Sudden onset of systemic hypoxia associated with both tricuspid regurgitation and persistent foramen ovale: a case report

A 33-year-old female who had undergone closure of VSD 20 years before, was hospitalized for sudden onset of dyspnea without history of febrile or traumatic disorder. On admission, she had cyanotic lips and nailbeds but no clubbed finger. Chest x-ray film showed neither lung congestion nor cardiomegaly. Arterial blood gas analysis revealed deep hypoxia (PaO2 = 49.6 mmHg). Echocardiogram clarified massive tricuspid regurgitation (TR) due to chordal rupture of anterior leaflet, small VSD jet stream through the membranous aneurysm and a great deal of R-L shunt on the atrial level through a persistent foramen ovale. Cardiac catheterization data confirmed 35% of R-L shunt. At operation, a torn chordal tendon of anterior leaflet and an adhered septal leaflet to aneurysm of membranous portion of ventricular septum were seen. There were two pledgets, used at the first surgery, at the base of the aneurysm and a couple of tiny holes (VSDs) above and below the pledgets were recognized. Following resection of anterior and posterior leaflet, plication of septal leaflet and closure of VSD, a Xenograft valve (Carpentier-Edwards 29-M) was implanted. Then persistent foramen ovale, 20 x 20 mm in large, was closed directly. Her postoperative course was excellent with disappearance of cyanosis, normalized oxygen saturation in arterial blood and improved activity without dyspnea.