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Forum Name: Cardiology Diagnostics

Question: Atrial-septal aneurism, PFO, trivial mitral regurge

 itsmethere - Sat Jan 27, 2007 9:01 pm

I am a 22 year old female. Since age 9, I've been having prolonged episodes (lasting several days at a time) of horrible shortness of breath accompanied by dizziness, lightheadedness, fatigue and chest pain. I often felt like I may pass out (although it never happened). I also feel that my horrible shortness of breath may have caused a stroke recently since, after my last shortness of breath episode, I feel numbness at the back of my head and feel that my cognition became impaired .

Over the years, I've seen a total of 6 cardiologists. I've had the standard heart (and lung) work-up, although nothing invasive: EKGs, echos, stress-test, 24 hour monitor, and recently, a heart MRI.

All my tests have showed PFO and a trivial mitral regurge. The recent heart MRI has detected another anomaly: atrial-septal aneurism. Yet my cardiologist thinks that none of these findings can cause my horrible symptoms. However, I strongly believe my symptoms have a physical cause and are not attributed to psychological phenomena.

Do you think my symptoms can be caused by ASA, PFO and trivial mitral regurge? If yes, how should I proceed? If no, what do you recommend?
 John Kenyon, CNA - Tue Jan 30, 2007 1:24 pm

User avatar Hello itsmethere - One of the most common abnormalities found in the general population is mitral valve prolapse (MVP), which also occurs (or at least is diagnosed) much more frequently in women. While you haven't mentioned a specific diagnosis of MVP, many of the abnormalities you've mentioned, though, are often associated with Mitral Valve Prolapse Syndrome (also known as dysautonomia). While the physical abnormalities often cannot be connected directly to the symptoms, there seems to be an association of some sort. This opinion has been controversial at times, but Montclair Baptist Hospital's Heart Hospital in Birmingham, Alabama, has a long-established clinic devoted to this especially annoying and anxiety-producing phenomenon. Most of the symptoms you describe could possibly
be ascribed to MVPS associated in some obscure way with your congenital heart abnormalities.

As for the suspicion of stroke, while not impossible, it does seem unlikely that a stroke would manifest itself in such a way. However, the additional symptoms might fit with MVPS.

While emotions play a role in this (or any) illness, to a greater or lesser degree, there can be no doubt the symptoms you feel and describe are physical and quite real. The important question is "What is causing them and what can be done to minimize them?"

MVPS/dysautonomia, while not life threatening, can be "lifestyle threatening" (a phrase borrowed from one of the founders of the Birmingham center). It might be worth exploring this possibility, since six cardiologists have declared your heart to be functioning in a healthy way, but with some benigh abnormalities which are often found to be present in people with a syndrome which causes most of the symptoms you've described.

Good luck with this. I hope this has been of some help.
 itsmethere - Fri Feb 02, 2007 4:41 pm

I appologize. I don't really mean stroke but rather brain damage of some sort.
 itsmethere - Fri Feb 02, 2007 4:43 pm

I am editing myself again. My question is: Could my prolonged severe hypoxia (without loss of consciousness) have caused brain damage?
 John Kenyon, CNA - Fri Feb 02, 2007 11:19 pm

User avatar Hi itsmethere - The short answer to your question is no. However, that begs another question, and that is: is your shortness of breath genuine and if so, is it causing you to go into a state of acute hyperventilation? What you described originally matches the description of episodic hypervenitlation more than it does classic shortness of breath, and is often part of the overall galaxy of symptoms associated with MVP Syndrome, even when actual MVP is not proven.

Brain damage may be caused by prolonged anoxia (no oxygen to the brain) which occurs during cardiac arrest from any cause, and usually occurs after 4-6 minutes have passed. In these instances the patient is unconscious virtually the entire time. Hypoxia, if real, will not cause brain damage. The additonal
work we do to breathe is what compensates and allows us to function during periods of hypoxia.

Have you ever been told you have been hypoxic by a medical person who has actually applied a pulse oximetry device's clip on your finger? The borderline range for concern is between 90-93 per cent O2 saturation. Below 90 is hypoxic but still quite sufficient to sustain consciousness and bodily function. On the other hand, hyperventilation can make one feel as though breathing is being done in an airless environment and often involves more physical effort than is involved in true shortness of breath (except, of course, in cases of severe asthma, where one is actually breathing against an obstruction). Some patients with emphysema walk around with pulse oxygen levels in the low 80's. They walk slowly, but they do walk.

Hyperventilation is often an unwelcome diagnosis or suggestion, because it sounds a lot like being told "it's all in your head." That's not the case. We can often breathe in a faulty way either due to emotional causes or physical ones, and either way the result is the same: we blow off more carbon dioxide (CO2) than we are designed to. There has to be some CO2 left in our blood in order to let the brain know to tell the body to take the next breath. When we accidentally blow off too much (through sighing, overbreathing, etc.), the signal is not received, but since breathing is a semi-voluntary action, we are then aware that our impulse to breathe is missing, which feels like an inability to breathe, and so we commence to overcompensate, resulting in a truly horrible cycle where we continue to blow off ever more CO2 until there is virtually none in our system, we feel as though we cannot possibly breathe, get lightheaded (but almost never actually faint), become weak, shaky, experience numbness in the face, scalp and hands, and may even develop spasm in the hands and/or feet. The more we fight for air the more we feel as though we are not getting any air at all! Eventually we are unable to sustain the energy level to do this, and it corrects itself - until the next episode.

A sense of impaired cognition is often another very real phenomenon known as depersonalizatoin, which may take place before and/or during hyperventilation.

This does not mean you might not have some degree of shortness of breath (or even hypoxia) to start with, but it makes it a moot point, and of course it is impossible to know, long distance like this, if my hypothesis is correct, but I strongly suspect it is. Some people deal with this problem for many years because no one takes the time to demonstrate to them how it can be controlled and even eliminated. Some healthcare providers believe it is unwise to discuss even normal clinical findings with an anxious patient, and sometimes this is a wise course, but more often, in my experiene, a little extra time spent explaining, reassuring and even demonstrating (this is fairly easy if you are having bouts of hyperventilation) the cause and effect process involved.

I sincerely hope you find a practitioner who will take the time to determine what is causing the shortness of breath, let you know exactly what your oxygen saturation level is and why, and if it is normal proceed to demonstrate to you how hyperventilation can be triggered, stopped and ultimately avoided. If there is true underlying shortness of breath this simple cardiorespiratory check would expose it and it could be traced to its cause, which doesn't seem likely to be due to any of the anatomical abnormalities which have been found so far.

The best of luck to you and please do keep us apprised of anything new you may find out.
 itsmethere - Sat Feb 03, 2007 12:22 pm

No, I am definitely not hyperventilating; I just have prolonged periods of very bad shortness of breath, accompanied by lightheadedness, dull chest pain, and my limbs feel cold. It feels like it's coming from the heart (but guess you never know).

A couple of times, during these episodes, there was like a minute or two when my heart would beat really fast and seemingly uncontrollably (but it quited down after a few minutes), and I felt really lightheaded and one moment as if my legs were going from under me.

But apparently, my heart anomalies are benign and according to doctors, can't cause symptoms that bad.
 John Kenyon, CNA - Sat Feb 03, 2007 1:18 pm

User avatar Hi itsmethere - Barring any possibility of hyperventilation this really doesn't fit any textbook scenario very neatly. There are, of course, other possibilities. The best chance you have to uncover what is going on is to somehow manage to be in a clinical setting when these symptoms take place. The racing heart could, of course, be paroxysmal atrial tachycardia, which is essentially benign (except that it can be momentarily disabling for some people) but the severe shortness of breath, being intermittent and also paroxysmal, is much more difficult to pin down from afar. How long do these episodes usually last? Is there ever a chance you could get a paramedical unit to where you are or get yourself into an ER while they were still going on? A cardiac monitor and hemodynamic monitoring during an episode would be very telling, as would getting an accurate oxygen saturation level. It's conceivable you're having some sort of atypical asthma (and not all asthmatics produce audible wheezing without benefit of a stethescope - it's not always obvious). Other than these ideas I'm pretty much stumped at this point and would urge you to try and capture one of these events
in a clinical setting, even if it means dialing 9-1-1 to catch the event in action. If this has already been done and there is no detectable abnormality then I'm totally stumped.

You do have some physical abnormalities which have been documented, but they are not capable of causing this sort of intermittent problem (except for episodes of rapid heart rate, which can sometimes be caused, indirectly, by an atrial septal aneurism). With any of these symptoms a feeling of faintness and leg weakness would be unsurprising, regardless of the root cause.

Good luck to you with this very frustration situation.
 itsmethere - Sat Feb 03, 2007 4:51 pm

The symptoms (shortness, of breath, chest pain, lightheadedness) last for several days. I did go the emergeny room a couple of times while I was still having them. The last time I had my symptoms was like 6 months ago.

What they did there was an EKG and a chest x-ray (and of course took all my vital signs as well) and had a doctor examine me (the first time I came, they called a pediatric cardiologist to examine me). The EKG was fine, I did see them write "a possible intravascular shunt" for the EKG findings, in the papers though, but I guess it's not considered a big deal.

Basically, from the ER people's standpoint (and the cardiologists I've seen think the same) I don't have anything life-threatening going on and so they've sent me home. And of course, everyone leans towards an anxiety explanation.
 John Kenyon, CNA - Sat Feb 03, 2007 5:33 pm

User avatar Well then you've done everything you can do in the short term, and they are still telling you everything's fine, which it may be - from their perspective. Something, however, is obviously causing a perceived and possibly intermittent shortness of breath - and it's not affecting your uptake of room air oxygen. That doesn't make it any more pleasant. It's possible the PFO (or intravascular shunt) changes its dynamic in some way from time to time (I only say this as speculation because some parts of the heart appear to be able to almost shape-shift at times). Grasping at straws here, because the problem is so weird relative to the clinical findings. And yes, everyone will, at some point, try on the anxiety answer to see if it fits. It's not unreasonable, but if you've totally ruled it out then there has to be some really unusual problem, possibly with perception of breathing effort, or perhaps there is some unrecognized neurological problem affecting the breathing apparatus alone, such as a pinched diaphragmatic nerve or something, which could make breathing intermittenly difficult without upsetting the hemodynamics. It's a stretch, but if it's the case it wouldn't be the first time.

Again, best of luck, and do keep us updated.

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