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Ma MR, Shi L, Wang F, Cai X, Ma L. Complex Pulmonary Arteriovenous Fistula Presented With Ventricular Tachycardia and Type 2 Acute Myocardial Infarction. Cureus 2024; 16:e61347. [PMID: 38947641 PMCID: PMC11214123 DOI: 10.7759/cureus.61347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 07/02/2024] Open
Abstract
Pulmonary arteriovenous fistula (PAVF) is a rare congenital vascular malformation primarily manifested as dyspnea, migraine, ischemic stroke, hemoptysis, and nervous system complications. However, in our case, an 18-year-old male patient with PAVF presented with sudden onset of ventricular tachycardia and type 2 acute myocardial infarction as initial symptoms. A diagnosis was achieved through pulmonary artery computer tomography angiography (CTA) and three-dimensional (3D) computed tomography (CT) reconstruction, revealing a complex and giant PAVF. Following multidisciplinary team (MDT) consultation, the patient underwent thoracoscopic surgery and experienced a successful recovery during follow-up.
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Affiliation(s)
- Ming Ren Ma
- Cardiology, 940th Hospital, Joint Logistics Support Force, Chinese People's Liberation Army (PLA), Lanzhou, CHN
| | - Liang Shi
- Cardiology, 940th Hospital, Joint Logistics Support Force, Chinese People's Liberation Army (PLA), Lanzhou, CHN
| | - Fei Wang
- Cardiology, 940th Hospital, Joint Logistics Support Force, Chinese People's Liberation Army (PLA), Lanzhou, CHN
| | - Xiaoqing Cai
- Cardiology, 940th Hospital, Joint Logistics Support Force, Chinese People's Liberation Army (PLA), Lanzhou, CHN
| | - Ling Ma
- Cardiology, 940th Hospital, Joint Logistics Support Force, Chinese People's Liberation Army (PLA), Lanzhou, CHN
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2
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Mukhtar G, Shovlin CL. Unsupervised machine learning algorithms identify expected haemorrhage relationships but define unexplained coagulation profiles mapping to thrombotic phenotypes in hereditary haemorrhagic telangiectasia. EJHAEM 2023; 4:602-611. [PMID: 37601877 PMCID: PMC10435691 DOI: 10.1002/jha2.746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 08/22/2023]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) can result in challenging anaemia and thrombosis phenotypes. Clinical presentations of HHT vary for relatives with identical casual mutations, suggesting other factors may modify severity. To examine objectively, we developed unsupervised machine learning algorithms to test whether haematological data at presentation could be categorised into sub-groupings and fitted to known biological factors. With ethical approval, we examined 10 complete blood count (CBC) variables, four iron index variables, four coagulation variables and eight iron/coagulation indices combined from 336 genotyped HHT patients (40% male, 60% female, 86.5% not using iron supplementation) at a single centre. T-SNE unsupervised, dimension reduction, machine learning algorithms assigned each high-dimensional datapoint to a location in a two-dimensional plane. k-Means clustering algorithms grouped into profiles, enabling visualisation and inter-profile comparisons of patients' clinical and genetic features. The unsupervised machine learning algorithms using t-SNE and k-Means identified two distinct CBC profiles, two iron profiles, four clotting profiles and three combined profiles. Validating the methodology, profiles for CBC or iron indices fitted expected patterns for haemorrhage. Distinct coagulation profiles displayed no association with age, sex, C-reactive protein, pulmonary arteriovenous malformations (AVMs), ENG/ACVRL1 genotype or epistaxis severity. The most distinct profiles were from t-SNE/k-Means analyses of combined iron-coagulation indices and mapped to three risk states - for venous thromboembolism in HHT; for ischaemic stroke attributed to paradoxical emboli through pulmonary AVMs in HHT; and for cerebral abscess attributed to odontogenic bacteremias in immunocompetent HHT patients with right-to-left shunting through pulmonary AVMs. In conclusion, unsupervised machine learning algorithms categorise HHT haematological indices into distinct, clinically relevant profiles which are independent of age, sex or HHT genotype. Further evaluation may inform prophylaxis and management for HHT patients' haemorrhagic and thrombotic phenotypes.
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Affiliation(s)
- Ghazel Mukhtar
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College School of MedicineLondonUK
| | - Claire L. Shovlin
- National Heart and Lung InstituteImperial College LondonLondonUK
- Specialist MedicineImperial College Healthcare NHS TrustLondonUK
- NIHR Imperial Biomedical Research CentreLondonUK
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Parrot A, Barral M, Amiot X, Bachmeyer C, Wagner I, Eyries M, Alamowitch S, Ederhy S, Epaud R, Dupuis-Girod S, Cadranel J. [Hereditary hemorrhagic telangiectasia]. Rev Mal Respir 2023; 40:391-405. [PMID: 37062633 DOI: 10.1016/j.rmr.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023]
Abstract
Hereditary hemorrhagic telangiectasia, also known as Rendu-Osler - Weber disease, is a rare, autosomal dominant vascular disease, with prevalence of 1/5,000. The condition is characterized by muco-cutaneous telangiectasias, which are responsible for a hemorrhagic syndrome of variable severity, as well as arteriovenous malformations (AVMs) appearing in the lungs, the liver, and the nervous system. They can be the source of shunts, which may be associated with high morbidity (neurological ischemic stroke, brain abscess, high-output heart failure, biliary ischemia…). It is therefore crucial to establish a clinical diagnosis using the Curaçao criteria or molecular diagnosis based on genetic analysis of the ENG, ACVRL1, SMAD4 and GDF2 genes. In most cases, multidisciplinary management allows patients to have normal life expectancy. Advances in interventional radiology and better understanding of the pathophysiology of angiogenesis have resulted in improved therapeutic management. Anti-angiogenic treatments, such as bevacizumab (BVZ, an anti-VEGF antibody), have proven to be effective in cases involving bleeding complications and severe liver damage with cardiac repercussions. Other anti-angiogenic agents are currently being investigated, including tyrosine kinase inhibitors.
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Affiliation(s)
- A Parrot
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France.
| | - M Barral
- Service de radiologie, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
| | - X Amiot
- Service de gastroentérologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - C Bachmeyer
- Service de médecine interne, hôpital Tenon, AP-HP, 75020 Paris, France
| | - I Wagner
- Service d'ORL, hôpital Tenon, AP-HP, 75020 Paris, France
| | - M Eyries
- Service de génétique, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Alamowitch
- Service des urgences cérébrovasculaires, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Ederhy
- Service de cardiologie et GRC no 27, hôpital Saint-Antoine, AP-HP, 75020 Paris, France
| | - R Epaud
- Service de pédiatrie, centre intercommunaux de Créteil, Créteil, France
| | - S Dupuis-Girod
- Service de génétique, centre de référence pour la maladie de Rendu-Osler, hospices civils de Lyon, hôpital Mère-Enfant, 69500 Bron, France
| | - J Cadranel
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
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Sha L, Li Y, Zhang Y, Tang Y, Li B, Chen Y, Chen L. Heart-brain axis: Association of congenital heart abnormality and brain diseases. Front Cardiovasc Med 2023; 10:1071820. [PMID: 37063948 PMCID: PMC10090520 DOI: 10.3389/fcvm.2023.1071820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.
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Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwu Zhang
- Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, China
| | - Yusha Tang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Baichuan Li
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Lei Chen
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Xu S, Hong M, Zhou Z. Images of the month 1: Ischaemic stroke due to pulmonary arteriovenous fistula. Clin Med (Lond) 2022; 22:278-279. [PMID: 38589090 PMCID: PMC9135091 DOI: 10.7861/clinmed.2022-0092] [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] [Indexed: 11/27/2022]
Abstract
A 38-year-old man was admitted to the hospital due to a "suddenly developed right hemiplegia, unconsciousness and gaze to the right". Pulmonary arteriovenous fistulas (PAVFs) are rare but an important cause of stroke in young people, which is easy to be clinically neglected. Therefore, for young patients with pulmonary diseases and cerebral infarction, the possibility of PAVF should be considered.
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Affiliation(s)
- Shunpeng Xu
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
| | - Mingfan Hong
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China.
| | - Zhihua Zhou
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong, China
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Topiwala KK, Patel SD, Saver JL, Streib CD, Shovlin CL. Ischemic Stroke and Pulmonary Arteriovenous Malformations: A Review. Neurology 2022; 98:188-198. [PMID: 34880092 PMCID: PMC8826462 DOI: 10.1212/wnl.0000000000013169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023] Open
Abstract
The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/American Stroke Association (AHA/ASA) Guidelines and the single case report biased literature of recent years. We performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974, through April 3, 2021. This identified 24 major observational studies, 3 societal guidelines, 1 nationwide analysis, 3 systematic reviews, 21 other review/opinion articles, and 18 recent (2017-2021) case reports/series that were synthesized. Key points are that patients with PAVMs have ischemic stroke a decade earlier than routine stroke, losing 9 extra healthy life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005 and 2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. More than 80% of patients have underlying hereditary hemorrhagic telangiectasia. The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron deficiency emerging as a modifiable risk factor. PAVM-related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy may be effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron deficiency. This review summarizes the ischemic stroke burden from PAVMs, the implicative pathophysiology, and relevant diagnostic and treatment overviews to facilitate future incorporation into AHA/ASA guidelines.
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Affiliation(s)
- Karan K Topiwala
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK.
| | - Smit D Patel
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Jeffrey L Saver
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Christopher D Streib
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Claire L Shovlin
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
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Kasner SE, Lattanzi S, Fonseca AC, Elgendy AY. Uncertainties and Controversies in the Management of Ischemic Stroke and Transient Ischemic Attack Patients With Patent Foramen Ovale. Stroke 2021; 52:e806-e819. [PMID: 34702068 DOI: 10.1161/strokeaha.121.034778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multiple randomized clinical trials have demonstrated the benefit of patent foramen ovale closure over medical therapy alone for patients who have had a stroke that has been attributed to the patent foramen ovale. Nevertheless, there are many areas of uncertainty and controversy related to patient selection, pathophysiology, diagnosis, and treatment. We summarize the available data on these challenging topics and attempt to provide some clarity and future directions for clinicians and investigators.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.E.K.)
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy (S.L.)
| | - Ana Catarina Fonseca
- Department of Neurology, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Portugal (A.C.F.)
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, University of California San Francisco (A.Y.E.).,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH (A.Y.E.)
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