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Vieri M, Brümmendorf TH, Beier F. Treatment of telomeropathies. Best Pract Res Clin Haematol 2021; 34:101282. [PMID: 34404536 DOI: 10.1016/j.beha.2021.101282] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 10/21/2022]
Abstract
Telomeropathies or telomere biology disorders (TBDs) are a group of rare diseases characterised by altered telomere maintenance. Most patients with TBDs show pathogenic variants of genes that encode factors involved in the prevention of telomere shortening. Particularly in adults, TBDs mostly present themselves with heterogeneous clinical features that often include bone marrow failure, hepatopathies, interstitial lung disease and other organ sites. Different degrees of severity are also observed among patients with TBDs, ranging from very severe syndromes manifesting themselves in early childhood, such as Revesz syndrome, Hoyeraal-Hreidarsson syndrome, and Coats plus disease, to dyskeratosis congenita (DKC) and adult-onset "cryptic" forms of TBD, which often affect fewer organ systems. Overall, the most relevant clinical complications of TBD are bone marrow failure, lung fibrosis, and liver cirrhosis. In this review, we summarise recent advances in the management and treatment of TBD and provide a brief overview of the various treatment approaches.
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Affiliation(s)
- Margherita Vieri
- Department of Hematology, Oncology, Hemostaseology, Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany.
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany.
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology, Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany.
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Niewisch MR, Savage SA. An update on the biology and management of dyskeratosis congenita and related telomere biology disorders. Expert Rev Hematol 2019; 12:1037-1052. [PMID: 31478401 DOI: 10.1080/17474086.2019.1662720] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Telomere biology disorders (TBDs) encompass a group of illnesses caused by germline mutations in genes regulating telomere maintenance, resulting in very short telomeres. Possible TBD manifestations range from complex multisystem disorders with onset in childhood such as dyskeratosis congenita (DC), Hoyeraal-Hreidarsson syndrome, Revesz syndrome and Coats plus to adults presenting with one or two DC-related features.Areas covered: The discovery of multiple genetic causes and inheritance patterns has led to the recognition of a spectrum of clinical features affecting multiple organ systems. Patients with DC and associated TBDs are at high risk of bone marrow failure, cancer, liver and pulmonary disease. Recently, vascular diseases, including pulmonary arteriovenous malformations and gastrointestinal telangiectasias, have been recognized as additional manifestations. Diagnostics include detection of very short leukocyte telomeres and germline genetic testing. Hematopoietic cell transplantation and lung transplantation are the only current therapeutic modalities but are complicated by numerous comorbidities. This review summarizes the pathophysiology underlying TBDs, associated clinical features, management recommendations and therapeutic options.Expert opinion: Understanding TBDs as complex, multisystem disorders with a heterogenous genetic background and diverse phenotypes, highlights the importance of clinical surveillance and the urgent need to develop new therapeutic strategies to improve health outcomes.
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Affiliation(s)
- Marena R Niewisch
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Successful use of calcium channel blocker for management of arterio-venous malformations following Fontan procedure. Cardiol Young 2018; 28:1468-1470. [PMID: 30156174 DOI: 10.1017/s1047951118001488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In diffuse forms of arteriovenous malformation following Fontan procedure, "classical" medical therapy, inhaled nitric oxide and sildenafil, may play a role, until re-direction of hepatic flow to pulmonary circulation cures it. However, in refractory cases, as reported in our 2-year-old patient, unusual medications such as calcium channel blockers can be tried and continued if patients respond adequately.
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Khincha PP, Bertuch AA, Agarwal S, Townsley DM, Young NS, Keel S, Shimamura A, Boulad F, Simoneau T, Justino H, Kuo C, Artandi S, McCaslin C, Cox DW, Chaffee S, Collins BF, Giri N, Alter BP, Raghu G, Savage SA. Pulmonary arteriovenous malformations: an uncharacterised phenotype of dyskeratosis congenita and related telomere biology disorders. Eur Respir J 2017; 49:13993003.01640-2016. [PMID: 27824607 DOI: 10.1183/13993003.01640-2016] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/07/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Payal P Khincha
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Suneet Agarwal
- Division of Haematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Danielle M Townsley
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Siobán Keel
- Division of Haematology, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Akiko Shimamura
- Division of Haematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Farid Boulad
- Paediatric Oncology and Bone Marrow Transplant Service, Dept of Paediatrics, Memorial Sloan Kettering Cancer Centre, New York, NY, USA
| | - Tregony Simoneau
- Dept of Pulmonology, Connecticut Children's Medical Centre, Hartford, CT, USA
| | | | - Christin Kuo
- Dept of Pulmonology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Steven Artandi
- Cancer Biology Program, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Des W Cox
- Paediatric Respiratory Medicine, Our Lady's Children's Hospital, Dublin, Ireland
| | - Sara Chaffee
- Paediatric Haematology Oncology, Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Bridget F Collins
- Centre for Interstitial Lung Diseases, Division of Pulmonary and Critical Care Medicine/Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Neelam Giri
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ganesh Raghu
- Centre for Interstitial Lung Diseases, Division of Pulmonary and Critical Care Medicine/Dept of Medicine, University of Washington, Seattle, WA, USA.,Both authors contributed equally
| | - Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.,Both authors contributed equally
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Pulmonary complications post hematopoietic stem cell transplant in dyskeratosis congenita: analysis of oxidative stress in lung fibroblasts. Bone Marrow Transplant 2017; 52:765-768. [PMID: 28092351 DOI: 10.1038/bmt.2016.353] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Gorgy AI, Jonassaint NL, Stanley SE, Koteish A, DeZern AE, Walter JE, Sopha SC, Hamilton JP, Hoover-Fong J, Chen AR, Anders RA, Kamel IR, Armanios M. Hepatopulmonary syndrome is a frequent cause of dyspnea in the short telomere disorders. Chest 2016; 148:1019-1026. [PMID: 26158642 DOI: 10.1378/chest.15-0825] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Telomere syndromes have their most common manifestation in idiopathic pulmonary fibrosis and emphysema. The short telomere defect in these patients may manifest systemically as bone marrow failure and liver disease. We sought to understand the causes of dyspnea in telomerase and telomere gene mutation carriers who have no parenchymal lung disease. METHODS Clinical and pathologic data were reviewed as part of a Johns Hopkins-based natural history study of short telomere syndromes including dyskeratosis congenita. RESULTS Hepatopulmonary syndrome (HPS) was diagnosed in nine of 42 cases (21%). Their age at presentation was significantly younger than that of cases initially presenting with pulmonary fibrosis and emphysema (median, 25 years vs 55 years; P < .001). Cases had evidence of intra- and extrapulmonary arteriovascular malformations that caused shunt physiology. Nodular regenerative hyperplasia was the most frequent histopathologic abnormality, and it was seen in the absence of cirrhosis. Dyspnea and portal hypertension were progressive, and the median time to death or liver transplantation was 6 years (range, 4-10 years; n = 6). In cases that underwent liver transplantation, dyspnea and hypoxia improved, but pulmonary fibrosis subsequently developed. CONCLUSIONS This report identifies HPS as a frequent cause of dyspnea in telomerase and telomere gene mutation carriers. While it usually precedes the development of parenchymal lung disease, HPS may also co-occur with pulmonary fibrosis and emphysema. Recognizing this genetic diagnosis is critical for management, especially in the lung and liver transplantation setting.
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Affiliation(s)
| | | | - Susan E Stanley
- Department of Oncology, Baltimore, MD; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Amy E DeZern
- Department of Oncology, Baltimore, MD; Department of Medicine, Baltimore, MD
| | - Jolan E Walter
- Department of Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA
| | | | | | - Julie Hoover-Fong
- Department of Pediatrics, Baltimore, MD; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Mary Armanios
- Department of Oncology, Baltimore, MD; Department of Pathology, Baltimore, MD; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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Steal phenomenon-induced lung perfusion defects in pulmonary arteriovenous fistulas: assessment with automated perfusion SPECT-CT fusion images. Nucl Med Commun 2010; 31:821-9. [DOI: 10.1097/mnm.0b013e32833c303a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Boueiz A, Abougergi MS, Noujeim C, Assaf EB, Jamaleddine G. Fatal bilateral pneumothoraces complicating dyskeratosis congenita: a case report. J Med Case Rep 2009; 3:6622. [PMID: 19830116 PMCID: PMC2726487 DOI: 10.1186/1752-1947-3-6622] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Accepted: 01/22/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Dyskeratosis congenita is a rare genodermatosis, characterized by a triad of reticular skin pigmentation, nail dystrophy and leukoplakia of mucous membranes. It is also associated with a variety of non-cutaneous abnormalities such as bone marrow failure, malignancy and pulmonary complications. Among its wide range of clinical manifestations, fatal pneumothorax has rarely been reported. CASE PRESENTATION We report the case of a 31-year-old Lebanese woman with dyskeratosis congenita who succumbed to devastating bilateral pneumothoraces. CONCLUSION Careful surveillance of patients with dyskeratosis congenita is required as incipient respiratory failure due to pneumothorax may be successfully treated if detected at an early stage.
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Pierucci P, Murphy J, Henderson KJ, Chyun DA, White RI. New Definition and Natural History of Patients With Diffuse Pulmonary Arteriovenous Malformations. Chest 2008; 133:653-61. [DOI: 10.1378/chest.07-1949] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Noli K, Solomon M, Golding F, Charron M, Ling SC. Prevalence of hepatopulmonary syndrome in children. Pediatrics 2008; 121:e522-7. [PMID: 18310172 DOI: 10.1542/peds.2007-1075] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The hepatopulmonary syndrome is defined as a triad of liver disease, hypoxemia, and intrapulmonary vascular dilation. The reported prevalence of hepatopulmonary syndrome in adults with cirrhosis ranges from 4% to 29%; however, the prevalence of hepatopulmonary syndrome and its outcome in children is unknown. The objective of this study was to describe prospectively the prevalence of intrapulmonary vascular dilation and hepatopulmonary syndrome in children with liver disease. METHODS Pulse oximetry was undertaken in children with liver disease, and those with oxygen saturation < or = 97%, those with cirrhosis, and those with clinically severe portal hypertension from other causes underwent contrast-enhanced echocardiography for detection of intrapulmonary vascular dilations. Patients with intrapulmonary vascular dilation underwent arterial blood gas analysis and technetium-99m-labeled macroaggregated albumin scan. RESULTS Oxygen saturation was measured in 301 children and was < or = 97% in 8. These 8 and an additional 18 patients with cirrhosis or portal hypertension underwent contrast-enhanced echocardiography. Seven (27%) patients had intrapulmonary vascular dilation detected by contrast-enhanced echocardiography; 2 of these patients had abnormal arterial blood gas analysis and thus met diagnostic criteria for hepatopulmonary syndrome (representing 8% of patients with cirrhosis or severe portal hypertension). Both patients with hepatopulmonary syndrome had abnormal pulse oximetry. Technetium-99m-labeled macroaggregated albumin scans for 6 patients showed a median 6.5% (range: 4%-12%) tracer uptake outside the lungs. CONCLUSIONS Hepatopulmonary syndrome occurs in an important minority of children with cirrhosis or severe portal hypertension. Additional studies should be undertaken to determine the importance of intrapulmonary vascular dilation without hepatopulmonary syndrome and the impact of hepatopulmonary syndrome on the outcomes of affected children.
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Affiliation(s)
- Khalid Noli
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada
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Alehan D, Dogan OF, Karagoz T. Idiopathic bilaterally diffuse arteriovenous fistulas causing severe central cyanosis. Pediatr Cardiol 2007; 28:412-3. [PMID: 17710358 DOI: 10.1007/s00246-005-8023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- D Alehan
- Division of Pediatric Cardiology, Hacettepe University Medical Faculty, Sihhiye, Ankara, Turkey
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Pfleger A, Gamillscheg A, Popper HH, Smolle-Jüttner FM, Zach MS. Diffuse Pulmonary Arteriovenous Malformations in a Teenager with Corrected Total Anomalous Pulmonary Venous Drainage. Respiration 2005; 74:106-9. [PMID: 16106112 DOI: 10.1159/000087367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 09/15/2004] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED This case report describes a 13-year-old boy with diffuse microvascular pulmonary arteriovenous malformations, in whom total anomalous pulmonary venous drainage had been corrected surgically in the newborn period. Contrast transesophageal echocardiography, cardiac catheterization and a lung perfusion scan suggested, and lung biopsy confirmed the diagnosis in our patient. Treatment with nifedipin was commenced. CONCLUSION This case illustrates the diagnostic difficulties with this rare malformation.
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Affiliation(s)
- Andreas Pfleger
- Respiratory and Allergic Disease Division, Pediatric Department, University of Graz, Graz, Austria.
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Hirota T, Yamagami T, Nakamura T, Okuyama C, Ushijima Y, Nishimura T. Small pulmonary arteriovenous fistulae revealed by scintigraphy during selective injection of 99Tc(m)-macroaggregated albumin. Br J Radiol 2004; 77:445-8. [PMID: 15121712 DOI: 10.1259/bjr/80737867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report a case of small pulmonary arteriovenous fistulae precisely diagnosed by a combination of selective pulmonary arteriography and scintigraphy during (99)Tc(m)-macroaggregated albumin injection via the peripheral pulmonary artery.
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Affiliation(s)
- T Hirota
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
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Gordijn SJ, Brand PLP. A boy with breathlessness, digital clubbing and central cyanosis. Eur J Pediatr 2004; 163:129-30. [PMID: 14652749 DOI: 10.1007/s00431-003-1368-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2003] [Accepted: 10/16/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Sanne J Gordijn
- Department of Paediatrics, Isala Klinieken, 10500, 8000 GM Zwolle, The Netherlands
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Abstract
A 3-week-old full-term female neonate was admitted with a 4-day history of episodic stridor, desaturations and difficult feeding. Initial assessment using fluoroscopy suggested distal tracheomalacia. Inhalational induction for examination under anaesthesia of the upper airway at 4 weeks of age caused almost complete airway obstruction due to severe anterior, or epiglottic, laryngomalacia. This airway obstruction was unresponsive to continuous positive airway pressure, the use of an oropharyngeal airway and hand ventilation and required urgent tracheal intubation using suxamethonium. Epiglottopexy, a relatively unknown procedure, was performed uneventfully 2 days later, with complete relief of the respiratory compromise. However, the infant remained desaturated postoperatively. A ventilation perfusion scan subsequently revealed multiple pulmonary arteriovenous malformations, unsuitable for embolization and requiring nocturnal home oxygen therapy. Review at 3 months of age found a thriving infant with no airway obstruction and good epiglottic positioning on examination under anaesthesia. Although the patient's oxygen requirements had diminished, the long-term outcome remains uncertain.
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Affiliation(s)
- David De Beer
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Chessa M, Drago M, Krantunkov P, Bini MR, Butera G, De Rosa G, Bossone E, Carminati M. Differential diagnosis between patent foramen ovale and pulmonary arteriovenous fistula in two patients with previous cryptogenic stroke caused by presumed paradoxical embolism. J Am Soc Echocardiogr 2002; 15:845-6. [PMID: 12174357 DOI: 10.1067/mje.2002.120289] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Development of improved devices for interventional closure of atrial septal defect and patent foramen ovale increased the number of adult patients who are being referred for transcatheter closure. We report two cases that were scheduled for patent foramen ovale closure because of a right-to-left atrial shunt detected at contrast transesophageal echocardiography in another institution and that were found to have pulmonary arteriovenous fistulas. Embolization of pulmonary arteriovenous fistulas was carried out successfully by transcatheter technique.
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Affiliation(s)
- Massimo Chessa
- Pediatric Cardiology, Istituto Policlinico San Donato, Milan, Italy.
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