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The online version of this article contains one video. The article and the video are online available (https://doi.org/10.1007/s12471-025-01943-6). The video can be found in the article back matter as “Electronic Supplementary Material”.
A 59-year-old previously healthy woman developed severe hypoxaemia during a mastectomy, with postoperative oxygen saturation levels as low as 77%, preventing ventilator weaning. Once extubated in the ICU, her oxygen saturation varied significantly (78–97%) despite high-flow nasal oxygen therapy. Hypoxaemia worsened in upright positions and improved in the right lateral decubitus position. No hypoxaemia had been noted before this episode.
Pulmonary computed tomography angiography revealed a 50-mm ascending aortic aneurysm with no evidence of pulmonary embolism. A transoesophageal echocardiogram showed the aneurysm compressing the right atrium, distorting the atrial septum, and stretching a patent foramen ovale (PFO) (Fig. 1a), causing a significant right-to-left shunt (Fig. 1b; see Supplementary Material, video 1). This confirmed platypnoea-orthodeoxia syndrome (POS).
Fig. 1
Ascending aortic aneurysm, compressing the right atrium and stretching a patent foramen ovale (a); large right-to-left shunt visualised on bubble study (b)
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We hypothesise that mechanical ventilation during surgery increased right cardiac chamber pressures, unmasking hypoxaemia. Percutaneous PFO closure normalised oxygen saturation to 99% on room air. The aneurysm was newly diagnosed during this episode, and the patient remains under cardiology follow-up to monitor its progression.
Funding
No funding was received for this work.
Conflict of interest
J. Guimarães, P. Costa and J. Ferreira declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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