hashimotofrom the right side of the left
atrium to the right ventricle. The
cyst had a thick scar tissue andcontained 300 mL of old, black serous liquid. Just after opening
the cyst, the pulse oximetry improved, from 79% to 100%. The
right atriotomy was performed during ventricular fibrillation withcardiopulmonary bypass. There was a patent foramen ovale, andthe slit was closed in a continuous fashion. Because the rightventricle was covered with thick pericardium and expressed constrictive pericarditis, a complete pericardiectomy was performed.
The postoperative course was uneventful, and weaning frommechanical ventilation was quite easy. The patient could be withdrawn from oxygen supplementation and was discharged on postoperative day 15.

Discussion
Platypnea-orthodeoxia syndrome is infrequent, and the diagnosis
can be difficult. Cheng1 points out that two conditions must coexist
to cause this syndrome. One is an anatomic component in the formof an interarterial communication, and the other is a functional
component that produces a deformity in the atrial septal defect. In
this case the former component is patent foramen ovale and thelatter is the cyst above the heart and constrictive pericarditis.
Constrictive pericarditis and the cyst above the heart can be afunctional component of this syndrome but are rare in the literature.2,3 In this case two functional components coexisted, and it
was of concern in regard to selection of treatments. To close theshunt, some reports recommend transcatheter occlusion because itis less invasive.1 In this case constrictive pericarditis might also
contribute to the cause of this symptom, and therefore pericardiectomy was needed simultaneously. In addition, the pathology ofthe cyst was not unknown before treatment. These factors let us
choose a surgical repair. The cyst was formed from the hematoma
between a polytetrafluoroethylene sheet and the pericardium. One
possible explanation why our patient presented with this symptomis that distortion of the right atrium and right ventricle by the cyst
occurred, and as constrictive pericarditis was getting worse, herequired high filling pressure to maintain an adequate cardiac
output.4 With the patient in the upright position, the right ventricular preload diminished, resulting in decreased right-sided cardiac*Gore Preclude, registered trademark of W. L. Gore & Associates, Inc, Newark,Del.

The Journal of Thoracic and Cardiovascular Surgery ● Volume 132, Number 51225

Brief Communications

TABLE 1. Cardiac catheterization parameters (supine)
RAPAPCWLVLA
AoPressure, mm Hg (mean)

Oximetry (%)(5)
13/6 (9)(5)
70/edp 8(7)70/54 (61)73.9
75.6
95.4
86.2
92.8

RA, Right atrium; PA, pulmonary artery; PCW, pulmonary capillary wedge;
LV, left ventricle; edp, end-diastolic pressure; LA, left atrium; Ao, aorta.

infarctions and the characteristic pattern of occurrence of dyspnea,
and these suggested this syndrome. It is important to note thepattern of occurrence of dyspnea for accurate diagnosis.
Figure 1. Preoperative computed tomography revealed an abnormal cyst above the heart. The cyst compressed the right atrium
and right ventricular outflow.

output. As a result, there would be an increase in V/Q mismatch inzone I pulmonary circulation and increased dyspnea.
Although there is a high incidence of patent foramen ovale in
the general population (ie, autopsy studies indicate an incidence of27%), this kind of complication after surgical intervention isoccurring more frequently but is not being recognized because ofa lack of awareness.5 The patient has a history of multiple cerebral

References
1. Cheng TO. Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv. 1999;47:64-6.
2. Mashman WE, Silverman ME. Platypnea related to constrictive pericarditis. Chest. 1994;105:636-7.
3. Miller DC, Ricks W, Oyer PE, Cipriano PR, Shumway NE. Localized
tamponade of the right atrium and right ventricle: Induction of intracardiac right-to-left shunting after the use of a Gott shunt. Arch Surg.
1978;113:764-6.
4. Zanchetta M, Rigatelli G, Ho YS. A mystery featuring right-to-leftshunting despite normal intracardiac pressure. Chest. 2005;128:9981002.
5. Hussain SF, Mekan SF. Platypnea-orthodeoxia: report of two cases andreview of the literature. South Med J. 2004;97:657-62.

Against the odds: Long-term outcome of drastic-risk cardiac surgery
Serban Stoica, AFRCS, Hiremagalur Balaji, MRCS, Adel Helmy, MRCS, Jago Kitcat, BA, Carol Freeman, MSc,Linda Sharples, PhD, and Samer A. M. Nashef, FRCS, Cambridge, UKA

n average early mortality in low, single-percentage figures is now the norm in most cardiac surgical centers.
Nevertheless, the spectrum of risk for individual
patients is wide, and there are times when surgeons
are called on to perform operations in patients in a precarioussituation, for example, with associated comorbidity, an inherent
From the Papworth Hospital, Cambridge, United Kingdom.
Received for publication June 14, 2006; accepted for publication June 28,2006.
Address for reprints: Samer A. N. Nashef, FRCS, Consultant Cardiothoracic
Surgeon, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK(E-mail: Sam.Nashef@papworth.nhs.uk).

risk of complex surgery, or, commonly, both. Risk-assessment
models can help identify high-risk patients who require cardiac
surgery. Some studies report good results for patients who have a
protracted stay in the intensive care unit because of perioperative
problems, but the majority of such patients have an acceptable risk
to start with. Little is known about the long-term outcomes ofdrastic-risk cardiac surgery. Are such high-risk, resource-intensive
interventions worthwhile?
We sought to determine late survival and quality of life (QOL) inpatients undergoing cardiac surgery with a predicted risk of death
greater than 50% at the time of operation. Estimated mortality wascalculated using the logistic EuroSCORE because of its good trackrecord for accurately identifying high-risk cases.1

J Thorac Cardiovasc Surg 2006;132:1226-80022-5223/$32.00

Patients and Methods

Copyright © 2006 by The American Association for Thoracic Surgery

Ethical approval for the study was sought and obtained. Of 9971
consecutive patients who underwent cardiac surgery at Papworth
Hospital between 1998 and 2004, 142 (1.4%) had a logistic

doi:10.1016/j.jtcvs.2006.06.036

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The Journal of Thoracic and Cardiovascular Surgery ● November 2006