Platypnea-Orthodeoxia Syndrome Revealing a Patent Foramen Ovale in a Middle-Aged Woman

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HATIM, Z. HAMDANI, M. KHALDI, S. AROUS, A. DRIGHIL, R. HABBAL This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6869871/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Platypnea-orthodeoxia syndrome is a rare condition characterized by dyspnea and arterial desaturation that worsen in the upright position and improve when supine. We report the case of a 53-year-old woman with significant obesity, hypertension, dyslipidemia, and a history of two ischemic strokes, admitted for refractory hypoxemia. Clinical examination revealed dyspnea and desaturation in the sitting position, with improvement when lying down, showing a 7% difference in oxygen saturation. Transesophageal echocardiography (TEE) identified a patent foramen ovale (PFO). Percutaneous closure of the PFO was successfully performed. Follow-up transthoracic echocardiography showed no residual shunt. Clinical evolution was favorable, with complete resolution of dyspnea, and no recurrence during follow-up. Platypnea-orthodeoxia syndrome dyspnea patent foramen ovale Percutaneous closure of the PFO Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Although rare, platypnea-orthodeoxia syndrome should be suspected in patients presenting with positional dyspnea and unexplained refractory hypoxemia. We report the case of a middle-aged woman in whom a patent foramen ovale (PFO) was discovered and successfully treated with percutaneous closure. Clinical Presentation A 53-year-old woman with hypertension, dyslipidemia, significant obesity (BMI kg/m²), and a history of two ischemic strokes, was admitted for evaluation of chronic dyspnea and recurrent episodes of hypoxemia refractory to oxygen therapy. On clinical examination, she was conscious, mildly tachycardic at 105 bpm with a regular rhythm, hypertensive at 145/85 mmHg, tachypneic at 23 breaths per minute, and afebrile at 36.7°C. Cardiac auscultation was normal, without murmurs or pericardial rubs. Pulmonary examination revealed no crackles or wheezing. Pulse oximetry showed a 7% drop in oxygen saturation when changing from the supine (96%) to the sitting position (89%). Given the positional nature of her symptoms and the absence of significant pulmonary findings, a cardioembolic source or intracardiac shunt was suspected. Diagnostic Investigations A thoracic CT scan performed initially showed no evidence of pulmonary embolism or parenchymal lung disease. Transesophageal echocardiography (TEE) performed in both supine and upright positions revealed a patent foramen ovale with significant right-to-left microbubble passage at rest, accentuated during the Valsalva maneuver. ( Fig. 1, 2 , 3, 4) No atrial septal aneurysm, intracardiac thrombus, or other cardiac abnormalities were identified. Management and Outcome A decision was made to proceed with percutaneous closure of the PFO. The procedure was performed successfully without perioperative complications. Post-procedural transthoracic echocardiography confirmed complete closure of the PFO with no residual shunting. Clinically, the patient experienced complete resolution of dyspnea and normalization of oxygen saturation. At three months of follow-up, she remained asymptomatic, with no recurrence of dyspnea or hypoxemia. Discussion Platypnea-orthodeoxia syndrome is a rare clinical entity characterized by postural dyspnea and hypoxemia that improve when supine. This condition often results from an anatomical shunt between the right and left atria, most commonly due to a patent foramen ovale. Physiological factors such as elevated right atrial pressure or anatomical distortion of the interatrial septum can exacerbate the shunt in the upright position. In the presence of platypnea-orthodeoxia syndrome, systematic investigation for a right-to-left shunt is mandatory. Bubble contrast transesophageal echocardiography remains the gold standard for confirming the diagnosis, particularly when performed in both supine and upright positions. Percutaneous PFO closure is a safe and effective treatment, often leading to rapid and durable symptom resolution, as observed in our patient. Conclusion This case highlights the importance of suspecting platypnea-orthodeoxia syndrome in patients presenting with unexplained positional dyspnea and refractory hypoxemia. Recognition of this rare syndrome and timely PFO closure can result in spectacular clinical improvement and prevent further complications. Declarations Patient Consent Statement: Written informed consent was obtained from the patient for the publication of this case report, including the use of clinical data and any accompanying images. Conflict of Interest: The authors declare no conflicts of interest regarding the publication of this manuscript. Funding: This study did not receive any specific funding from governmental, commercial, or non-profit organizations. References Burchell HB, Helmholz HF, Wood EH (1949) Reflex orthostatic dyspnea associated with pulmonary hypotension. Am J Physiol 159:563–564 Altman M, Robin ED, Platypnea (1969) N Engl J Med 281:1347–1348 Hussain FS, Mekan FS (2004) Platypnea-orthodeoxia: Report of two cases and review of the literature. South Med J 97(7):657–662 Schwerzmann M, Windecker S, Wahl A, Mehta H et al (2004) Percutaneous closure of patent foramen ovale: Impact of device design on safety and efficacy. Heart 90:186–190 Reynard C, Némitz N, Pernet R, Tschopp JM (2005) Platypnoea and orthodeoxia syndrome, a rare cause of dyspnoea. Rev Med Suisse 1:1569–1572 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6869871","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":469689376,"identity":"ddd546ac-1f39-4a12-9436-7795e5113a12","order_by":0,"name":"H. 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We report the case of a middle-aged woman in whom a patent foramen ovale (PFO) was discovered and successfully treated with percutaneous closure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Clinical Presentation","content":"\u003cp\u003eA 53-year-old woman with hypertension, dyslipidemia, significant obesity (BMI kg/m\u0026sup2;), and a history of two ischemic strokes, was admitted for evaluation of chronic dyspnea and recurrent episodes of hypoxemia refractory to oxygen therapy.\u003c/p\u003e \u003cp\u003eOn clinical examination, she was conscious, mildly tachycardic at 105 bpm with a regular rhythm, hypertensive at 145/85 mmHg, tachypneic at 23 breaths per minute, and afebrile at 36.7\u0026deg;C.\u003c/p\u003e \u003cp\u003eCardiac auscultation was normal, without murmurs or pericardial rubs. Pulmonary examination revealed no crackles or wheezing.\u003c/p\u003e \u003cp\u003ePulse oximetry showed a 7% drop in oxygen saturation when changing from the supine (96%) to the sitting position (89%).\u003c/p\u003e \u003cp\u003eGiven the positional nature of her symptoms and the absence of significant pulmonary findings, a cardioembolic source or intracardiac shunt was suspected.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic Investigations\u003c/h2\u003e \u003cp\u003eA thoracic CT scan performed initially showed no evidence of pulmonary embolism or parenchymal lung disease.\u003c/p\u003e \u003cp\u003eTransesophageal echocardiography (TEE) performed in both supine and upright positions revealed a patent foramen ovale with significant right-to-left microbubble passage at rest, accentuated during the Valsalva maneuver. ( Fig.\u0026nbsp;1, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 3, 4)\u003c/p\u003e \u003cp\u003eNo atrial septal aneurysm, intracardiac thrombus, or other cardiac abnormalities were identified.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eManagement and Outcome\u003c/h3\u003e\n\u003cp\u003eA decision was made to proceed with percutaneous closure of the PFO. The procedure was performed successfully without perioperative complications.\u003c/p\u003e \u003cp\u003ePost-procedural transthoracic echocardiography confirmed complete closure of the PFO with no residual shunting.\u003c/p\u003e \u003cp\u003eClinically, the patient experienced complete resolution of dyspnea and normalization of oxygen saturation.\u003c/p\u003e \u003cp\u003eAt three months of follow-up, she remained asymptomatic, with no recurrence of dyspnea or hypoxemia.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePlatypnea-orthodeoxia syndrome is a rare clinical entity characterized by postural dyspnea and hypoxemia that improve when supine.\u003c/p\u003e \u003cp\u003eThis condition often results from an anatomical shunt between the right and left atria, most commonly due to a patent foramen ovale.\u003c/p\u003e \u003cp\u003ePhysiological factors such as elevated right atrial pressure or anatomical distortion of the interatrial septum can exacerbate the shunt in the upright position.\u003c/p\u003e \u003cp\u003eIn the presence of platypnea-orthodeoxia syndrome, systematic investigation for a right-to-left shunt is mandatory.\u003c/p\u003e \u003cp\u003eBubble contrast transesophageal echocardiography remains the gold standard for confirming the diagnosis, particularly when performed in both supine and upright positions.\u003c/p\u003e \u003cp\u003ePercutaneous PFO closure is a safe and effective treatment, often leading to rapid and durable symptom resolution, as observed in our patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the importance of suspecting platypnea-orthodeoxia syndrome in patients presenting with unexplained positional dyspnea and refractory hypoxemia. Recognition of this rare syndrome and timely PFO closure can result in spectacular clinical improvement and prevent further complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient Consent Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report, including the use of clinical data and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest regarding the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific funding from governmental, commercial, or non-profit organizations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBurchell HB, Helmholz HF, Wood EH (1949) Reflex orthostatic dyspnea associated with pulmonary hypotension. Am J Physiol 159:563\u0026ndash;564\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltman M, Robin ED, Platypnea (1969) N Engl J Med 281:1347\u0026ndash;1348\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussain FS, Mekan FS (2004) Platypnea-orthodeoxia: Report of two cases and review of the literature. South Med J 97(7):657\u0026ndash;662\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwerzmann M, Windecker S, Wahl A, Mehta H et al (2004) Percutaneous closure of patent foramen ovale: Impact of device design on safety and efficacy. Heart 90:186\u0026ndash;190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynard C, N\u0026eacute;mitz N, Pernet R, Tschopp JM (2005) Platypnoea and orthodeoxia syndrome, a rare cause of dyspnoea. Rev Med Suisse 1:1569\u0026ndash;1572\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Centre Hospitalier Universitaire Ibn Rochd","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Platypnea-orthodeoxia syndrome, dyspnea, patent foramen ovale, Percutaneous closure of the PFO","lastPublishedDoi":"10.21203/rs.3.rs-6869871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6869871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePlatypnea-orthodeoxia syndrome is a rare condition characterized by dyspnea and arterial desaturation that worsen in the upright position and improve when supine. We report the case of a 53-year-old woman with significant obesity, hypertension, dyslipidemia, and a history of two ischemic strokes, admitted for refractory hypoxemia. Clinical examination revealed dyspnea and desaturation in the sitting position, with improvement when lying down, showing a 7% difference in oxygen saturation. Transesophageal echocardiography (TEE) identified a patent foramen ovale (PFO). Percutaneous closure of the PFO was successfully performed. Follow-up transthoracic echocardiography showed no residual shunt. Clinical evolution was favorable, with complete resolution of dyspnea, and no recurrence during follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Platypnea-Orthodeoxia Syndrome Revealing a Patent Foramen Ovale in a Middle-Aged Woman","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 09:25:03","doi":"10.21203/rs.3.rs-6869871/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"129e3412-57fa-4cb6-a82f-1ee70af430e3","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-13T09:25:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-13 09:25:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6869871","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6869871","identity":"rs-6869871","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}