Double Shunt on Echocardiogram What do you see on this saline contrast study, in a patient with end-stage liver disease and pulmonary hypertension? 1. Early transit of bubbles = PFO 2. Late appearance with replenishment via pulm veins = intrapulmonary. #2 c/w hepatopulmonary syndrome #1: Pulm HTN (portopulmonary or other) causing ⬆️ RA pressure and R➡️L shunt as RAP>LAP as atrial septum shifts left In addition to dilated and probably dysfunctional RV, R-L shunt in two phases, first likely due to stretched PFO or ASD, and later (after ~5 seconds) appears to be coming from PVeins (extra-cardiac shunt in cirrhosis). by David H. Wiener, MD @DavidWienerMD #DoubleShunt #Echocardiogram #clinical #pocus #a4c #intrapulmonary #cardiology #saline #contrast
