Chonnam Med J.  2011 Apr;47(1):54-56. 10.4068/cmj.2011.47.1.54.

Masking of Pressure Overload in a Patient with Pulmonary Thromboembolism Accompanied by Atrial Septal Aneurysm

• Yu TK
• Kim WS
• Kim W

• KMID: 2172248
• DOI: http://doi.org/10.4068/cmj.2011.47.1.54

Abstract

A pulmonary thromboembolism (PTE) causes a dramatic pressure overload to the right heart. Previous case reports have shown that elevated right atrial pressure secondary to a PTE can cause right-to-left shunting in the presence of an atrial septal aneurysm (ASA). A 57-year-old female with diabetes, hypertension, and an old cerebral infarction was admitted to our hospital with acute PTE. Initial transthoracic echocardiography (TTE) showed an ASA swing from the right side to the left side, and right-to-left shunting was detected immediately in the agitated saline test. However, definite signs of pressure overload of the right heart were not detected in the TTE. This educational case shows that right-to-left shunting via a patent foramen ovale in the ASA can cause normal right atrial pressure, thus masking the pressure overload of the right heart in a patient with PTE.

Keyword

Interatrial aneurysm; Pulmonary embolism

MeSH Terms

Aneurysm
Atrial Pressure
Cerebral Infarction
Dihydroergotamine
Echocardiography
Female
Foramen Ovale, Patent
Heart
Humans
Hypertension
Masks
Middle Aged
Pulmonary Embolism
Dihydroergotamine

Figure

• 

  FIG. 1 Chest CTA (A and B), TTE (C, D, G, and H), and TTE with agitated saline (E and F) at initial presentation and at the follow-up after 2 weeks. The initial chest CTA revealed acute PTE (large arrow in A) and the TTE showed an ASA swing from the right side to the left side (small arrows in C), and right-to-left shunting was detected immediately in the agitated saline test (E). Pulmonary artery (PA) systolic pressure calculated by maximal velocity of tricuspid regurgitation (G) and predicted RA pressure (H) was in the normal range. The follow-up CTA revealed improved PTE (B) and the TTE showed the ASA fixed to the right side (small arrows in D) and dissapearance of large quantity of right-to-left shunt (F) after 2 weeks.

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