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Shu L, Luo L, Zuo Y. Attention to pulmonary arteriovenous fistula in a case of transient hypoxemia and cerebral infarction during pregnancy: a case report and literature review. BMC Pregnancy Childbirth 2023; 23:626. [PMID: 37653522 PMCID: PMC10469831 DOI: 10.1186/s12884-023-05946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 08/22/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Pulmonary arteriovenous fistula is rare during pregnancy. Pulmonary arteriovenous fistula presents no pulmonary symptoms in most patients but can be exacerbated by pregnancy. If not diagnosed and treated promptly, pulmonary arteriovenous fistula can lead to respiratory failure, stroke, spontaneous hemothorax, or other fatal complications. CASE PRESENTATION A 29-year-old healthy pregnant woman presented with a transient drop in blood oxygen level of unknown cause during a routine examination at 34 weeks of gestation and during a cesarean section at 38 weeks of pregnancy. The patient's oxygen saturation quickly returned to normal and was not further investigated. On day 3 postpartum, the patient suddenly displayed slurred speech and right limb myasthenia. A head magnetic resonance imaging revealed cerebral infarction in the left basal ganglia. Subsequent computed tomography pulmonary arteriography revealed bilateral pulmonary arteriovenous fistula, which was likely the cause of cerebral infarction. The patient was transferred to the Department of Thoracic Surgery after one month of treatment and successfully underwent percutaneous embolization of pulmonary arteriovenous fistula. CONCLUSION Pulmonary arteriovenous fistula should not be neglected if a pregnant woman presents with transient hypoxemia and cerebral infarction. A transient decrease in pulse oxygen saturation that cannot be explained by common clinical causes can be an early warning sign of the disease. Early diagnosis and multidisciplinary management could improve the prognosis.
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Affiliation(s)
- Lijuan Shu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
- The Research Units of West China (2018RU012) - Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, Sichuan, P.R. China
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
| | - Linli Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, Sichuan, P.R. China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China.
- The Research Units of West China (2018RU012) - Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China.
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Evolution of Pulmonary Arteriovenous Malformations: The Role of Contrast Echocardiography. Chest 2023; 163:669-677. [PMID: 36368615 DOI: 10.1016/j.chest.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Pulmonary arteriovenous malformations (PAVMs) are direct connections between the pulmonary artery and the pulmonary vein, mostly associated with hereditary hemorrhagic telangiectasia (HHT). PAVMs can lead to severe neurologic complications such as stroke and brain abscess. The risk of complications decreases after embolization. Therefore, screening for PAVMs using transthoracic contrast echocardiography (TTCE) is recommended, including a rescreening interval of 5 years. RESEARCH QUESTION Is extension of the interval for rescreening patients without a pulmonary right-to-left shunt (RLS) of up to 10 years appropriate? STUDY DESIGN AND METHODS Adult patients with HHT with 5- or 10-year follow-up TTCE, or both, were included. Patients who underwent PAVM embolization in the past or at baseline were excluded. The RLS grades and presence of a treatable PAVM were compared with baseline. RESULTS In total, 387 patients (median age, 45 years [interquartile range, 33-54 years]; 56% women) involving 5- and 10-year follow-up data in 363 and 166 patients, respectively, were included. None of the patients (n = 148) without a pulmonary RLS at baseline demonstrated a treatable PAVM after 5 and 10 years. Of the patients with a pulmonary RLS at baseline, 20 patients (9%) and three patients (3%) demonstrated a treatable PAVM at the 5- and 10-year follow-up, respectively. In most patients, the RLS grade remained stable over time. INTERPRETATION On the basis of the results of this retrospective study, we believe that the rescreening interval for patients with HHT without a pulmonary RLS at initial screening may be extended to 10 years. Those with a pulmonary RLS should be rescreened every 5 years because treatable PAVMs can evolve.
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Kroon S, Van Thor MCJ, Vorselaars VMM, Hosman AE, Swaans MJ, Snijder RJ, Mager HJ, Post MC. The use of echo density to quantify pulmonary right-to-left shunt in transthoracic contrast echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:1190-1196. [PMID: 32667638 DOI: 10.1093/ehjci/jeaa155] [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] [Received: 12/06/2019] [Revised: 03/11/2020] [Accepted: 05/14/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Transthoracic contrast echocardiography (TTCE) is the recommended screening tool to detect pulmonary right-to-left shunt (RLS) caused by pulmonary arteriovenous malformations (PAVMs). We assessed a novel method to quantify the RLS using the change in echo density (ED) following contrast injection. METHODS AND RESULTS An analysis of 437 consecutive patients [58% female, 47 years, interquartile range (IQR) 33-60] who underwent TTCE for the detection of a pulmonary RLS. Using ImageJ (National Institutes of Health), the change in ED was measured for each patient. This method was strongly correlated (Spearman's ρ = 0.89; P < 0.0001) with our standard method based on a four-point grading scale (no, mild, moderate, and severe RLS). In patients without a history of embolotherapy (n = 334), a PAVM was detected with chest computed tomography (CT) in 66 and embolotherapy was judged possible in 35 of these patients. The median increase in ED was higher in the latter: +20.1% (IQR 12.3-34.0) compared to non-treatable PAVM +0.2% (IQR -0.2 to 1.1). The specificity to detect treatable PAVMs increased from 87% to 90% when using the novel method without affecting the sensitivity (of 100%). Using the optimal cut-off value of +4.5% increase in ED, 8/74 (11%) needed chest CT-scans-individuals with a moderate or severe RLS-were no longer required without missing any treatable PAVM. CONCLUSIONS The use of ED quantification for pulmonary RLS is promising; resulting in a substantial decrease in the number of chest CT scans needed. However, this method and the threshold should be validated in an independent study population.
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Affiliation(s)
- Steven Kroon
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Mitch C J Van Thor
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Veerle M M Vorselaars
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Anna E Hosman
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Repke J Snijder
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Hans-Jurgen Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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Olsen LB, Kjeldsen AD, Poulsen MK, Kjeldsen J, Fialla AD. High output cardiac failure in 3 patients with hereditary hemorrhagic telangiectasia and hepatic vascular malformations, evaluation of treatment. Orphanet J Rare Dis 2020; 15:334. [PMID: 33243256 PMCID: PMC7691053 DOI: 10.1186/s13023-020-01583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This report addresses how patients with hereditary hemorrhagic telangiectasia (HHT) and high output cardiac failure (HOCF) due to hepatic vascular malformations, should be evaluated and could be treated. HHT is a genetic disorder, leading to vascular abnormalities with potentially serious clinical implications. In the liver, arteriovenous malformations occur in more than 70% of patients, but only about 8% present clinical symptoms such as HOCF with pulmonary hypertension and less commonly portal hypertension, biliary ischemia and hepatic encephalopathy. RESULTS Three female patients with HHT type 2 and HOCF caused by severe arteriovenous malformations in the liver are presented in this case series. The patients were seen at the HHT-Centre at Odense University Hospital. Treatment with either orthotopic liver transplantation (one patient) or bevacizumab (two patients) was initiated. All patients experienced marked symptom relief and objective improvement. New York Heart Association-class were improved, ascites, peripheral edema and hence diuretic treatment was markedly reduced or discontinued in all three patients. Bevacizumab also resulted in notable effects on epistaxis and anemia. CONCLUSION Our findings substantiate the importance of identification of symptomatic arteriovenous malformations in the liver in patients with HHT. Bevacizumab may possibly, as suggested in this case series and supported by previous case studies, postpone the time to orthotopic liver transplantation or even make it unnecessary. Bevacizumab represents a promising new treatment option, which should be investigated further in clinical trials.
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Affiliation(s)
- Lilian B Olsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark
| | - Anette D Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Otorhinolaryngology Head and Neck Surgery, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Mikael K Poulsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Jens Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Annette D Fialla
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark. .,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. .,Institute of Clinical Research, Odense, Denmark.
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Majumdar S, McWilliams JP. Approach to Pulmonary Arteriovenous Malformations: A Comprehensive Update. J Clin Med 2020; 9:E1927. [PMID: 32575535 PMCID: PMC7356967 DOI: 10.3390/jcm9061927] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are abnormal direct vascular communications between pulmonary arteries and veins which create high-flow right-to-left shunts. They are most frequently congenital, usually in the setting of hereditary hemorrhagic telangiectasia (HHT). PAVMs may be asymptomatic or present with a wide variety of clinical manifestations such as dyspnea, hypoxemia, or chest pain. Even when asymptomatic, presence of PAVMs increases patients' risk of serious, potentially preventable complications including stroke or brain abscess. Transcatheter embolotherapy is considered the gold standard for treatment of PAVMs. Though previous guidelines have been published regarding the management of PAVMs, several aspects of PAVM screening and management remain debated among the experts, suggesting the need for thorough reexamination of the current literature. The authors of this review present an updated approach to the diagnostic workup and management of PAVMs, with an emphasis on areas of controversy, based on the latest literature and our institutional experience.
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