Anaesthetic management of a parturient with hereditary haemorrhagic telangiectasia (HHT) and pulmonary haemorrhage requiring urgent caesarean section

A 25-year-old gravida 3 para 3 with a history of hereditary haemorrhagic telangiectasia (HHT) and embolised pulmonary arteriovenous malformations (PAVMs) was admitted at 36 weeks gestation with haemoptysis, epistaxis and CT evidence of recent alveolar haemorrhage. An urgent caesarean section was planned. Both previous pregnancies had been delivered by elective lower segment caesarean section (LSCS) under subarachnoid block (SAB) at term. Preanaesthetic planning involved consultation with our tertiary maternity referral centre, the national HHT centre and our tertiary adult referral centre, which has interventional radiology and cardiothoracic capabilities. A whole spine MRI was carried out to rule out vascular malformation. Following multidisciplinary discussion, the decision was made to proceed with caesarean section in our hospital under SAB. Wide bore intravenous access was sited and blood product availability was ensured in case of acute pulmonary haemorrhage. The LSCS was uneventful. Postoperatively following discharge from the hospital, the patient experienced recurrent episodes of small volume haemoptysis, and had further PAVM embolisation in the national HHT centre. This report highlights the difficulties in managing complex parturients in a non-tertiary referral centre and underlines the importance of communication and multidisciplinary team discussion to determine the most appropriate management.

Emergency surgery for hemothorax due to a ruptured pulmonary arteriovenous malformation

Pulmonary arteriovenous malformation (PAVM) is a potential cause of hemothorax. The risk of PAVM rupture is reported to be higher during pregnancy for several reasons, including increased body fluid and a change in hormonal conditions. A 34-year-old pregnant woman suddenly felt right chest pain and dyspnea in the 28th week of gestation. Chest X-ray and computed tomography showed massive right pleural effusion. Her vital signs gradually deteriorated with hemorrhagic shock, necessitating emergency surgery. During exploratory thoracoscopy, active bleeding from the middle lobe was noticed and gauze packing was required to maintain her blood pressure. Following conversion to major thoracotomy, wedge resection of the middle lobe was performed with a linear stapler, and finally, her general condition became stable. Her postoperative course was uneventful. A histological examination of the resected specimen confirmed the diagnosis of ruptured PAVM. Her baby was successfully delivered at the 38th week of gestation.

Treatment of pulmonary arteriovenous malformations: clinical experience using different embolization strategies

PURPOSE

To evaluate embolization efficacy of pulmonary arteriovenous malformations (PAVM) using Amplatzer vascular plugs (AVP) and coils.

MATERIALS AND METHODS

Eighty-eight embolized simple PAVMs in 38 patients were retrospectively analyzed by follow-up CT. Mean age was 50.2 ± 15.6 years and 22 (57.9%) patients were females. Mean follow-up interval was 38.2 ± 28.4 months (median 29.9 months). Embolization devices included AVP I, AVP II, AVP 4, and coils. Technical success was defined as no visualization of an early draining vein at angiography after embolization. Treatment success was defined as complete disappearance or decrease in size of the venous aneurysm ≥ 70% at follow-up CT.

RESULTS

Technical success rate was 100% and treatment success rate evaluated by CT for the various embolization strategies was 100% for AVP I (n = 6), 100% for AVP I + coils (n = 5), 83.3% for AVP II (n = 6), 40.0% for AVP II + coils (n = 5), 87.5% for AVP 4 (n = 8), 50.0% for AVP 4 + coils (n = 8), and 78.0% for coils alone (n = 50). No statistically significant difference in embolization efficacy was seen between different devices (P = 0.083). Although not statistically significant, combination use of coils with AVPs demonstrated lower rates of clinical embolization success (P = 0.053).

CONCLUSION

Embolization of PAVMs demonstrated high technical and treatment success rates with available embolic devices. No significant statistical differences were demonstrated between AVPs. However, the need for both coils and AVPs may suggest a more complicated underlying lesion at risk for recurrence.

Pulmonary arteriovenous malformation exhibiting recanalization >10 years after coil embolization: Two case reports

RATIONALE

Some patients with pulmonary arteriovenous malformation (PAVM) present with hypoxemia and life-threatening complications, including stroke and cerebral abscess. Catheter embolization is currently the preferred treatment for PAVM. However, previous studies have revealed that the incidence of PAVM recanalization is approximately 10% 5 to 7 years after embolization. In contrast, there are no studies where recanalization has occurred over 10 years after embolization.

PATIENT CONCERNS

Herein, we report 2 cases diagnosed with cerebral embolism due to PAVM recanalization 13 years and 30 years after catheter treatment, in case I and II, respectively.

DIAGNOSES

Both cases were diagnosed with PAVM recanalization on chest computed tomography (CT) examination performed after cerebral embolism development. Furthermore, pulmonary artery angiography revealed blood flow from the pulmonary artery to the vein in the PAVM, confirming PAVM recanalization.

INTERVENTIONS

Coil re-embolization was performed for the all recanalized PAVM.

OUTCOMES

All the target lesions were successfully re-embolized in both cases. However, in case I, the second recanalization of embolized PAVM was confirmed 1 year after coil re-embolization. Consequently, the third embolization was performed in case I. In contrast to case I, the patient in case II was followed up without recanalization for 2 years after embolization.

LESSONS

We described the first 2 cases diagnosed with PAVM recanalization >10 years after the first catheter embolization. These cases suggest that patients with PAVMs should undergo life-long follow-up after catheter embolization.

Superior Vena Cava Flap to Reroute Partial Anomalous Pulmonary Venous Connection

A 46-year-old man who had undergone atrial septal defect closure during childhood was referred for surgery for residual partial anomalous pulmonary venous connection. The anomalous pulmonary veins were connected to the higher (cephalad) segment of the superior vena cava. As the usual caval division technique was not applicable, we chose to utilize the anterior wall of the superior vena cava as a flap for anomalous pulmonary vein rerouting. Bovine pericardium was used to reconstruct the systemic venous pathway. Systemic or pulmonary venous stenosis was not detected. The patient was discharged with a sinus rhythm.

Multimodal Endovascular approach in a Case of Multiple Dural Arteriovenous Fistulae

Dural arteriovenous fistulae (DAVF) are vascular abnormalities in which arteriovenous shunts are contained in between the periosteal and meningeal lamellae of the dura matter. Rarely, multiple DAVF are diagnosed in a single patient; occurring in only about 8% of the diagnosed cases. We describe a rare presentation of DAVF in a patient with multiple DAVF, at 3 separate sites within the cranial cavity; associated with a medical history of two traumatic motor-vehicle accidents, total anomalous pulmonary venous return (TAPVR), and acquired aplastic anemia. We describe our approach in the treatment of this complex condition.

[A Total Right Heart Bypass Operation for Polysplenia with Unilateral Pulmonary Arteriovenous Fistula;the Usefulness of the Anastomosis of the Hepatic Vein to the Azygous Vein Combined with Dilatable Pulmonary Artery Banding]

Right pulmonary arteriovenous fistula(PAVF) developed in a 18-month-old girl after total cavopulmonary shunt(TCPS) operation. The patient was diagnosed as polysplenia, single atrium, single ventricle, dextrocardia, pulmonary atresia, congenitally complete atrioventricular block, and absent infrahepatic segment of the inferior vena cava with azygous continuation to the right superior vena cava. The hepatic veins were connected to the left-side atrium. At age of 7 month, TCPS operation was performed. Arterial oxygen saturation decreased to 70% at 8 months after TCPS operation. We performed total right heart bypass operation with connected hepatic vein to the azygous vein using a 8-mm ePTFE tube graft, combined with dilatable right pulmonary artery banding( PAB). With PAB on the right pulmonary artery adjacent to the Glenn anastomosis, arterial saturation was 80% and the patient was successfully weaned off cardiopulmonary bypass. At 3 months after TRHB operation, systemic saturation increased to 90%.The right pulmonary artery banding site was successfully dilated by balloon angioplasty.

Isolated partial right lower lobe pulmonary venous drainage into the right atrium as a cause of pulmonary hypertension in a middle-aged woman

Partial anomalous pulmonary venous connection is a rare congenital disease characterized by drainage of one or several pulmonary veins into the systemic venous system. It is extremely rare as an isolated anomaly. We report the case of a middle-aged woman with isolated drainage of an enormously enlarged right lower pulmonary vein into the right atrium with significant left-to-right shunt, severe right ventricular enlargement, and pulmonary hypertension.

Recurrence of Pulmonary Arteriovenous Malformation with Non-tuberculous Mycobacteria Infection Caused by Perfusion from the Pulmonary Artery and Bronchial Artery after Coil Embolization

Recurrence of an embolized pulmonary arteriovenous malformation (PAVM) is common after coil embolization. A 23-year-old woman who had undergone multiple instances of transcatheter coil embolization was admitted with hypoxia and hemoptysis. A PAVM in the left S6 was found to be recanalized by reperfusion through the pulmonary and bronchial arteries. The left S6 was partially resected; the specimen contained necrotic granulomas and non-tuberculous mycobacteria (NTM) around the PAVM. Clinicians should consider possible recurrence of PAVM after reperfusion of the pulmonary and bronchial arteries, as well as the risk of NTM infection during follow-up of patients who have undergone repeated coil embolization.

Partial anomalous pulmonary venous connection associated with hemoptysis: A case report

RATIONALE

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital anomaly characterized by the failure of fusion of embryologic pulmonary venous system with left atrium.

PATIENT CONCERNS

A 45-year-old male patient with PAPVC who was hospitalized because of mild hemoptysis. Images showed the anomalous vein originated from the left upper pulmonary vein and flowed into the left brachiocephalic vein. No other underlying causes for hemoptysis were detected.

DIAGNOSIS

After multi-disciplinary discussion, the patient was diagnosed as PAPVC of left upper pulmonary vein draining into the left brachiocephalic vein with intact atrial septum.

INTERVENTIONS

Although surgical correction of PAPVC was feasible, left upper lobectomy was performed as the definitive treatment for both hemoptysis and PAPVC.

OUTCOMES

The patient had an uneventful postoperative hospital course and was followed up for nearly 2 years without recurrence of hemoptysis.

LESSONS

PAPVC is associated with atrial septal defect in 80% to 90% of cases while isolated PAPVC with intact atrial septum is an extremely rare entity. We present a rare isolated PAPVC patient with hemoptysis. To our best knowledge, PAPVC associated with hemoptysis has never been reported before.

Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations

BACKGROUND

Pulmonary arteriovenous malformations (PAVMs) generate a right-to-left shunt. Impaired gas exchange results in hypoxaemia and impaired CO2 clearance. Most patients compensate effectively but some are dyspneic, and these are rarely the most hypoxaemic.

AIM

To test degrees of concurrent pathology influencing exercise capacity.

DESIGN

Replicate, sequential single centre, prospective studies.

METHODS

Cardiopulmonary exercise tests (CPETs) were performed in 26 patients with PAVMs, including individuals with and without known airflow obstruction. To replicate, relationships were tested prospectively in an independent cohort where self-reported exercise capacity evaluated by the Veterans Specific Activity Questionnaire (VSAQ) was used to calculate metabolic equivalents (METs) at peak exercise (n = 71). Additional measurements included oxygen saturation (SpO2), forced expiratory volume in 1 s (FEV1), vital capacity (VC), fractional exhaled nitric oxide (FeNO), haemoglobin and iron indices.

RESULTS

By CPET, the peak work rate was only minimally associated with low SpO2 or low arterial oxygen content (calculated as CaO2=1.34 × SpO2 × haemoglobin), but was reduced in patients with low FEV1 or VC. Supranormal work rates were seen in patients with severe right-to-left shunting and SpO2 < 90%, but only if FEV1 was >80% predicted. VSAQ-calculated METS also demonstrated little relationship with SpO2, and in crude and CaO2-adjusted regression, were lower in patients with lower FEV1 or VC. Bronchodilation increased airflow even where spirometry was in the normal range: exhaled nitric oxide measurements were normal in 80% of cases, and unrelated to any PAVM-specific variable.

CONCLUSIONS

Exercise capacity is reduced by relatively mild airflow limitation (obstructive or restrictive) in the setting of PAVMs.

Pulmonary Arteriovenous Malformation Masquerading as Massive Pulmonary Thromboembolus

We present a case of a 78-year-old male with hereditary haemorrhagic telangiectasia and severe hypoxia incorrectly diagnosed as pulmonary embolism following a false positive ventilation/perfusion scan. Anti-coagulation and thrombolysis was complicated by an upper gastro-intestinal haemorrhage. Pulmonary arteriovenous malformations resulted in a clinically significant right-left shunt and created an apparent perfusion defect evident upon radionuclide imaging, leading to diagnostic uncertainty and a potentially dangerous treatment modality.

Complex pulmonary arteriovenous fistula in mother and daughter: Case report

RATIONALE

Complex pulmonary arteriovenous fistula (PAVF) is unusual, and even rarer in 2 members of a family. PAVF may not appear on chest X-ray or computed tomography imaging, especially in asymptomatic patients, and therapy is limited. Herein, PAVFs occurring in a mother and daughter are described, with the current standard methods of diagnosis and treatment of PAVF.

PATIENT CONCERNS

A 34-year-old woman and her 13-year-old daughter presented with light cyanosis of the nail beds but were otherwise asymptomatic, and physical examination was unremarkable. Their arterial oxygen saturation levels were low (80-85%).

DIAGNOSES

Angiography led to a diagnosis of PAVF involving the bilateral lung in both women.

INTERVENTIONS

The combined use of coils with occluder (patent ductus arteriosus, or PDA) to obstruct the fistula.

OUTCOMES

After interventional treatment, the patients' arterial oxygen saturation improved rapidly (90-95%). At 6-month follow-up, the patients' symptoms and oxygen saturation were normal.

LESSONS

PAVF is an autosomal dominant disease. Here, the characteristics of the 2 patients were very similar. Using detachable coils and then a PDA occluder is a highly efficient method for treating complex PAVFs.

Clinical, echocardiographic and advanced imaging characteristics of 13 dogs with systemic-to-pulmonary arteriovenous fistulas

OBJECTIVES

The objective is to describe the clinical, radiographic, echocardiographic and angiographic findings in dogs with systemic-to-pulmonary arteriovenous fistula (SPAVF).

ANIMALS

Thirteen medical records of client-owned dogs with a diagnosis of SPAVF were reviewed/analysed.

METHODS

This is a retrospective study of case records. Thoracic radiography, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), three-dimensional TEE, intracardiac echocardiography, fluoroscopy-guided or computed tomography (CT) angiography were carried out.

RESULTS

Based on the TTE, SPAVF was identified in seven of the included dogs. In eight cases, TEE and angiography were both performed and confirmed the diagnosis. Computed tomography angiography was performed in three dogs. A case was diagnosed by TEE alone, another one by three-dimensional TEE and the latter by intracardiac echocardiography.

CONCLUSIONS

Transthoracic echocardiography identified seven cases of SPAVF, while definitive diagnosis in the remaining dogs required selective angiography or computed tomography angiography.

Hybrid Pulmonary Vein Stenting in Infants with Refractory to Surgical Pulmonary Vein Stenosis Repair

Pulmonary vein stenosis (PVS) is still a frustrating disease with extremely high mortality, especially in children with multiple severe PVS. Hybrid pulmonary vein stenting (HPVS) is a rescue treatment for recurrent and malignant PVS. The aim of this study is to share our successful experience with intraoperative HPVS for recurrent PVS after total anomalous pulmonary venous connection (TAPVC) repair in infant. Six patients were identified between 2013 and January 2018, who were diagnosed with recurrent PVS and underwent HPVS in the operating room. The mean age at the time of the HPVS was 10.3 ± 2.7 months (range 7-14 months) and the mean body weight was 7.9 ± 2.6 kg (range 4.1-10.5 kg). Prior pulmonary vein surgery had been performed on average 2.7 times (range 2-3) in all patients. We used a bare-metal stent (BMS) of 6-8 mm diameter in 15 veins of five patients and a drug-eluting coronary stent (DES) in two veins of one patient. All patients had undergone several elective further pulmonary vein in-stent balloon dilatations or another stent insertion after HPVS. Over a mean follow-up of 17.3 ± 13.7 months (range 6-44 months), all patients maintained patency of stents although two patients died due to respiratory failure not associated with PVS. HPVS is a useful treatment modality for recurrent PVS patient that could save the life and achieve longer freedom from restenosis than repetitive surgical pulmonary vein widening only. Even though the prognosis of severe multiple PVS is very poor, planned HPVS could be a good palliation in this patients group.

Pulmonary arteriovenous malformations

Pulmonary arteriovenous malformation, a condition most commonly associated with hereditary hemorrhagic telangiectasia, is an abnormal communication between the pulmonary artery and pulmonary vein without an intervening capillary communication. Although asymptomatic in ~ 50% individuals, it can present with the dreaded complications of stroke or intracranial abscess in high-risk individuals including pregnant women, if untreated. The mainstay of treatment is now endovascular embolization of the feeding artery which can alleviate the symptoms and prevent these complications. In this review, we describe the pathophysiology, methods of screening, diagnostic workup and treatment of these vascular lesions with a particular focus on the currently used embolization techniques and their outcomes.

Left upper pulmonary vein connected to the persistent left superior vena cava and the left atrium

Persistent left superior vena cava (PLSVC) is the most common anomalous thoracic venous drainage. A PLSVC usually drains into the right atrium through a dilated coronary sinus. It is rare that a PLSVC flows directly into the left atrium, and even rarer that it connects to the left upper pulmonary vein (LUPV). We report a case, wherein the LUPV connected to both the PLSVC and the left atrium.

Pulmonary arteriovenous malformations: a radiological and clinical investigation of 136 patients with long-term follow-up

AIM

To assess the clinical outcome of patients with and without hereditary haemorrhagic telangiectasia (HHT) after embolisation of pulmonary arteriovenous malformations (PAVM) from a single national centre.

MATERIALS AND METHODS

The present register-based observational study including all patients with PAVM treated with embolisation at a reference centre for HHT and PAVM was undertaken over a 20-year period. Demographic data, HHT genotyping, clinical presentation, and outcome were registered. Patients with HHT were compared to the patients without HHT. Clinical examination, contrast-enhanced echocardiography, and computed tomography (CT) were used to assess the clinical outcome at follow-up.

RESULTS

One hundred and thirty-six patients with 339 PAVM underwent embolisation during the study period: 22 did not have HHT; 62% had HHT1, 10% had HHT2, 4% had JP-HHT, 8% had clinical HHT without identified genetic mutations. Solitary PAVM were more common among patients without HHT than with HHT. Mean follow-up after the first embolisation was 58 months. Mean age at first embolisation was 46.5 years, and at last follow-up 51.8 years. The clinical success without shunt at follow-up was 87%. The 30-day mortality related to the embolisation was 0%. Twenty patients died during follow-up (mean age 69 years). Most patients could be treated during one session, but many will need a long follow-up with repeated clinical examinations and embolisation.

CONCLUSION

The majority of patients referred for embolisation of PAVM had HHT. Multiple PAVM is associated with HHT. Patients with PAVM should be screened for HHT and patients with HHT for PAVM. Embolisation is a safe procedure with high clinical success.

Isolated unilateral pulmonary vein atresia with hemoptysis in a child: A case report and literature review

RATIONALE

Hemoptysis is an uncommon chief complaint but a distressing symptom in pediatric patients. Due to the recurrence and mortality in minor patients, an accurate diagnosis of the underlying cause is quite essential for treatment. The etiologies causing hemoptysis in children are similar to that in adults. Isolated unilateral pulmonary vein atresia (PVA), as an unusual cardiovascular anomaly, has rarely been reported to be an etiology of hemoptysis in children.

PATIENT CONCERNS

A 2-year and 11-month-old boy was admitted into our hospital with a complaint of recurrent hemoptysis for 2 months and the symptom became more aggravated in recent 4 days before admission. Physical examination was only remarkable for slightly diminished breath sounds over the left lung field, pale face, and colorless lip. Series of targeted laboratory evaluation were negative expect for anemia. Due to the identification of asymmetrical transparency of bilateral lung, slight emphysema of right lung, less volume of left lung with ground-glass opacity and reticular opacity, and ipsilateral mediastinal shift on chest CT, and varices of submucosal vessels in the left bronchial tree on the fiber-optic bronchoscope.

DIAGNOSES

It more likely indicated a congenital cardiovascular disease. The diagnosis of left isolated unilateral PVA was ultimately confirmed through chest CT angiography (CTA) with three-dimensional (3D) reconstruction.

INTERVENTIONS

Since the boy did not complain with hemoptysis after admission, respiratory tract infections seldom occurred and no pulmonary hypertension was detected, a conservative approach was chosen with periodic clinical follow-up after discussing with the cardiac surgeons and in accordance to his parents' own wishes.

OUTCOMES

Fortunately, he was doing well after 3 months of clinical observation.

LESSONS

We firstly reported a rare case of hemoptysis in children secondary to isolated unilateral PVA with no associated congenital heart disease in Chinese population. It is significant to improve the recognition and prompt diagnosis of this rare condition for pediatric clinicians, and widen the etiology spectrum of hemoptysis in children. The diagnosis of unilateral PVA should be considered for a patient with recurrent hemoptysis and imaging findings that indicate hypoplastic lung, ipsilateral mediastinal shift, and smooth margins of left atrium without evidence of rudimentary pulmonary veins.

Prenatal diagnosis of total and partial anomalous pulmonary venous connection: multicenter cohort study and meta-analysis

OBJECTIVES

The aims of this study were to review systematically literature on and describe the sonographic features and associated anomalies of total (TAPVC) and partial (PAPVC) anomalous pulmonary venous connection and scimitar syndrome (SS).

METHODS

A retrospective cohort study was carried out of cases of TAPVC, PAPVC and SS that underwent comprehensive ultrasound examination, seen over a 20-year period at two tertiary referral centers. Assessed variables included TAPVC subtype, gestational age at diagnosis, area behind the left atrium, ventricular disproportion, vertical vein, pulmonary venous obstruction, mode of diagnosis, association with cardiac and extracardiac conditions, and pregnancy and fetoneonatal outcomes. The outcome was considered favorable if the individual was alive and well (no functional impairment from surgery or cardiac or extracardiac conditions). Cases associated with right isomerism were excluded from the analysis, as TAPVC in these cases was only one of several major cardiac anomalies affecting sonographic signs. A systematic review was performed in order to obtain a synthesis of characteristics associated with TAPVC, PAPVC and SS. The literature search of PubMed and EMBASE (1970-2016) included reviews, case series and case reports. A meta-analysis was conducted only for TAPVC. Random-effects models were used to obtain pooled estimates of the frequencies of clinical characteristics and sonographic features.

RESULTS

For TAPVC, a total of 15 studies involving 71 patients (including 13 from the current cohort study) were included in the systematic review and meta-analysis. The pooled estimate for the association of TAPVC with congenital heart disease was 28.3% (95% CI, 18.1-41.3%) and with extracardiac anomalies it was 18.5% (95% CI, 10.5-30.6%). Of TAPVC cases, obstructed venous return was observed in 34.1% (95% CI, 22.7-47.7%), a favorable outcome in 43.8% (95% CI, 24.0-65.8%), ventricular disproportion in 59.2% (95% CI, 45.1-72.0%), increased area behind the left atrium in 58.1% (95% CI, 41.1-73.5%) and a vertical vein in 59.3% (95% CI, 41.1-75.3%). Diagnosis was established by using color or power Doppler in 84.9% (95% CI, 67.3-93.9%) of cases. For SS, there were only three studies describing eight cases, to which the current study added another five. Ventricular disproportion was present in three out of nine SS cases for which data were available, but for two of these, there was a concurrent heart anomaly. Color Doppler was used for all SS diagnoses, and four-dimensional echocardiography was useful in two out of six cases in which it was used. Outcome for SS cases was generally good. For PAPVC, there were only five studies describing five cases, to which the current study added another two. Major cardiac anomalies were associated in four out of seven of these cases, and extracardiac anomalies in three out of six cases for which data were available.

CONCLUSIONS

TAPVC can be associated with other cardiac and extracardiac anomalies in a significant percentage of cases. Leading sonographic signs are ventricular disproportion, increased area behind the left atrium and the finding of a vertical vein. Color/power Doppler is the key mode for diagnosis of TAPVC. Obstructed venous return can be expected in roughly one-third of cases of TAPVC and outcome is favorable in less than half of cases. Data for SS and PAPVC are too few to synthesize. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Conventional repair of total anomalous venous drainage without primary sutureless technique: surgical tips to prevent pulmonary vein obstruction

OBJECTIVES

Although primary sutureless technique for total anomalous pulmonary venous drainage has been introduced to reduce postoperative pulmonary vein obstruction (PVO), controversy still exists about superiority of the procedure between the conventional repair and primary sutureless technique at the initial repair. In our unit, the conventional repair has been consistently used based on four important surgical policies: (1) mark incision lines between 2 chambers to gain anatomically natural alignment, (2) place precise stitches by "intima-to-intima" using monofilament suture, (3) adequate orifice size should be guaranteed in greater than expected mitral valve size, (4) do not hesitate to undertake a redo additional anastomosis by a different approach when an echocardiography shows the velocity more than 1.5 m/s. This study aims to evaluate mid-term outcome of the conventional repair for total anomalous pulmonary venous drainage.

METHODS

Between 2004 and 2016, consecutive 15 patients who underwent the conventional repair without the primary sutureless technique were included in this study. Survival, Freedom from reoperation, and PVO were retrospectively reviewed.

RESULTS

Mean follow-up period was 4.6 ± 3.7 years. Except for one patient who died of uncontrollable pleural effusion, all other patients survived with 5-year survival rate of 93.3%. For the 14 survivors, there was no PVO, nor reoperation.

CONCLUSIONS

Following these policies, the mid-term outcome of the conventional total anomalous pulmonary venous drainage repair was excellent without the primary sutureless technique showing no obstruction. The conventional repair can be safely applied at the initial operation when the morphological condition allows for it.

An overlooked cause in a patient with recurrent ischemic stroke: A case report

RATIONALE

The majority of ischemic strokes are due to cardioembolism, large vessel atherothromboembolism, small vessel occlusive disease, or other unusual mechanisms. In most clinical settings, many strokes without a well-defined etiology requires a thorough diagnostic evaluation, otherwise the underlying cause might be easily overlooked. Here we report on the rare cause of a patient with recurrent stroke.

PATIENT CONCERNS

A 50-year-old female patient had a 4-year history of recurrent acute onset of neurological deficits.

DIAGNOSES

Contrast transcranial Doppler ultrasound detected a typical "curtain" appearance of microbubbles, indicative of a right-to-left shunt. Computed tomography pulmonary angiogram was then initiated and a pulmonary arteriovenous malformation (PAVM) in the left lower lobe was found.

INTERVENTIONS

The patient underwent percutaneous closure of PAVM. Afterward, warfarin was commenced because of the high risk of further thromboembolic complications in the following weeks to months. Post-treatment computed tomography pulmonary angiogram (CTPA) demonstrated successful closure of PAVM. No microbubble signals were detected on post-treatment contrast transcranial Doppler ultrasound (TCD) study.

OUTCOMES

The patient suffered no further embolic events during 3-year follow-up. No recanalization or new PAVMs were detected on CT scan.

LESSONS

Neurological PAVM-associated risks are common but remain poorly recognized. A strategic protocol is imperative in searching for the etiologies of cryptogenic stroke.

Surgical Approaches to Total Anomalous Pulmonary Venous Connection

Total anomalous pulmonary venous connection (TAPVC) constitutes a spectrum of congenital lesions whereby the pulmonary veins remain connected to systemic venous vessels or aberrantly connect to the right atrium. Definitive management requires surgical intervention and, in patients with obstruction to pulmonary venous flow, urgent operation is required. Use of temporizing catheter-based interventions allow for optimization in hemodynamically unstable neonates. Overall, survival has significantly improved over the past decades through better perioperative management and evolution of surgical approaches to minimize post-repair pulmonary vein stenosis, which persists as a major determinant of long-term outcomes.

Systemic-pulmonary arteriovenous fistulae with pulmonary hypertension: A case report

BACKGROUND

Arteriovenous (AV) fistulae is an extremely rare disease of vascular malformation that involves fistulae formation between the systemic and pulmonary AV systems.

CASE REPRESENTATION

This case report describes a rare systemic-pulmonary AV fistulae of congenital origin, accompanied by pulmonary hypertension, as determined by aortic angiography and echocardiography.

CONCLUSION

Characteristics, diagnosis, and therapeutic approaches of this rare abnormality are explored.

Embolisation for pulmonary arteriovenous malformation

BACKGROUND

Pulmonary arteriovenous malformations are abnormal direct connections between the pulmonary artery and pulmonary vein which result in a right-to-left shunt. They are associated with substantial morbidity and mortality mainly from the effects of paradoxical emboli. Potential complications include stroke, cerebral abscess, pulmonary haemorrhage and hypoxaemia. Embolisation is an endovascular intervention based on the occlusion of the feeding arteries the pulmonary arteriovenous malformations thus eliminating the abnormal right-to-left-shunting. This is an update of a previously published review.

OBJECTIVES

To determine the efficacy and safety of embolisation in patients with pulmonary arteriovenous malformations including a comparison with surgical resection and different embolisation devices.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Trials Register; date of last search: 10 April 2017.We also searched the following databases: the Australian New Zealand Clinical Trials Registry; ClinicalTrials.gov; International Standard Randomised Controlled Trial Number Register; International Clinical Trials Registry Platform Search Portal (last searched 27 August 2017). to be updatedWe checked cross-references and searched references from review articles.

SELECTION CRITERIA

Trials in which individuals with pulmonary arteriovenous malformations were randomly allocated to embolisation compared to no treatment, surgical resection or embolisation using a different embolisation device.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by two authors, with excluded studies further checked by a third author. No trials were identified for inclusion in the review and hence no analysis was performed.

MAIN RESULTS

There were no randomised controlled trials included in the review; one ongoing trial has been identified which may be eligible for inclusion in the future.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials for embolisation of pulmonary arteriovenous malformations. However, randomised controlled trials are not always feasible on ethical grounds. Accumulated data from observational studies suggest that embolisation is a safe procedure which reduces morbidity and mortality. A standardised approach to reporting with long-term follow-up through registry studies can help to strengthen the evidence for embolisation in the absence of randomised controlled trials.

[Echocardiographic diagnosis of infracardiac total anomalous pulmonary venous connection]

OBJECTIVE

To investigate the clinical usefulness of echocardiography in the diagnosis of infracardiac total anomalous pulmonary venous connection (ITAPVC) in neonates and infants.

METHODS

Retrospective analysis on 8 patients with ITAPVC was performed using echocardiography between April 2006 and December 2016. There were 4 boys and 4 girls with a mean age of 79.8 days (ranging from 15 to 195 days). A combined scanning via parasternal, subcostal and apical acoustic windows had been employed to diagnose ITAPVC and to trace the course and site of the anomalous pulmonary venous drainage, and to confirm the direction of the inter-atrial shunt and enlargement of right atrium and right ventricle.

RESULTS

Of the 8 patients who received echocardiography, ITAPVC was diagnosed in 7 patients. Mis-diagnosis by echocardiography was encountered in one patient. The diagnosis by echocardiography was compatible with the operative findings in 5 patients receiving surgery and with the results of multislice computed tomography in 6 patients. The diagnostic accuracy rate of ITAPVC was 87.5%. The indirect signs obtained from echocardiogram was coexistence of a small malformed, triangle-shaped left atrium and right to left shunting at atrial level with dilatation and tortuousness of portal vein or hepatic vein and abundant blood flow in liver. The direct signs was total pulmonary veins unconnected with left atrium, whose confluence joining into vertical vein drained right-inferiorly to portal vein or hepatic vein through diaphragm. Three parallel vessels including vertical vein, abdominal aorta and inferior vena cava arranged anteriorly, left-posteriorly and right-posteriorly with the opposite flow directions of inferior vena cava and the other two were found on sub-costal view. Sites of the drainage to the infra-diaphragm veins located portal vein in 8 patients. Stenosis of site of vertical vein connecting to portal vein or hepatic veins occurred in 3 patients.

CONCLUSION

Echocardiography has significant value in the diagnosis of pediatric ITAPVC and is capable of providing important structural and hemodynamic information for preoperative assessment of surgery. With multiple windows and multiple sections, ITAPVC could be diagnosed accurately by echocardiography. However, it is necessary to differentiate ITAPVC with intrahepatic portosystemic venous shunts or hepatic arteriovenous fistula.

Single-port thoracoscopic lung wedge resection using the Endo GIA Radial Reload

The GIA Radial Reload is a surgical stapler with a curved cut line that is perpendicular to the direction of instrument insertion. We used the GIA Radial Reload in three cases of single-port thoracoscopic lung wedge resection. The operations were performed through a 3.0-4.5-cm incision. For the first stapler, we selected the GIA Radial Reload. The orientation of this device's cut line enabled us to easily cut the lung behind the lesion during single-port thoracoscopic surgery.

Surgery versus percutaneous transcatheter embolization for pulmonary arteriovenous malformation: Analysis of a national inpatient database in Japan

OBJECTIVE

Although the treatment options for pulmonary arteriovenous malformation are surgery and percutaneous transcatheter embolization, no study has compared the outcomes between these 2 treatments.

METHODS

From the Japanese Diagnosis Procedure Combination database, the medical records of 996 patients who received treatment for pulmonary arteriovenous malformation between 2010 and 2015 were retrospectively reviewed. We created balanced groups for surgery or percutaneous transcatheter embolization using propensity scoring. The primary outcome was the rate of reintervention for pulmonary arteriovenous malformation, and the secondary outcomes were composite complications and postoperative length of stay. Patients who had any 1 of the complications during hospitalization were considered to have experienced a composite complication.

RESULTS

Of the total sample, 211 patients underwent surgery and 785 patients underwent percutaneous transcatheter embolization. By using 1-to-1 propensity score matching, 202 pairs were selected. Compared with percutaneous transcatheter embolization, surgery was associated with a significantly higher proportion of composite complications (6.9% vs 2.0%, P = .027) and longer postoperative length of hospital stay (median, 6 vs 2 days, P < .01). However, surgery resulted in a significantly lower rate of reintervention for pulmonary arteriovenous malformation (2.1% vs 8.3% at 2 years; P < .01).

CONCLUSIONS

Percutaneous transcatheter embolization had the advantage in composite complications and shorter postoperative length of stay compared with surgery, but surgery had higher curability than percutaneous transcatheter embolization. Surgery may be considered as a therapeutic option for patients with lesions that can be completely resected and are difficult to treat with percutaneous transcatheter embolization.

Hepatopulmonary syndrome with large pulmonary arteriovenous malformations: CT findings with emphasis on its association with a mosaic pattern of the lung parenchyma

We present a case of a 54-year-old patient with cirrhosis, progressive dyspnea, and platypnea. Thoracic computed tomography (CT) showed multiple pulmonary arteriovenous malformations (PAVM), confirming the diagnosis of hepatopulmonary syndrome (HPS). Besides precisely identifying the number and location of PAVM, CT also demonstrated a striking mosaic pattern of the lung parenchyma, characterized by the presence of alternating geographic areas of low attenuation (showing pulmonary vessels with a decreased diameter) with regions of relatively increased attenuation (showing pulmonary vessels with a normal diameter). This mosaic pattern of the lung parenchyma has scarcely been described in patients with HPS since it is not always present and usually requires a post-processing of the CT images in order to increase the contrast between the low attenuation areas (representing hypoperfused regions) and the areas with a relatively increased attenuation (representing better perfused regions). The decision was made to embolize the major PAVM, achieving an improvement of both the oxygen partial pressure and the patient's symptoms. This improvement allowed the patient to become an acceptable candidate for liver transplantation. We believe that, unlike other radiological signs of HPS, the mosaic pattern has not been sufficiently described in the scientific literature. If the association of the mosaic pattern on CT with HPS is confirmed in larger studies, it could become a useful sign for detecting hypoperfused pulmonary areas related to small nonvisible PAVM.

A Novel De Novo Pathogenic Variant in FOXF1 in a Newborn with Alveolar Capillary Dysplasia with Misalignment of Pulmonary Veins

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is an autosomal dominant, fatal developmental disorder of the lungs, with a mortality rate of about 100%. ACD/MPV is caused by mutations in FOXF1. Herein, we describe a newborn boy with ACD/MPV carrying a novel pathogenic variant of FOXF1. The patient developed respiratory distress and severe pulmonary hypertension on the first day of life. Despite aggressive cardiorespiratory management, including veno-venous extracorporeal membrane oxygenation, his condition deteriorated rapidly, and he died within the first month of his life. Lung histology showed the characteristic features of ACD/MPV at autopsy. Sequence analysis of FOXF1 from genomic DNA obtained from autopsied lung tissue revealed that the patient was heterozygous for a novel missense variant (c.305T>C; p.Leu102Pro). Further analysis of both parents confirmed the de novo occurrence of the variant. To the best of our knowledge, this is the first report of genetically confirmed ACD/MPV in Korea.

Multiple Pulmonary Arteriovenous Malformations: An Unusual Cause of Shortness of Breath and Recurrent Strokes

OBJECTIVE

To discuss an uncommon case of a patient with multiple pulmonary arteriovenous malformations (PAVMs) presenting with dyspnea on exertion and recurrent strokes.

BACKGROUND

A 79-year-old woman with recent onset recurrent cerebrovascular accidents (CVAs) was referred to cardiology for evaluation of dyspnea on exertion. Clinical examination was unrevealing.

METHODS

A transthoracic echocardiogram (TTE) with agitated saline was suggestive of an extra-cardiac shunt. Subsequent chest computed tomographic angiography (CTA) demonstrated five large PAVMs.

RESULTS

The patient underwent transcatheter coil embolization of the five PAVMs, resulting in marked improvement in dyspnea and resolution of the shunt on bubble study echocardiography.

CONCLUSIONS

Although PAVMs are rare, they remain an important entity to consider when evaluating patients with extracardiac shunts. They may present with nonspecific features such as dyspnea on exertion and recurrent CVAs. All patients with multiple PAVMs should undergo thorough skin screening for telangiectasia as well as radiologic imaging to screen for additional AVMs in the liver and brain in order to exclude hereditary hemorrhagic telangiectasia (HHT).

Prenatal diagnoses of an uncommon isolated obstructed supracardiac total anomalous pulmonary venous connection: Case report and review of the literature (CARE compliant)

INTRODUCTION

Total anomalous pulmonary venous connection is an uncommon congenital heart disease. Four types are described based on the site of pulmonary venous drainage: supracardiac, cardiac, infradiaphragmathic, and mixed connection. In most cases of supracardiac type, the common venous confluence drains through an ascending left vertical vein into the brachiocephalic vein, right superior vena cava, and then into the right atrium. Anomalous connection of the pulmonary venous confluence directly to the right SVC, especially the obstructed form is an unusual and severe supracardiac variant. The prenatal diagnosis is challenging.

PATIENT CONCERNS

We present a case report of a fetus diagnosed with TAPVC at 23 gestational weeks.

DIAGNOSIS INTERVENTIONS

The 4-chamber view showed a small left atrium, with a "smooth" posterior wall and the absence of pulmonary vein connection. This is the first case of prenatally diagnosed isolated, obstructed supracardiac type with drainage directly into the right superior vena cava.

CONCLUSION

The obstetrician and fetal cardiologist should be cautious at the direct and indirect echocardiographic signs of this condition. A prenatal diagnose of isolated, obstructed form is important for adequate planning of delivery and postnatal surgery in a tertiary center.

Pulmonary Arterio-Venous Malformation (PAVM): A Rare Case Report

A 6-year-old boy from Comilla, was admitted in Dhaka Medical College Hospital with exertional dyspnea, central cyanosis, clubbing and was finally diagnosed as pulmonary Arterio-Venous Malformation (PAVM) by bubble contrast echocardiography, and pulmonary CT angiography. As PAVM is rare in children, it is often not thought of in differential diagnoses and the diagnosis remains in disguise. In this report, we described the clinical presentation of 6-year-old child with PAVM and also how to investigate the case to get the diagnosis.

Pulmonary Hypertension Is Associated with Mortality and Cardiovascular Events in Chronic Kidney Disease Patients

BACKGROUND

We evaluated the prevalence, determinants and prognosis value of pulmonary hypertension (PH) in non-dialysis chronic kidney disease (CKD) patients.

METHODS

This is a prospective study with stages 3-5 non-dialysis-dependent CKD patients. PH was estimated by Doppler echocardiography and defined as a pulmonary artery systolic pressure above 35 mm Hg.

RESULTS

Three hundred fifty-three patients were recruited, of whom 94 (26.6%) had PH. Prevalence of PH increased with the decline of renal function: 21.6, 24.1, and 31.7% in stages 3, 4, and 5, respectively. Independent predictors of PH were age, estimated glomerular filtration rate (eGFR), history of cardiovascular (CV) events, the presence of an arteriovenous fistulae (AVF), and left ventricular (systolic and diastolic) dysfunction. Over a median follow-up of 22 months, 71 patients died (20%). After multivariate adjustment for age, gender, previous CV disease, diastolic and systolic dysfunction, PH remained as an independent predictor of all-cause mortality (hazards ratio [HR] 1.84, 95% CI 1.06-3.18, p = 0.02). One hundred patients (28%) had a new onset CV event. After adjustment for age, gender, previous CV disease, systolic and diastolic dysfunction, PH maintains its independent association with CV events (HR 2.77, 95% CI 2.00-3.25, p < 0.001).

CONCLUSIONS

PH prevalence rises as kidney function declines. Main determinants of PH are age, eGFR, previous CV disease, the presence of an AVF and left ventricular systolic or diastolic dysfunction. PH is an independent predictor of all-cause mortality and CV events.

Warden procedure for correction of sinus venosus atrial septal defect and partial anomalous pulmonary venous connection

A superior sinus venosus defect is a congenital cardiac disease which is commonly associated with partial anomalous pulmonary venous connection. Here we present the Warden procedure - our preferred technique for repair. Our goal is to highlight the principles of repair with a focus on critical aspects of the surgical technique.

[Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations in children]

Hereditary hemorrhagic telangiectasia is a constitutional vascular dysplasia characterized by chronic epistaxis, mucocutaneous and visceral telangiectasias and arteriovenous malformations. Apart from family screenings, the disease is rarely diagnosed during the pediatric age given the late advent of typical clinical symptoms. Nevertheless, arteriovenous malformations are sometimes already present at a young age with significant morbidity risk. Therefore, it is important to establish an early diagnosis. We describe two pediatric cases of hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations with divergent clinical presentation.

Pulmonary Arteriovenous Malformations Embolized Using a Micro Vascular Plug System: Technical Note on a Preliminary Experience

AIM

To report our preliminary experience using a Micro Vascular Plug (MVP) deployed through a 2.8Fr micro-catheter for the treatment of pulmonary arteriovenous malformations (PAVMs) in a cohort of patients affected by Hereditary Haemorrhagic Telangiectasia (HHT).

MATERIALS AND METHODS

Four consecutive female patients (mean age 38.0 years; range 25-55 years) with PAVMs diagnosed on echocardiogram/bubble test and contrast-enhanced CT (CECT) underwent MVP embolization. One patient was symptomatic with recent transient ischaemic attack. Follow-up was undertaken at 1-month post-procedure with CECT to assess PAVMs permeability and MVP positioning and at 1-, 6-, and 12-month post-procedure, with echocardiography/bubble test and standard neurological history, to confirm absence of right-to-left shunts and recurrent symptoms.

RESULTS

Eight PAVMs were treated in 4 patients over 5 interventional sessions (mean 1.6 PAVMs per session). All PAVMs were simple, with mean feeding artery diameter of 4.25 mm. Eight 6.5 mm MVPs were deployed in total (one per lesion). Technical success was 100%. Mean procedural time and patient dose per session were 70 min (range 40-70 min) and 53418 mGy.cm² (range 6113-101628 mGy.cm²), respectively. No signs of reperfusion neither of MPV migration were noted at 1-month CECT follow-up. At early follow-up (mean 3.75 months; range 1-12 months), clinical success was 100% with no evidence of recurrent right-to-left shunt, and no neurological symptoms. No immediate or late complications were observed.

CONCLUSIONS

MVP embolization of PAVMs appears technically feasible, safe, and effective at early follow-up. Further prospective studies are required to confirm long-term safety and efficacy of this promising technique.

Echocardiographic diagnosis of anomalous pulmonary venous connections: Experience of 84 cases from 1 medical center

We sought to evaluate the value of echocardiography in the diagnosis of different types of anomalous pulmonary venous connections (APVCs) and summarize the diagnostic experience. A total of 84 patients with APVC were confirmed by surgery (n = 82) or computerized tomography angiography (CTA) (n = 2) in the last 6 years (2008-2014) at the Wuhan Union Hospital. The total anomalous pulmonary venous connection (TAPVC) cases account for 60.7%, and partial anomalous pulmonary venous connection (PAPVC) cases account for 39.3% among the 84 cases that were identified. The 51 TAPVCs were classified by the Darling method-type I (41.1%), type II (52.9%), type III (1.9%), and type IV (3.9%). The most common drainage path of type I was common pulmonary drainage to the left innominate vein via vertical vein, and the coronary sinus drainage was the most common path in type II. Compared with surgical or CTA results, the sensitivity and specificity of echocardiography in the diagnosis of APVCs were 97.6% and 99.9%, respectively. The echocardiography misdiagnoses were mainly seen in PAPVCs. Of the TAPVCs and PAPVCs correctly diagnosed by echocardiography, the diagnostic accuracy of classification were 94% and 100%, respectively. Echocardiography has specific value in diagnosing and classification of APVC, especially the supracardiac and cardiac TAPVCs. Multiplane scan views and color Doppler improve the display of drainage pathway.