PFO, Shunts, Bradycardia, Lightheaded Teenager

[Ohio Mom]

2 ½ years ago, at the age of 15, my daughter experienced a severe attack of upper left abdominal pain with nausea, shortness of breath and lightheadedness at basketball practice. She had a lot of pain and nausea the next day and felt like she was going to faint.  Her blood pressure was really low so I took her to the pediatrician (should have taken her to the ER). The pediatrician examined her, did some blood work and scheduled a follow up visit.  The nausea and pain got better gradually over two weeks but the dizziness never improved.  She would see black when rising in the morning and felt lightheaded when standing, pretty much all the time.  She was referred to a pediatric cardiologist.

She had a positive tilt table test (.03 mg nitroglycerin) in April 2006, and given a diagnosis of Neurocardiogenic Syncope. (She left the test with a numb arm and upper lip).  She was prescribed .1mg Florinef, the first dose caused a severe migraine headache, so Inderal was added.  She was instructed to increase fluids and salt.  She eventually started feeling better.

She has had an EKG at each cardio visit for the past two years indicating bradycardia with sinus arrhythmia (rate as low as 38), early transition, qrs positive in V2, otherwise normal.  She is an athlete (basketball and softball) but not a long distance runner and to the best of my knowledge this low heart rate didn’t exist prior to the painful event at basketball.  Her echocardiogram in March 2006 found a PFO with a left to right shunt. She had another echo in April 2007 with a bubble study after I expressed concerns over two episodes of garbled speech, one of those with loss of vision in one eye, and occasional numb cold arms, nausea and chest pain while exercising.  The bubble study was positive for a right to left shunt (lots of bubbles with no coughing or straining).  The cardiologist ordered an MRI of her brain and it was normal.  

In November 2006 the cardiologist weaned her gradually from her medication, first the Florinef and then the Inderal.  She did fairly well with occasional lightheadedness until March of 2007 at which time she became lightheaded when standing and became very weak to the point that she could no longer participate in her softball games.  She resumed the medication and eventually improved.  Her cardiologist made another attempt at weaning her off the medication in October 2007.  Once again, the lightheadedness returned and she resumed the Florinef with 25mg of Atenolol. Over the 2+ years she has had occasional episodes of chest pain, numb arms and severe abdominal pain during exercise and more recently shortness of breath after a basketball game.  

I’m grateful that the medication helps to make her feel better and allows her to resume her activities but I can’t help but wonder if we are on the right track with the Neurocardiogenic Sycope diagnosis.  Here are my concerns:  1) why the sudden and dramatic change in health from an attack of upper left abdominal pain  2) She’s not occasionally dizzy like a kid standing too long on stage - without medication she “blacks out” every morning and is lightheaded pretty much every time she stands up  3) I’m concerned that the shunt puts her at higher risk for stroke and could overwork her heart and that the bradycardia/arrhythmia may not be just an athlete’s bradycardia (or the result of 25 mg of Atenolol).  4) One of the possible side effects of Florinef is compression fractures of the spine and she has already had 3 pars fractures of the 4th and 5th lumbar vertebra over the past four years.   5) She has a softball scholarship to a Division 1 university and will undergo a physical exam this summer and I’m a little nervous about their discovering that she has to take medication to get enough oxygen to her brain just to be able to stand upright.  

Her cardiologist feels that the shunts and bradycardia have nothing to do with her symptoms; her pediatrician says they are probably just “a red herring”.  My “mother’s intuition – gut feeling” wonders if the Neurocardiogenic Syncope diagnosis could be the “red herring”.  Could there be something else going on here?  

[Ohio Mom]

I think what you are going through with your little one is even more frightening than what I have experienced with my teenager.  She has never actually fainted, only feels as though she will if she doesn't take the medication.  I don't dwell on the what if's when she is doing well but when she has a frightening episode during exercise it always make me wonder if it isn't a warning and that one of these times something really bad will happen so I know what you are going through.  

Red herring is just an old manner of speech that refers to an event or problem that distracts from seeing the real problem.  

I hope that your son just outgrows his condition and I think that does happen sometimes.   All the best.

[momtofourboys]

did they say how big her PFO was isshe shunting all of the time? if her PFO is small then I was told it has nothing to do with my little mans issues
Chris is 4/5 years old (you can't forget the.5) he has a very smal PFO and bi directional shunting. he has had episodes of rapis HR when just sitting and then very slow HR when just sitting and this can also happen when he is running or sleeping. he had a 24 hour holter and it showed his lowest HR 48(I had it at 40 once (passed out with this one icident) on his Sat machine with a low Sat reading) and his HR as high before of 202. he just had a cardiac cath and a EP study his "surgeon" that did this test said that they couldn't get his HR to go into an rapid arrythemia and that a HR of 45-200 was fine unless he passes out 2 more time. I told him the same fears you have that I am afriad that when he goes high then low and is shunting his will stroke out on me, I was told no it couldn't happen.
does your daughter ever turn bluegrey what about while in the warm water like a  baht(she probablly takes showers anyways)

I would ask for a 24 hour holter and maybe ask for a cath. you really need to know what is gong on.
I am still very very nervous about my little man I am so afraid of loosing him
I am gong to look up what res herring is thanks you your input
michelle