Posters / International Journal of Cardiology 155S1 (2012) S129–S227
distension. He underwent coronary angiography 1 year ago which
revealed normal coronary arteries. He had no prior surgery.
Physical examination and electrocardiogram were within normal
limits. Transthoracic echocardiography (TTE) revealed right atrial
compression by a colonic segment on apical four chamber and
parasternal short axis view. A chest X-ray disclosed elevation of
the right hemidiaphragm and hepato-diaphragmatic interposition
of the colon consistent with Chilaiditi’s syndrome.
Results: A thoraco-abdominal computed tomography (CT)
confirmed interposition of the right colic flexure between the liver
and diaphragm. The patient was conservatively treated with stool
softeners and abstinence from solid food. His further clinical course
was unremarkable.
Conclusions: Chilaiditi’s syndrome was first described in 1910
by Demetrius Chilaiditi. It is defined as the interposition of
the colon (usually hepatic flexure) and the liver below the
right hemidiaphragm. Although the precise mechanism remains
unknown, there are some predisposing factors for Chilaiditi’s
syndrome, such as elongated colon, small liver, relaxation of
the suspensory ligament or phrenic nerve injury. Patients are
usually asymptomatic. However, it could be associated with right
upper quadrant pain, vomiting, abdominal distension or cardiac
complications such as angina and arrhythmias. Although CT is the
main diagnostic tool, in case of cardiovascular complaints, TTE may
reveal this strange neighbourhood.
PP-168
A CASE OF PARTIAL ANOMALOUS PULMONARY VENOUS RETURN
WITH AN INITIAL DIAGNOSIS OF PULMONARY HYPERTENSION
DUE TO CHRONIC VENOUS THROMBOEMBOLISM AT ADVANCED
AGE
E. Büyükkaya1 , A.B. Akçay1 , F. Aydoğan3 , M.F. Karakaş1 , P. Bilen1 ,
M. Kurt1 , S. Akoğlu2 , N. Şen1 . 1 Mustafa Kemal University Faculty of
Medicine, Department of Cardiology, Hatay, Turkey; 2 Mustafa Kemal
University Faculty of Medicine, Department of Chest Diseases, Hatay,
Turkey; 3 Mustafa Kemal University Faculty of Medicine, Department
of Nuclear Medicine, Hatay, Turkey
Objective: Pulmonary hypertension (PHT) is defined as an increase
of ≥25 mmHg in mean pulmonary artery pressure (PAB) measured
through right heart catheterization at rest. Partial anomalous
pulmonary venous return (PAPVR) occurs when one or more
pulmonary veins enter right atrium or systemic circulation instead
of left atrium.
Methods: A 57-year-old male patient applied to our clinic with
the complaints of shortness of breath and swelling at his feet
for last two months. On physical examination, arterial blood
pressure was 120/85 mmHg, pulse rate was 81 beats/minute, a
grade 3 holosystolic murmur was detected at right lower margin
of the sternum on auscultation and there were bilateral pretibial
2+ pitting edema and scrotal edema. Electrocardiogram (ECG)
showed sinusal rhythm and right bundle branch block. On
echocardiography (ECHO), there were grade 3–4 tricuspid
insufficiency and grade 2 pulmonary insufficiency and approximate
pulmonary artery systolic pressure was 70 mmHg, no shunt was
observed. Tests were performed to investigate the etiology of PHT
and no abnormality was detected. The patient could not tolerate
transesophageal echocardiography (TEE). Bilateral lower extremity
venous Doppler ultrasound (US), thoracic computed tomography
(CT), pulmonary ventilation-perfusion scintigraphy and portal
system Doppler US were performed. As pulmonary embolism
with high probability was suspected on pulmonary ventilation-
perfusion scintigraphy (Figure 1), right-left heart catheterization
was planned for chronic pulmonary thromboembolism (CPTE).
Pulmonary capillary wedge pressure was 7 mmHg; pulmonary
arterial pressure, 62/37/18 mmHg; right ventricular pressure,
63/0/5 mmHg; mean right atrial pressure, 12 mmHg; left ventricular
pressure, 120/0/7 mmHg; and aortic pressure, 120/98/77 mmHg. In
S153
oxymetric study, the saturations were as follows: 95% in superior
vena cava, 62% in inferior vena cava, 81% in pulmonary artery, 81%
in right ventricle, 88% in upper right atrium, 70% in middle right
atrium, 71% in lower right atrium, 92% in left ventricle, and 92% in
aorta. The ratio of the pulmonic blood flow (Qp) to the systemic
blood flow(Qs) was 2.9. Thereon, anomalous pulmonary venous
return was suspected in the patient and cardiac CT angiography
was planned. The CT angiography showed that the pulmonary
vein draining the right upper lobe entered the superior vena cava
(Figure 2) and the pulmonary vein draining the right lower lobe
entered the right atrium (Figure 3). In addition, a sinus venosus
atrial septal defect (ASD) was detected in the patient (Figure 4).
The patient was referred for surgical treatment.
Results: In patients initially diagnosed for CPTE, congenital
anomalies should definitely be considered in differential diagnosis.
Figures 1–4. Perfusion scintigraphy, multiple segmental and
subsegmental perfusion defects in the left lung; the pulmonary
vein draining the right upper lobe entering the superior vena cava;
the pulmonary vein draining the right lower lobe entering.
PP-169
COEXISTENT PERIMEMBRANOUS VENTRICULAR SEPTAL DEFECT,
SUBAORTIC MEMBRANE AND MODERATE RHEUMATIC AORTIC
INSUFFICIENCY IN A MIDDLE-AGED WOMAN
E. Aydın1 , A. Ösken1 , İ. Kocayiğit1 , S. Yaylacı2 , H. Gündüz1 . 1 Sakarya
Education and Research Hospital Cardiology Department, Sakarya,
Turkey; 2 Sakarya Education and Research Hospital Internal Medicine
Department, Sakarya, Turkey
Objective: Rheumatic aortic insufficiency (AI) is an autoimmune
valvular heart disease (VHD) which usually develops years to
decades after rheumatic fever (RF). Ventricular septal defect (VSD)
is a common congenital heart defect in both children and adults.
Coexistent congenital VSD, subaortic membrane and acquired
rheumatic AI in an adult is a very rare combination that has
not been reported previously. We discuss an unusual presentation
of a middle-aged woman with coexistent perimembranous VSD,
subaortic membrane and moderate rheumatic AI presenting with
progressive exertional dyspnea and palpitations.
Methods: 18-year-old girl was referred for evaluation of worsening
exertional breathlessness and palpitations. She has no history of
rheumatic fever. On physical examination a loud second heart
sound, and a grade 4/6 pansystolic precordial murmur were noted,
lungs are clear to auscultation. An electrocardiogram showed
sinus rhythm. Two-dimensional echocardiography demonstrated
a calcified stenotic aortic valve with subaortic membrane and
moderate aortic insufficiency. These findings strongly suggest the
possibility of rheumatic valvular heart diseases. Echocardiography