Abstract 15788: Patent Foramen Ovale With Platypnea-Orthodeoxia Precipitated by Large Hepatic Cyst Requiring Closure: Novel Approach

Abstract

Case Presentation: A 71-year-old female with history of liver cyst presented with severe epigastric and RUQ pain. Abdominal CT demonstrated interval worsening of the liver cyst (largest cyst 18cm) causing right hemi-diaphragmatic elevation. She was hemodynamically stable, and plan was for elective surgical cyst fenestration in 2 weeks. However, her pain worsened, and was readmitted with severe dizziness and hypoxia. Chest CTA workup revealed subsegmental pulmonary emboli (PE) bilaterally and lower extremity dopplers showed deep vein thrombosis. She was started on anticoagulation, but her hypoxemia worsened, requiring maximum high flow oxygen. Persistent hypoxia disproportionate to the PE that worsened in the right lateral decubitus position led to repeat transthoracic echocardiogram with bubble study, that demonstrated a large patent foramen ovale (PFO) and a normal right ventricle. Mechanism of this severe hypoxemia was largely attributed to the shunting from the IVC directly across the PFO and couldn’t be explained by a small PE. Given the high risk for paradoxical emboli, the need for PFO closure versus debulking the liver cyst was discussed at the time. Aspiration of the cyst was attempted initially to avoid PFO closure, with temporary improvement in her hypoxemia. Hence a decision was made to close the PFO before further definitive management of the cyst. The PFO was closed with 30mm Amplatzer Talisman occlude device and post operatively her oxygen was weaned down to room air sating 95%. However, her abdominal fullness continued to be present, and she underwent successful fenestration of her cyst. Discussion: There have been cases where large hepatic cysts causing compression of the right atrium were treated either with surgical drainage or cyst resection. Rare cases have the need for a PFO closure with hemodynamic changes, as this one, where it was successfully done, leading to significant improvement.