Platypnea-Orthodeoxia Syndrome: Presentation of a 90-Year-Old

Platypnea-orthodeoxia syndrome (POS) is a clinical syndrome of dyspnea and hypoxemia that is exacerbated by sitting upright or standing and resolved with lying flat. Here, we discuss an initial presentation of POS as a result of a previously undiagnosed patent foramen ovale (PFO) in a 90-year-old man. Diagnosis of the PFO was limited by technically difficult transthoracic echocardiograms with inconclusive agitated saline studies. Transesophageal echocardiogram (TEE) with Doppler and agitated saline study was eventually diagnostic, and his symptoms resolved after percutaneous PFO closure. The diagnosis and treatment in this patient were complicated by his age, moderate dementia, and limited decision-making capacity. Although our patient was dependent for virtually all instrumental activities of daily living (iADLs), he and his family reported an excellent quality of life prior to presentation, and we anticipated he would be able to regain this post-procedurally, allowing us to advocate for TEE and subsequent PFO repair. In the geriatric population, special consideration must be taken to discuss the risks and benefits of extensive workup and treatment depending on the effectiveness and invasiveness of both; approaching these cases with this holistic approach can thus help guide their clinical course appropriately.