Hepatopulmonary Syndrome and Multiple Arteriovenous Fistulas in a Child with Niemann-Pick Disease

Background: Niemann-Pick disease (NPD) is caused by abnormal storage of sphingomyelin. NPD may affect the pulmonary system and cause hypoxia. In the present case, both hepatopulmonary syndrome (HPS) and pulmonary arteriovenous fistulas (PAVFs) developed in a child with NPD and were successfully treated with repeated embolization. Case Presentation: We have reported the case of a 16-year-old-girl with NPD who suffered severe hypoxia, dyspnea, fatigue, had multiple PAVFs, and was diagnosed with type 2 HPS. To improve oxygenation, 10 PAVFs were embolized. She needed re-embolization after 9 months because of hypoxia redevelopment. Conclusions: Pulmonary involvement, HPS, and/or PAVFs could be responsible for hypoxemia in patients with NPD, who should, therefore, be investigated for HPS and PAVFs. Embolization could be beneficial. Some patients may need repeated embolization.

Prenatal diagnosis of double-outlet right ventricle with tricuspid valve atresia, anomalous pulmonary vein connection, persistent left superior vena cava, and right atrial isomerism

Double-outlet right ventricle is a conotruncal cardiac disease in which both the aorta and the pulmonary artery predominantly or completely originate from the right ventricle. Here, we report a complex variant double-outlet right ventricle detected in utero and identified on the basis of a segmental approach.

Pulmonary arteriovenous fistula diagnosed by transthoracic contrast echocardiography: A case report

We report the case of a 38-year-old woman who was admitted due to right limb numbness. A right-to-left shunt (RLS) was detected by transthoracic contrast echocardiography (cTTE), and microbubbles appeared in the left heart seven cardiac cycles after opacification of the right heart, suggesting pulmonary arteriovenous fistula. This was supported by computed tomography angiography. She underwent thoracoscopic partial right lower pneumonectomy and recovered after surgery. At 1 year follow-up, she had no relapse of stroke or cerebral infarction. This case shows the typical signs of pulmonary arteriovenous fistula on contrast-enhanced trans-thoracic echocardiography, which allowed an accurate and rapid diagnosis.

A Rare Variant of Hypogenetic Lung Syndrome Mimicking Scimitar Vein

Hypogenetic lung syndrome, also known as scimitar syndrome, is a rare and well-known congenital condition that includes hypoplastic right pulmonary artery and lung, right displacement of the heart, anomalous systemic arterial supply to the lung, and a characteristically curved anomalous right pulmonary vein draining into the inferior vena cava. In exceptional cases, the anomalous pulmonary vein may drain into left atrium. We here report a case of a 17-year-old girl with a rare variant of hypogenetic lung syndrome diagnosed by means of multimodality imaging and treated with percutaneous occlusion of the aortopulmonary collateral.

OUP accepted manuscript

The coexisting of oesophageal varices with total anomalous pulmonary venous connection is extremely rare but contains a potential leading to a lethal haemorrhage. The fate of the oesophageal varices after total anomalous pulmonary vein connection repair remains largely unknown. We herein report a case with infracardiac type total anomalous pulmonary venous connection with remarkable oesophageal varices. In the present case, of note, the oesophageal varices were completely regressed after total anomalous pulmonary venous connection repair without any intervention. This case might help a surgical team reduce the hesitation to repair the total anomalous pulmonary venous connection regardless of oesophageal varices, a potentially fatal condition.

Outcomes of Coil Embolization for Pulmonary Arteriovenous Fistula as Evaluated Using a Novel Soft Ultrasound Probe Pasted to the Neck

An 81-year-old woman presented to our emergency room by ambulance with gait disturbance and pain in her left neck. Magnetic resonance imaging (MRI) showed acute left-sided dorsolateral medullary infarction and an occluded left vertebral artery. The temporal bone echo window was insufficient, but our pastable soft ultrasound probe attached to the cervix (PSUP) detected many microembolic signals caused by the contrast agent (cMES) in the common carotid artery. Chest CT revealed right pulmonary arteriovenous fistula (PAVF) and she underwent coil embolization for PAVF considering the possibility of paradoxical embolism via PAVF. After embolization, the cMES disappeared on PSUP. Therefore, PSUP was useful for diagnosing and confirming the interventional procedural success for performing PAVF.

[Brain abscess and Osler-Weber-Rendu syndrome: Do not forget to look for pulmonary arteriovenous malformations]

INTRODUCTION

Osler-Rendu-Weber syndrome or hereditary hemorrhagic telangiectasia affects between 1/5000 and 1/8000 people. It is characterized by presence of recurrent epistaxis, mucocutaneous telangiectasia and visceral arteriovenous malformations. It is a genetic disease with autosomal dominant transmission inducing an endothelial cells hyper-proliferation.

CASE REPORT

A 68-year-old women with Osler-Rendu-Weber syndrome was referred for management of general impairment with confusional syndrome and hyperthermia. Various examinations have allowed us to conclude at diagnosis of brain abscess with ventriculitis probably favored by right-left shunt secondary to pulmonary arteriovenous malformations. Evolution was favorable after antibiotic treatment and endovascular embolization.

CONCLUSION

In case of brain abscess without obvious promoting factor, don't forget to looking for a right-left shunt providing septic or aseptic emboli. Furthermore, diagnosis of Rendu-Osler-Weber syndrome should be considered presence of telangiectasias and/or epistaxis.

Aspergillus mediastinitis in a post-operative immunocompetent child

Post-operative Aspergillus mediastinitis is regarded to be a devastating infection, usually affecting patients undergoing cardiothoracic surgery with specific predisposing factors characterised by a high mortality and chronic morbidity. Patient outcome after such a complication is extremely poor despite antifungal therapy and surgery. We describe the case of an immunocompetent 2-month-old child with obstructed supracardiac total anomalous pulmonary venous circulation (TAPVC) and severe pulmonary artery hypertension, who underwent TAPVC repair through median sternotomy and developed post-operative mediastinitis due to Aspergillus flavus.

Meandering pulmonary veins: Two case reports

RATIONALE

Meandering pulmonary vein is a rare congenital pulmonary vascular anomaly. It presents unilateral single pulmonary vein that takes a circuitous route in the lung and drains normally into the left atrium. Most cases of meandering pulmonary vein have been reported to be right-sided. A few of them coincided with features of scimitar syndrome.

PATIENT CONCERNS

A 71-year-old woman and a 20-year-old man presented with incidentally found abnormal findings on chest radiographs.

DIAGNOSIS

Through multi-detector chest computed tomography, the 71-year-old woman was diagnosed as left-sided meandering pulmonary vein without any other anomalies while the 20-year-old man was diagnosed as having right-sided meandering pulmonary vein with features of scimitar syndrome.

INTERVENTIONS

Specific intervention was not performed for either patient.

OUTCOMES

These patients were reassured and discharged. They are doing well without any respiratory symptoms.

LESSONS

Meandering pulmonary veins can occur on the left side and coincide with features of scimitar syndrome. Multi-detector computed tomography with 3D reconstruction allows clear depiction of vascular connections and associated anomalies, obviating the need for invasive procedures.

Management of paradoxical embolism in a patient with coexisting patent foramen ovale and masked pulmonary arteriovenous fistula: A case report

RATIONALE

Paradoxical embolism (PE) is an important cause of cryptogenic stroke, particularly in young patients, which usually have a relation with an unexpected route in circulation. Here we report a rare case of cryptogenic stroke carried 2 uncommon malformations.

PATIENT CONCERNS

A 48-year-old female experienced double neurological events in just 2 months.

DIAGNOSIS

Patent foramen ovale was diagnosed with transesophageal echocardiography and successfully occluded in the first admission due to stroke. In the second admission, chest tomographic angiography found a chordae shadow in the right middle lobe, was the first clue for pulmonary arteriovenous fistula (PAVF), thereafter further confirmed by the enhanced pulmonary computed tomographic angiography.

INTERVENTIONS

This patient then received intervention occlusion therapy with coils for PAVF under the help of microcatheter. Given the possible native origin of the thrombus in PAVF due to the spiral morphology, dual antiplatelet therapy was prescribed for this patient for the first 3 months to prevent device-related embolism after discharge, and the following single antiplatelet therapy was mandated.

OUTCOMES

No recanalization was detected on the follow-up enhanced pulmonary computed tomographic angiography (PCTA), no neurological defect event recurred in the 16 months of follow-up.

LESSONS

Computed tomograph (CT) deserved more value in screening and depicting the morphology of the PAVF, particular in young adults with no apparent arteriosclerotic risk factor. Microcatheter would be helpful for intervention treatment. Antiplatelet therapy might be adequate in specific patients, yet definitely need more evidence to verify.

Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations in brain abscess patients: a nationwide, population-based matched cohort study

OBJECTIVES

The extent of hereditary haemorrhagic telangiectasia (HHT) and pulmonary arteriovenous malformations (PAVMs) as a risk factor for brain abscess is unknown.

METHODS

Nationwide and population-based registries were used to identify persons with first-time hospitalization for brain abscess (index date) and population controls matched by age, sex and residence (1:10). Accounting for competing risks, cumulative incidence curves of new diagnosis of HHT/PAVM after brain abscess were constructed. Next, Cox regression was used for computation of cause-specific hazard rate ratios (HRRs) adjusted for severe liver disease and congenital heart disease as potential confounders.

RESULTS

HHT/PAVM was prevalent before the index date in 2/1384 (0.1%; 95% CI 0.02-0.52) brain abscess patients and 6/13 838 (0.04%; 95% CI 0.02-0.09) matched population controls. After the index date, a new diagnosis of hereditary haemorrhagic telangiectasia or pulmonary arteriovenous malformations was made in 15/1384 brain abscess patients (range 0 days to 17 years) compared with 7/13 812 population controls yielding an adjusted hazard rate ratio of 31.4 (95% CI 9.95-98.9). Cumulative incidence was 1.5% for brain abscess patients and 0.1% for population controls.

DISCUSSION

HHT/PAVM should be considered in patients with cryptogenic brain abscess, although absolute risk is low.

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.