# Refractory hypoxaemia in the presence of two common conditions: a case report

## TL;DR

A 72-year-old woman with a pacemaker and a patent foramen ovale experienced hypoxaemia due to a right-to-left shunt caused by pacemaker-related tricuspid regurgitation.

## Contribution

The paper presents a novel explanation for hypoxaemia in the absence of pulmonary hypertension, linking pacemaker interference with a right-to-left shunt.

## Key findings

- Hypoxaemia was resolved immediately after percutaneous closure of the patent foramen ovale.
- Right-to-left shunt was attributed to pacemaker-mediated tricuspid regurgitation and elevated right atrial pressure.
- Pulmonary hypertension and platypnoea–orthodeoxia syndrome were ruled out as causes of the shunt.

## Abstract

A 72-year-old woman with a history of bicameral pacemaker implantation 12 years earlier due to high-degree atrioventricular block presented with progressively worsening exertional dyspnoea, which recently became evident even with minimal exertion.

When the patient consulted, marked hypoxaemia was observed, leading to the exclusion of pulmonary aetiology using computed tomography (CT) angiography. Subsequently, an echocardiogram revealed significant tricuspid regurgitation caused by interference with the pacemaker lead. A bubble study demonstrated a right-to-left shunt in the context of a patent foramen ovale. Given the patient’s age, the initial hypothesis was that the shunt direction resulted from a condition causing severe pulmonary hypertension, resembling Eisenmenger syndrome. However, right heart catheterization ruled out significant pulmonary hypertension. Since the presence of a patent foramen ovale had been documented, we also tested positional changes without observing any improvement in the degree of hypoxaemia, thereby ruling out platypnoea–orthodeoxia syndrome.

It was proposed that the direction of the jet and the increase in systolic pressure in the right atrium could explain the type of shunt in the absence of pulmonary hypertension. This was drawing from the nature of pacemaker-mediated tricuspid regurgitation and its rapid progression and eccentricity of the jet. Based on this hypothesis, a percutaneous closure of the foramen was performed, resulting in an almost immediate resolution of the hypoxaemia, as observed in the cath lab.