Massive pulmonary arteriovenous fistula in the newborn

Hemodynamic Assessment of a Large Pulmonary Arteriovenous Malformation in a Neonate: Case Report and Review of Literature

Herein we report the case of a neonate with a prenatally diagnosed large pulmonary arteriovenous malformation, managed with minimally invasive hemodynamic monitoring in our Neonatal Intensive Care Unit. The combination of Near-Infrared Spectroscopy and Pressure Recording Analytical Method could guide neonatal management of critical cases of vascular anomalies: immediate data are offered to clinicians, from which therapeutic decisions such as timing of surgical resection are made to achieve a positive outcome. We also systemically collected and summarized information on patients' characteristics of previous cases reported in literature to data, and we compared them to our case.

Closure of right pulmonary artery to left atrium fistula by duct occluder device

We report the successful transcatheter closure of the right pulmonary artery fistula to the left atrium in a 4-year-old boy, who had presented with cyanosis and easy fatigability, identified after two-dimensional echocardiogram with bubble contrast study, computed tomography (CT) angiography, and cardiac catheterization. The fistula was successfully closed by a transcatheter approach using an 18/16 duct occluder device. There was marked improvement clinically and no complication on 2-months follow-up.

Asymptomatic pulmonary arteriovenous malformations in children with hereditary hemorrhagic telangiectasia

BACKGROUND

Children with Hereditary Hemorrhagic Telangiectasia (HHT) may have pulmonary arteriovenous malformations (AVMs), which can lead to symptoms of shortness of breath, exercise intolerance, clubbing, cyanosis and hemoptysis. However, some patients with pulmonary AVMs may be asymptomatic, placing them at risk for complications such as stroke or brain abscess if they are not identified and treated. This study examines the incidence of signs and symptoms associated with pulmonary AVMs in children with HHT known to have pulmonary AVMs.

METHOD

Sixty-one children with HHT and documented pulmonary AVMs were questioned for any symptoms possibly associated with their pulmonary AVMs, prior to embolization.

RESULTS

The results show that the majority of these children were asymptomatic (56%), and their AVMs were discovered by routine screening. Those who did experience symptoms most often complained of shortness of breath and exercise intolerance, although there was a tendency to blame other conditions, such as asthma or deconditioning (being out of shape), for these symptoms. Migraine headaches were common in those with pulmonary AVMs, regardless of whether they were symptomatic or not (17 of 61 children, 28%), although they were more common in those who were symptomatic (10 of 27, 37%) versus those who were asymptomatic (7 of 34, 21%).

CONCLUSION

Children with HHT and pulmonary AVMs are often asymptomatic. Routine screening for the presence of AVMs should be performed regardless of symptomatology.

Right pulmonary artery to left atrial fistula in a neonate: case report and review of the literature

A communication between the right pulmonary artery (RPA) and the left atrium is a rare congenital anomaly that presents with cyanosis and heart failure. We describe the surgical repair of an RPA to left atrial fistula using cardiopulmonary bypass in a neonate. Advanced imaging (computed tomography scan) guided the surgical approach. Although previous reports have associated a patent ductus arteriosus with high neonatal mortality, in our case, the ductus arteriosus was actually important for maintaining enough total pulmonary blood flow.

Long-term follow-up in 12 children with pulmonary arteriovenous malformations: confirmation of hereditary hemorrhagic telangiectasia in all cases

OBJECTIVE

To assess whether pulmonary arteriovenous malformation (PAVM) is associated with hereditary hemorrhagic telangiectasia (HHT).

STUDY DESIGN

This study was a review of 12 children (sex ratio = 1) including family history, mutation analysis, and long-term follow-up.

RESULTS

Five children were under age 3 years when PAVM was diagnosed. Presentations included pulmonary symptoms (n = 8), cerebral abscess (n = 2), and transient ischemic attack (TIA) (n = 1); 1 patient was asymptomatic. Nine of the 12 children (75%) had a family history of PAVM. The diagnosis of HHT was confirmed in all cases. A mutation in ENG was found in 9 of the 10 children available for testing. No mutation in ACVRL1 was found. During long-term follow-up (mean, 16 years), the following complications occurred: TIA (n = 2), hemoptysis (n = 2), and cerebral abscess (n = 2). Nine children experienced recurrence of PAVM. The children with no recurrence were those without a family history of PAVM.

CONCLUSIONS

The diagnosis of HHT should be considered in a child with an apparently isolated PAVM. Because serious complications may occur at any age, we recommend screening for PAVM and long-term follow-up in children from families with HHT, especially those with an ENG mutation.

Right Pulmonary Artery to Left Atrium Communication

This is a collective review of 59 published cases of right pulmonary artery to left atrium communication in the English-language literature. In this article, we review the literature on the clinical presentation, anatomic variations, diagnostic features, and management considerations of previously reported cases. Two-dimensional echocardiography and cardiac catheterization including selective angiography provided the necessary diagnostic information and defined the anatomy before surgery in all patients. Various management options including medical, surgical, and transcatheter closure have been reported. The lesions have been classified into four types (I, II, III, and IV) that have a bearing on the appropriate surgical approach and techniques of repair that are discussed in the text. Use of extracorporeal circulation may be considered in selected instances. The operative mortality rate during the earlier era (1950 to 1979) was high, at 22%. More recently, the mortality rate has approached zero. An individualized surgical approach depending on the type of surgical connections is recommended.

Pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations rarely present in childhood. Two cases are presented in this report. Both the cases presented clinically with cyanosis and clubbing without a cardiac murmur. The second case had cerebral abscess in addition. Both the cases underwent a contrast-enhanced echocardiography which suggested the presence of pulmonary arteriovenous malformations. The first case also underwent 99mTc radionuclide scan and pulmonary angiography. The cases are being reported for their characteristic clinical features and for emphasizing the role of non-invasive modalities like contrast-enhanced echocardiography and radionuclide scan in reaching the diagnosis.

Right pulmonary artery left atrium communication

A 12-year-old boy presented with central cyanosis, clubbing, and ejection systolic murmur in the left second and third intercostal space. Chest roentgenogram showed a round opacity on the right border of cardiac silhouette. Echocardiography revealed a communication between right pulmonary artery and left atrium, which was later confirmed on selective pulmonary cineangiography. Successful surgical ligation without cardiopulmonary bypass resulted in the cure of the disease.

Surgical treatment of a fistula between the right pulmonary artery and the left atrium: presentation of two cases and review of literature

OBJECTIVE

A direct communication between the pulmonary artery and the left atrium is a rare anomaly. On the basis of two cases of our own and a literature review of 49 cases, we focus on clinical presentation, anatomy, diagnosis, and the role of surgery.

METHODS

Two cases of a fistula between the right pulmonary artery and the left atrium are described in a girl of 4 years and a boy of 15 years. Both presented with unexplained cyanosis. Diagnosis was made on echocardiography and angiography. The fistula was ligated using extracorporeal circulation in the first case and not in the second case.

RESULTS

The surgical results were successful with resolution of the cyanosis.

CONCLUSIONS

In newborns, urgent surgery may be necessary. In other patients, early elective surgical correction should be performed to prevent complications, especially systemic and cerebral emboli, cerebral abscesses, and rupture of aneurysmal fistulas. Complete cure can be achieved by ligation and possible division or by intracardiac repair.

Pulmonary arteriovenous malformation in the newborn: a familial case

Pulmonary arteriovenous malformation (PAVM) is a rare cause of cyanosis in the newborn with nine previously reported cases. Typical signs at presentation include cyanosis, murmur, and congestive heart failure. Abnormality on chest x-ray is common with cardiomegaly, oligemia, and focal pulmonary density. There is a male predominance, unlike older children and adults with PAVM. Familial cases of PAVM have been reported with Osler-Weber-Rendu syndrome. We report a familial case of PAVM presenting in the newborn.

Congenital vertebral-jugular fistula in an infant

Pediatric cardiologists are often consulted to evaluate continuous murmurs in children. This case report describes a child with a congenital vertebral-jugular fistula who presented with torticollis and a continuous murmur. The differential diagnosis of continuous murmurs in this setting is discussed.

Pulmonary artery to the left atrium fistula as an unusual cause of cyanosis in the newborn

A fistula between the pulmonary artery (PA) and the left atrium (LA) is a rare form of congenital heart disease, 34 cases having been described in the literature, all from the right pulmonary artery (RPA). Only six cases were diagnosed in the newborn period. We report such a case, diagnosed at 1 day of age by Doppler echocardiography, with an unusual site of the fistula.

Congestive heart failure secondary to cerebral arterio-venous fistula

Arteriovenous fistula is a relatively rare cause of severe congestive heart failure in the newborn. An intracranial arteriovenous malformation associated with an aneurysm of the great vein of Galen is the most frequent of such malformations and, although well known, it remains a difficult diagnosis in the neonate because the clinical picture first presents with findings suggesting cardiac disease. The newborn with a vein of Galen aneurysm has volume and pressure overload on his myocardium; cyanosis is often present due to persistent fetal circulation; peripheral pulses are generally decreased in amplitude except in those arteries near the fistula where they are bounding, as an expression of a hyperdynamic status. A continuous murmur may be heard over the scalp, but this highly suggestive sign is often not present. The majority of newborns with intracranial arteriovenous fistula die very soon. Unfortunately, most of these infants are at first considered to have congenital heart disease and are, therefore, subjected to cardiac catheterization and angiography, with their well-known risks, before a correct diagnosis is made. Cross-sectional echocardiography, by demonstrating normal intracardiac anatomy, eliminates the need for an invasive investigation in a very sick neonate. Ultrasonography of the head will then provide a rapid and accurate demonstration of the aneurysm of vein of Galen. Cerebral angiography will complete the diagnosis in those cases in which a neurosurgical intervention is contemplated.

Evaluation of pulmonary vascular resistance in the presence of a large pulmonary arteriovenous malformation

A 1 day old infant presented with severe cyanosis and congestive heart failure. Cardiac catheterization confirmed the clinical suspicion of a pulmonary arteriovenous malformation of the right lower lobe. Catheter occlusion of the right lower pulmonary artery allowed evaluation of the integrity of the remaining pulmonary vascular bed as well as improvement of the patient's hemodynamic condition pending more definitive therapy.

Direct communication between the pulmonary artery and left atrium

A case of direct communication between the right pulmonary artery and left atrium is described in a 5-day-old boy, who was successfully operated upon. All the 20 cases reported in the literature have been reviewed, with special reference to diagnosis, surgical treatment and pathoanatomical and embryological findings.

Congenital pulmonary arteriovenous fistula producing pulmonary arterial steal syndrome

This report describes a congenital pulmonary arterial steal syndrome manifested as cyanosis and acidosis in a newborn. A fistulous connection between the right pulmonary artery and a large, anomalous right common pulmonary vein stole blood from the pulmonary arteries. The anomaly was suspected because of a pericardiac shadow on frontal and lateral chest films, substantiated by M-mode echocardiogram, confirmed at cardiac catheterization with angiocardiography, and analyzed at postmortem examination.