Intracardiac platypnea–orthodeoxia syndrome diagnosed by forward-bending and abdominal compression

2021 ◽  
Vol 14 (7) ◽  
pp. e242719
Author(s):  
Ryo Kitamura ◽  
Satoshi Yoshikawa ◽  
Takeshi Ueda
Keyword(s):  
Venous Return ◽  
Pathological Condition ◽  
Right Atrial ◽  
Valsalva Manoeuvre ◽  
Sitting Position ◽  
Foramen Ovale ◽  
Abdominal Compression ◽  
Shunt Volume ◽  
Forward Bending ◽  
The Right

Intracardiac platypnea–orthodeoxia syndrome (POS) is a pathological condition that leads to a reduction in oxygenation in the sitting position. The detection rate of patent foramen ovale that causes POS increases with Valsalva manoeuvre and cough. We report the case of a 92-year-old woman with POS, which could not be diagnosed in the sitting position. The Valsalva manoeuvre could not be performed because of dementia, and POS was diagnosed on the forward-bending position and abdominal compression. It was assumed that forward-bending increases the right atrial pressure by compressing the right ventricle along with elongation of the aorta, and abdominal compression increases the shunt volume by increasing the venous return. If POS is suspected in patients with dementia which cannot be diagnosed in the sitting position, forward-bending and abdominal compression, instead of the Valsalva manoeuvre, might be useful.

scholarly journals Effect of PEEP, blood volume, and inspiratory hold maneuvers on venous return

2016 ◽  
Vol 311 (3) ◽  
pp. H794-H806 ◽  
Author(s):  
David Berger ◽  
Per W. Moller ◽  
Alberto Weber ◽  
Andreas Bloch ◽  
Stefan Bloechlinger ◽  
...  
Keyword(s):  
Blood Volume ◽  
Venous Return ◽  
Vena Cava ◽  
Balloon Occlusion ◽  
Right Atrial ◽  
Airway Occlusion ◽  
Volume State ◽  
The Right ◽  
Induced Changes ◽  
Artery Flow

According to Guyton's model of circulation, mean systemic filling pressure (MSFP), right atrial pressure (RAP), and resistance to venous return (RVR) determine venous return. MSFP has been estimated from inspiratory hold-induced changes in RAP and blood flow. We studied the effect of positive end-expiratory pressure (PEEP) and blood volume on venous return and MSFP in pigs. MSFP was measured by balloon occlusion of the right atrium (MSFPRAO), and the MSFP obtained via extrapolation of pressure-flow relationships with airway occlusion (MSFPinsp_hold) was extrapolated from RAP/pulmonary artery flow (QPA) relationships during inspiratory holds at PEEP 5 and 10 cmH2O, after bleeding, and in hypervolemia. MSFPRAO increased with PEEP [PEEP 5, 12.9 (SD 2.5) mmHg; PEEP 10, 14.0 (SD 2.6) mmHg, P = 0.002] without change in QPA [2.75 (SD 0.43) vs. 2.56 (SD 0.45) l/min, P = 0.094]. MSFPRAO decreased after bleeding and increased in hypervolemia [10.8 (SD 2.2) and 16.4 (SD 3.0) mmHg, respectively, P < 0.001], with parallel changes in QPA. Neither PEEP nor volume state altered RVR ( P = 0.489). MSFPinsp_hold overestimated MSFPRAO [16.5 (SD 5.8) vs. 13.6 (SD 3.2) mmHg, P = 0.001; mean difference 3.0 (SD 5.1) mmHg]. Inspiratory holds shifted the RAP/QPA relationship rightward in euvolemia because inferior vena cava flow (QIVC) recovered early after an inspiratory hold nadir. The QIVC nadir was lowest after bleeding [36% (SD 24%) of preinspiratory hold at 15 cmH2O inspiratory pressure], and the QIVC recovery was most complete at the lowest inspiratory pressures independent of volume state [range from 80% (SD 7%) after bleeding to 103% (SD 8%) at PEEP 10 cmH2O of QIVC before inspiratory hold]. The QIVC recovery thus defends venous return, possibly via hepatosplanchnic vascular waterfall.

scholarly journals Effect of body position and oxygen tension on foramen ovale recruitment

2015 ◽  
Vol 308 (1) ◽  
pp. R28-R33 ◽  
Author(s):  
Kayla L. Moses ◽  
Arij G. Beshish ◽  
Nicole Heinowski ◽  
Kim R. Baker ◽  
David F. Pegelow ◽  
...  
Keyword(s):  
Oxygen Tension ◽  
Body Position ◽  
Intrathoracic Pressure ◽  
Right Atrial ◽  
Foramen Ovale ◽  
Breathing Resistance ◽  
Pulmonary Vasoconstriction ◽  
Flow Through ◽  
The Right ◽  
Experimental Trials

While there is an increased prevalence of stroke at altitude in individuals who are considered to be low risk for thrombotic events, it is uncertain how venous thrombi reach the brain. The patent foramen ovale (PFO) is a recruitable intracardiac shunt between the right and left atrium. We aimed to determine whether body position and oxygen tension affect blood flow through the PFO in healthy adults. We hypothesized that hypoxia and body positions that promote right atrial filling would independently recruit the PFO. Subjects with a PFO ( n = 11) performed 11 trials, combining four different fractions of inhaled oxygen (FiO2) (1.0, 0.21, 0.15, and 0.10) and three positions (upright, supine, and 45° head down), with the exception of FiO2 = 0.10, while 45° head down. After 5 min in each position, breathing the prescribed oxygen tension, saline bubbles were injected into an antecubital vein and a four-chamber echocardiogram was obtained to evaluate PFO recruitment. We observed a high incidence of PFO recruitment in all conditions, with increased recruitment in response to severe hypoxia and some contribution of body position at moderate levels of hypoxia. We suspect that increased pulmonary vascular pressure, secondary to hypoxia-induced pulmonary vasoconstriction, increased right atrial pressure enough to recruit the PFO. Additionally, we hypothesize that the minor increase in breathing resistance that was added by the mouthpiece, used during experimental trials, affected intrathoracic pressure and venous return sufficiently to recruit the PFO.

Distribution of fetal cardiac output: importance of pacemaker location

1976 ◽  
Vol 231 (1) ◽  
pp. 204-208 ◽  
Author(s):  
PT Pitlick ◽  
SE Kirkpatrick ◽  
WF Friedman
Keyword(s):  
Heart Rate ◽  
Cardiac Output ◽  
Left Atrial ◽  
Left Ventricular ◽  
Right Atrial ◽  
Atrial Pacing ◽  
Foramen Ovale ◽  
Rate Versus ◽  
Left Ventricular Output ◽  
The Right

Important questions exist about the relative roles of changes in heart rate versus extent of myocardial shortening in regulating fetal cardiac output, because increases in heart rate created by left atrial pacing have been shown to increase right ventricular output and decrease left ventricular output. Since the pacemaker site could importantly influence foramen ovale flow and, hence, each ventricle's output, changes in individual ventricular outputs were examined when both the right and left atria were paced at a rate of 270 beats/min in five acute and in eight chronically instrumented fetal lamb studies. With pacing of either atrium, total cardiac output was unchanged compared to control values. However, the right ventricle contributed more to total cardiac output with left atrial pacing (73% acute, 65% chronic) than with right atrial pacing (51% acute, 57% chronic). Converse changes were observed in left atrial pacing (27% acute, 35% chronic) as compared to right atrial pacing (49% acute, 43% chronic). Thus the disparity that exists normally in the contributions of the right and left ventricles to total cardiac output is accentuated with left atrial pacing and minimized with right atrial pacing. Pressure measurements demonstrated changes in the atrial pressure relations that would be expected to alter flow across the foramen ovale depending on the chamber initially activated. Previous experimental differences can, therefore, be attributed to changes in the magnitude of shunting across the foramen ovale and depend on pacemaker location.

Behavior of the human pulmonary circulation during head-up tilt

1978 ◽  
Vol 45 (2) ◽  
pp. 249-254 ◽  
Author(s):  
M. L. Lewis ◽  
L. C. Christianson
Keyword(s):  
Venous Return ◽  
Mean Transit Time ◽  
Normal Subjects ◽  
Right Atrial ◽  
Right Heart ◽  
Vascular Bed ◽  
Head Up Tilt ◽  
Pulmonary Arterial ◽  
Zone Ii ◽  
The Right

Pulmonary blood volume (PBV), flow, and pressures were measured in 15 cardiopulmonary normal subjects, while supine and at 60 degrees head-up passive tilt. PBV, cardiac index (CI), right ventricular diastolic volume (VDVR), and mean pulmonary arterial (Ppa), venous (Pv), and mean right atrial (Pra) pressures all decreased during the first 4 min of tilting, with little subsequent change thereafter, to 30 min. Relative changes of CI, PBV, and VDVR were of similar magnitude (25--30%; mean Ppa and Pv fell 3.2 and 2.3 Torr, respectively. From measurements of thoracic dimensions and changes in intravascular pressures, we calculate that 11% of the pulmonary vascular bed falls into zone I condition, 34% goes from zone III to zone II, and 55% remains in zone III condition during tilt. A highly significant correlation exists between PBV and CI (P less than 0.001), with no significant change in pulmonary mean transit time during tilt. Significant correlations also exist between PBV and Pra (P less than 0.001), Pv (P less than 0.01), and Ppa (P less than 0.05). We conclude that outflow pressure plays a significant role in determining PBV during head-up tilt, but the major determinant is venous return to the right heart.

scholarly journals Venous return and the physical connection between distribution of segmental pressures and volumes

2019 ◽  
Vol 317 (5) ◽  
pp. H939-H953 ◽  
Author(s):  
George L. Brengelmann
Keyword(s):  
Steady State ◽  
Arterial Pressure ◽  
Venous Return ◽  
Pressure Profile ◽  
Model Fit ◽  
Right Atrial ◽  
The Difference ◽  
Mean Systemic Pressure ◽  
The Right ◽  
Compartment Pressures

More than sixty years ago, Guyton and coworkers related their observations of venous return to a mathematical model. Showing steady-state flow (F) as proportional to the difference between mean systemic pressure (Pms) and right atrial pressure (Pra), the model fit their data. The parameter defined by the ratio (Pms − Pra)/F, first called an “impedance,” came to be called the “resistance to venous return.” The interpretation that Pra opposes Pms and that, to increase output, the heart must act to reduce back pressure at the right atrium was widely accepted. Today, the perceived importance of Pms is evident in the efforts to find reliable ways to estimate it in patients. This article reviews concepts about venous return, criticizing some as inconsistent with elementary physical principles. After review of basic background topics—the steady-state vascular compliance; stressed versus unstressed volume—simulations from a multicompartment model based on data and definitions from Rothe’s classical review of the venous system are presented. They illustrate the obligatory connection between flow-dependent compartment pressures and the distribution of volume among vascular compartments. An appendix shows that the pressure profile can be expressed either as decrements relative to arterial pressure or as increments relative to Pra (the option taken in the original model). Conclusion: The (Pms − Pra)/F formulation was never about Pms physically driving venous return; it was about how intravascular volume distributes among compliant compartments in accordance with their flow-dependent distending pressures, arbitrarily expressed relative to Pra rather than arterial pressure.

Concealed pulmonary venous obstruction in right atrial isomerism with pulmonary outflow tract obstruction—surgical management following modified Blalock-Taussig shunt

1992 ◽  
Vol 2 (1) ◽  
pp. 95-99 ◽  
Author(s):  
Ing-Sh Chiu ◽  
Nan-Koong Wang ◽  
Mei-Hwan Wu ◽  
Fen-Fen Wu ◽  
Chi-Ren Hung
Keyword(s):  
Blood Flow ◽  
Pulmonary Edema ◽  
Cardiac Catheterization ◽  
Pulmonary Blood Flow ◽  
Venous Return ◽  
Balloon Catheter ◽  
Right Atrial ◽  
Initial Surgery ◽  
The Right ◽  
Blalock Taussig Shunt

SummaryObstruction to the pulmonary venous return is a frequent associated anomaly in patients with isomerism of the right atrial appendages. Yet, preoperative diagnosis by means of either cross-sectional echocardiography or cardiac catheterization can be intriguing. Indeed, the presence of two morphologically right lungs reduce considerably the size of window for precordial echocardiography. Also, in the presence of severe pulmonary stenosis or atresia, it can be difficult at cardiac catheterization to enter the pulmonary trunk. In these patients, construction of a systemic-to-pulmonary artery anastomosis will almost inevitably result in pulmonary edema. Between May 1984 and December 1988, five patients with isomerism of the right atrial appendages, severely decreased pulmonary blood flow and concealed obstruction to the pulmonary venous return were admitted to our hospital. A modified Blalock Taussig shunt by interposition of a polytetrafluoroethylene prosthesis was performed in each patients and all of them developed pulmonary edema. Three patients died despite appropriate medical treatment. The remaining two patients were successfully treated by banding of the Blalock shunt. This was performed in the first patient at the time of the initial surgery, when prior to closure of chest, pulmonary edema became manifest. The second patient who developed pulmonary edema early postoperatively, underwent cardiac catheterization to confirm the clinical diagnosis of obstruction to the pulmonary venous return. Reduction of blood flow through the Blalock shunt with resolution of edema was initially achieved by means of a partially occluding balloon catheter. Pulmonary edema recurred one week later because of rupture of the balloon and the patient eventually underwent a successful banding of the Blalock shunt through a left thoracotomy. We conclude that preoperative assessment of the pulmonary venous return is mandatory in patients with right isomerism and reduced pulmonary blood flow. Construction of a modified Blalock-Taussig shunt in the presence of concealed obstruction to the pulmonary venous return will almost inevitably cause pulmonary edema. Banding of the Blalock shunt can be successful, as observed in our experience, for the management of this serious complication.

scholarly journals Severe pulmonary regurgitation mimicking constrictive pericarditis: a case report—the sac or the content? That is the question

2020 ◽  
Vol 4 (3) ◽  
pp. 1-5
Author(s):  
Makiko Suto ◽  
Kensuke Matsumoto ◽  
Hidekazu Tanaka ◽  
Ken-Ichi Hirata
Keyword(s):  
Constrictive Pericarditis ◽  
Diastolic Pressure ◽  
Pathological Condition ◽  
Preoperative Evaluation ◽  
Pulmonary Regurgitation ◽  
Right Atrial ◽  
Diagnostic Pitfall ◽  
Physiological Limit ◽  
The Right ◽  
Pericardial Thickening

Abstract Background Constrictive pericarditis (CP) is a pathological condition of the pericardium, resulting from fibrosis, scarring, and calcification of the pericardium. Other conditions have been reported to mimic ‘constrictive physiology’ despite the presence of an intact pericardium. However, there has been no report of pulmonary regurgitation (PR) mimicking the haemodynamic characteristics of CP. Case summary A 51-year-old woman was admitted to our institute because of severe right-sided heart failure. Transthoracic echocardiography revealed severe PR concomitant with significant dilatation of the right-sided heart. Septal bounce and the respiratory reciprocation of the transmitral and transtricuspid inflow velocities were also observed, indicating exacerbated ventricular interdependence. Cardiac catheter examination demonstrated elevated right atrial pressure with a prominent y descent, dip, and plateau waveform in the right ventricular pressure, and equalization of the diastolic pressure of all cardiac chambers, which are quite consistent with CP. On surgical inspection, however, there was no pericardial thickening or adhesion, indicating no obvious signs of CP. Discussion Pericardial constriction results from the relative relationship between intrapericardial volume and pericardial reserve. When the intrapericardial volume exceeds the physiological limit, the cardiac chambers compete with each other in a fixed pericardial space. In this case, prominent dilation of the right-sided chambers caused by severe PR resulted in overstretching of the pericardium above the pericardial reserve, which led to a characteristic haemodynamic picture that resembled CP. Thus, it is important to recognize the diagnostic pitfall in the preoperative evaluation of a ‘CP mimic physiology’.

Influence of posture on isometric fatigue

1978 ◽  
Vol 45 (2) ◽  
pp. 270-274 ◽  
Author(s):  
A. R. Lind ◽  
R. Burse ◽  
R. H. Rochelle ◽  
J. S. Rinehart ◽  
J. S. Petrofsky
Keyword(s):  
Blood Flow ◽  
Maximum Voluntary Contraction ◽  
Voluntary Contraction ◽  
Right Atrial ◽  
Isometric Contractions ◽  
Sitting Position ◽  
Trained Subjects ◽  
Recumbent Posture ◽  
Flow Through ◽  
The Right

The isometric strength of four trained subjects was unaltered by changes in posture. But the endurance of an isometric contraction held to fatigue at 25 and 40% of the maximum voluntary contraction (MVC) was 20% greater in the sitting than in the recumbent posture. This difference was abolished when the exercise was performed with the arm's circulation arrested. At rest, the blood flow through the forearm was greater when the subjects were in the recumbent than in the sitting position but the reverse was true during isometric contractions. In these two postures, there was no difference in the right atrial pressure during the contraction, suggesting that the low-pressure baroreceptors are not responsible for the differences in blood flow during exercise. To date no mechanism is available to explain these observations.

Venous Return at Various Right Atrial Pressures and the Normal Venous Return Curve

1957 ◽  
Vol 189 (3) ◽  
pp. 609-615 ◽  
Author(s):  
Arthur C. Guyton ◽  
Arthur W. Lindsey ◽  
Berry Abernathy ◽  
Travis Richardson
Keyword(s):  
Venous Return ◽  
Atrial Pressure ◽  
Right Atrial ◽  
Right Atrial Pressure ◽  
Maximum Value ◽  
Open Chest ◽  
The Mean ◽  
Negative Pressures ◽  
Circulatory Reflexes ◽  
The Right

The normal venous return curve has been determined in 12 open-chest dogs with intact circulatory reflexes and in 14 open-chest areflex dogs. These curves show that venous return reaches a maximum value when the right atrial pressure falls to –2 to –4 mm Hg and remains at this maximum value down to infinitely low negative pressures. As the right atrial pressure rises to positive values venous return falls and reaches zero when the right atrial pressure has risen to equal the mean circulatory pressure. A venous return curve for the normal, intact dog has been tentatively formulated on the basis of these studies and previous studies in which individual points on the venous return curves of intact dogs have been measured.

scholarly journals Reoperations after the correction of partial abnormal venous return: a clinical case series

2020 ◽  
Vol 47 (8) ◽  
pp. 702-706
Author(s):  
D. S. Akatov ◽  
V. A. Belov ◽  
O. N. Bukhareva ◽  
D. E. Khomich ◽  
A. A. Makarov ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Venous Return ◽  
Pulmonary Veins ◽  
Right Atrial ◽  
Long Term Results ◽  
Pulmonary Vein Stenosis ◽  
Unsuccessful Attempt ◽  
One Year ◽  
The Right ◽  
Vein Stenosis

Rationale: The surgical procedure for partial abnormal pulmonary venous return (PAPV) implies the formation of a tunnel between the orifices of the right pulmonary veins and the left atrial cavity with the interatrial septum repair. To avoid any obstruction of the tunnel, a direct anastomosis between the superior vena cava (SVC) and the right atrial appendage is placed in a number of cases. However, the reparative procedure is potentially associated with such complications as SVC stenosis and/or pulmonary vein stenosis. Aim: To present our experience of reoperations for stenosis of systemic and pulmonary veins after primary PAPV repair. Materials and methods: From 2014 to 2018, seven patients (boys, 4) with SVC stenosis and/or with stenosis of the right pulmonary veins have been admitted to the FCHMT (Kaliningrad). Their mean bodyweight was 29.1 kg (± 12.5 kg), mean age 9.3 years (± 3.6 years). Three patients had an isolated SVC stenosis. In two patients, there was a combination of SVC stenosis and pulmonary vein obstruction (from stenosis to complete occlusion); in one patient the right pulmonary vein stenosis had been caused by thrombosis. SVC stenosis with subaortal obstruction after the repair of double-outlet right ventricle was diagnosed in one case. In six patients, various procedures for correction of SVC and/or pulmonary vein stenosis were performed. Only in one case the obstruction of systemic veins, confirmed by cardiac catheterization, turned out to be non-significant, making a reoperation unnecessary. Results: There were no deaths in this patient group. Endovascular procedures were performed in two patients. In one case, there was an unsuccessful attempt of transluminal balloon angioplasty for SVC stenosis, with subsequent Warden procedure. In another case, a 16-year old patient with SVC stenosis and high pulmonary hypertension was admitted after two previous surgeries had failed. We used a homograft as SVC prosthesis; however, after one year, a re-stenosis was identified. In this case, a SVC stent placement was successful. Due to sick sinus syndrome at one year after the Warden procedure and the repair of pulmonary veins by a homograft, an implantation of electric cardiac pacemaker was necessary in one patient. Conclusion: The curative repair of partial abnormal venous return is a well-established surgical technique with satisfactory shortand long-term results. A potential complication of the procedure is an obstruction of systemic and pulmonary veins. To prevent such complications during primary defect repair, as well as with reoperations for vein stenosis, the Warden procedure seems effective and highly reproducible technique associated with lower surgical risks.

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