Intrapulmonary shunt confirmed by intracardiac echocardiography in the diagnosis of hepatopulmonary syndrome

Abstract

A 59-year-old male with cirrhosis secondary to alco-hol use was referred to our pulmonary clinic for evalu-ation of hypoxemia and worsening dyspnea onexertion. Transthoracic echocardiogram (TTE) with sa-line contrast study suggested the presence of an inter-atrial septal defect. He had been started by a localphysician on continuous oxygen and maintained at 2-4 L/min. A repeat TTE with saline contrast showednormal right ventricle (RV) size and function, with anRV systolic pressure of 30 mmHg and bubbles in theleft atrium 5-6 beats after injection. His social historywas pertinent for 40 years of heavy alcohol use, withhis last drink 4 years earlier. His physical exam wasonly remarkable for a pulse oxygenation of 87%-93%on 2 L/min of oxygen and significant lower extremityedema bilaterally. Heart examination revealed no mur-murs or split-second sound.A diffusing capacity corrected for hemoglobin wasmoderately reduced at 15.94 mL/min/mmHg (55% ofpredicted). Arterial blood gas standing and on room airrevealed a pH of 7.45, pCO