A 48 year old man presents with progressively worsening dyspnea for 3 months, which is worse when sitting up. There is no history of fever, cough or chest pain and he is otherwise asymptomatic. He was diagnosed with alcoholic cirrhosis 5 years ago, following which he stopped drinking. An upper GI endoscopy performed 6 months ago showed grade II esophageal varices, which were banded. A chest x-ray and ECG are performed and found to be normal.
WBC/DC: 4,100/mm3 N: 70% L: 25% Hb: 14.3 g/dL Hct (PCV): 42% Platelets: 80,000/mm3
PaO2 (supine): 71 mmHg PaO2 (sitting up): 58 mmHg
The pulmonary parenchyma and bronchial tree appear normal. No pleural effusions are present. Multiple dilated peripheral pulmonary arterioles are noted.
The heart is structurally normal, with no evidence of intra-cardiac shunting. Contrast enhancement with agitated saline shows microbubble opacification of the left atrium 4 cardiac cycles after that of the right atrium.