Dynamic obstruction of inferior vena cava flow caused by right-sided diaphragmatic elevation/Sag-tarafli diyafram yükselmesinin neden oldugu vena kava inferiyor akiminin dinamik tikanikligi

A 74-year-old woman was admitted to our clinic for 3-month history of shortness of breath evolving on exertion. She did not have any cardiovascular risk factors but untreated hypertension. Physical examination and electrocardiogram were normal. The postero-anterior chest X-ray revealed right-sided diaphragmatic elevation (Fig. 1). Figure 1. Lateral chest X-ray film showing the bullet Subcostal echocardiographic examination showed that the right atrium (RA) was compressed by the liver. Narrowing of the inferior vena cava (IVC)-RA junction, at deep inspiration was remarkable (Video 1. See corresponding video/movie images at www.anakarder.com). A 72 mm Hg peak gradient emerging at deep inspiration and disappearing at expiration was documented with the pulsed-wave Doppler (Fig.2). Magnetic resonance imaging revealed that the liver was displaced due to the right-sided diaphragmatic elevation and was compressing the IVC and its entrance to RA in a temporal fashion (Fig.3). After excluding the probable underlying causes, the patient was diagnosed to have idiopathic unilateral diaphragmatic paralysis. Interestingly, the dynamic pattern of this obstruction changing with respiration prevented the right sided heart failure symptoms and signs; thus, the patient did not require treatment other than antihypertensive therapy.