A rare post-lobectomy complication of right-to-left shunt via foramen ovale



Various complications can cause hypoxemia after pulmonary resection for lung cancer, but intracardiac shunt that becomes symptomatic and causes severe hypoxemia postoperatively is very rare. We report a case that presented platypnea-orthodeoxia syndrome (POS) due to right-to-left shunt via patent foramen ovale (PFO).


A 71-year-old man with a lung cancer in the left upper lobe was referred to our hospital. Left upper lobectomy was performed. Dyspnea developed postoperatively, which was worsened by sitting or standing and relieved in a recumbent position. Contrast transesophageal echocardiogram (TEE) and right intracardiac catheterization revealed a right-to-left shunt via PFO. Open-heart closure of PFO was performed and the patient was free from POS.


Postoperative intracardiac shunt via PFO can cause severe hypoxemia after lung resection. POS suggests the possibility of intracardiac shunt and careful observation is needed.

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  1. 1.

    Marini C, Miniati M, Ambrosino N, Formichi B, Tonelli L, Di Ricco G, et al. Dyspnoea and hypoxaemia after lung surgery: the role of interatrial right-to-left shunt. Eur J Respir. 2006;28:174–81.

    CAS  Article  Google Scholar 

  2. 2.

    Smeenk FW, Postmus PE. Interatrial right to left shunting developing after pulmonary resection in the absence of elevated right-sided heart pressures. Review of the literature. Chest. 1993;103:528–31.

    CAS  Article  Google Scholar 

  3. 3.

    Agrawal A, Palkar A, Talwar A. The multiple dimensions of platypnea-orthodeoxia syndrome: a review. Respir Med. 2017;129:31–8.

    Article  Google Scholar 

  4. 4.

    Durand E, Bussy E, Gaillard JF. Lung scintigraphy in postpneumonectomy dyspnea due to a right-to-left shunt. J Nucl Med. 1997;38:1812–5.

    CAS  PubMed  Google Scholar 

  5. 5.

    Blanche C, Noble S, Roffi M, Testuz A, Muller H, Meyer P, et al. Platypnea-orthodeoxia syndrome in the elderly treated by percutaneous patent foramen ovale closure: a case series and literature review. Eur J Intern Med. 2013;24:813–7.

    Article  Google Scholar 

  6. 6.

    Franco DP, Kinasewitz GT, Markham RV, Tucker WY, George RB. Postural hypoxemia in the postpneumonectomy patient. Am Rev Respir Dis. 1984;129:1021–2.

    CAS  PubMed  Google Scholar 

  7. 7.

    Nonaka M, Kadokura M, Yamamoto S, Kataoka D, Itano K, Kushihashi T, et al. Analysis of the anatomic changes in the thoracic cage after a lung resection using magnetic resonance imaging. Surg Today. 2000;30:879–85.

    CAS  Article  Google Scholar 

  8. 8.

    Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001;38:613–23.

    CAS  Article  Google Scholar 

  9. 9.

    Godart F, Rey C. Platypnea-orthodeoxia syndrome: a probably underestimated syndrome? Chest. 2001;119:1624–5.

    CAS  Article  Google Scholar 

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Correspondence to Riken Kawachi.

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Arai, N., Kawachi, R., Nakazato, Y. et al. A rare post-lobectomy complication of right-to-left shunt via foramen ovale. Gen Thorac Cardiovasc Surg 68, 1337–1340 (2020). https://doi.org/10.1007/s11748-019-01238-9

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  • Platypnea-orthodeoxia syndrome
  • Lung cancer
  • Complication
  • Intracardiac shunt
  • Patent foramen ovale