Case Report

Refractory Hypoxemia in Right Ventricular Infarction: A Case Report

Authors: Lindsay C. Crawford, MD, Mukta Panda, MD, Suresh Enjeti, MD

Abstract

Abstract:Right ventricular infarction has many clinical features. Although hypoxemia is a common presenting symptom with multiple causes in the setting of myocardial infarction, the authors present a case resulting from an acute right-to-left shunt secondary to a previously dormant patent foramen ovale. A 74-year-old male presented to the hospital after feeling unwell for the previous 2 days. Initial evaluation revealed marked hypoxemia without respiratory distress. Electrocardiographic findings and cardiac seromarkers revealed a completed inferior myocardial infarction. The patient's hypoxemia was refractory to 100% oxygen, indicating a right-to-left shunt. A transesophageal echocardiogram confirmed clinical suspicions for a right-to-left shunt through a patent foramen ovale. Despite sporadic reports in the literature, this still is a poorly recognized clinical condition. The authors review a case report that will enable the general internist to consider a right-to-left shunt in the setting of hypoxemia in myocardial infarction.

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References

1. Pfisterer M. Right ventricular involvement in myocardial infarction and cardiogenic shock. Lancet2003;362:392–394.
 
2. Laham RJ, Kalon KL, Douglas P, et al. Right ventricular infarction complicated by acute right to left shunting. Am J Cardiol 1994;74:824–826.
 
3. Bansal RC, Marsa RJ, Holland DJ, et al. Severe hypoxemia due to shunting through a patent foramen ovale: A correctable complication of right ventricular infarction. J Am Coll Cardiol 1985;5:188–192.
 
4. Rietveld AP, Merrman L, Essed C, et al. Right to left shunt, with severe hypoxemia, at the atrial level in a patient with hemodynamically important right ventricular infarction. J Am Coll Cardiol 1983;2:776–779.
 
5. Fedullo AJ, Swinburne AJ, Mathew TM, et al. Case report: Hypoxemia from right to left shunting through patent foramen ovale. Am J Med Sci 1985;289:164–166.
 
6. Morris A, Dinen N. Hypoxia and intracardiac right to left shunt. Arch Intern Med 1978;138:1405–1406.
 
7. Mas JL, Arquizan C, Lamy C, et al. for the Patent Foramen Ovale and Atrial Septal Aneurysm Study Group.Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm or both. N Engl J Med 2001;345:1740–1745.
 
8. Kerut EK, Norfleet WT, Plotnick GD, et al. Patent foramen ovale: A review of associated conditions and the impact of physiological size. J Am Coll Cardiol 2001;38:613–621.
 
9. Cox D, Taylor J, Nand N. Refractory hypoxemia in right to left shunting via a patent foramen ovale: Efficacy of contrast transesophageal echocardiography. Am J Med 1991;91:653–655.
 
10. Kernis SJ, Goldstein J, Yerkey M, et al. Percutaneous atrial septostomy for urgent palliative treatment of severe refractory cardiogenic shock due to right ventricular infarction. Cathet Cardiovasc Interv 2003;59:44–48.
 
11. Upstrom EL, Kern MJ, Mezei L, et al. Balloon catheter closure of patent foramen ovale complicating right ventricular infarction: Improvement of hypoxia and intracardiac venous shunting. Am Heart J1998;116:1092–1096.