Platypnea-Orthodeoxia Syndrome Associated with Bioprosthetic Tricuspid Valve Stenosis and Reverse Lutembacher Syndrome

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A 43-year-old woman presented with shortness of breath. She developed dyspnea on exertion 6 months prior to presentation, with resting shortness of breath for 2 months. Dyspnea was worse in the upright position. She recently noted that her lips were turning blue in color. Her past medical history was significant for intravenous drug abuse, hepatitis C, and tricuspid valve (TV) endocarditis 3 years prior. She underwent TV replacement with a bioprosthetic valve that was complicated by chest wall necrotizing fasciitis and septic embolism with brain abscess requiring craniotomy. She reported tobacco use, medication noncompliance, and continued intravenous drug abuse. Medications included albuterol/ipratropium, pantoprazole, and furosemide. She had been started on continuous home oxygen. She presented to another institution and was found to have a patent foramen ovale (PFO). Coronary angiography showed no significant coronary artery disease, and chest computed tomography angiography demonstrated normal lung parenchyma and no pulmonary embolus. She was referred to our institution for percutaneous PFO closure. Admission vital signs and basic labs are shown in Table 1. Pulse oximetry on 5L continuous oxygen by nasal cannula was 75% to 78%. When upright, her oxygen saturation decreased to 65% and she became more tachypneic, findings consistent with the platypnea-orthodeoxia syndrome. Physical examination showed perioral cyanosis, no jugular venous distention, …