1
|
Tabrizi NS, Stout PA, Cahill J, Sunesara IR, Chan P, Singh C, Fabian T, Shapeton AD, Musuku SR. Positive Bubble Study But No Evidence of Interatrial Defect in a Patient with Recurrent Cryptogenic Stroke. Turk J Anaesthesiol Reanim 2023; 51:271-274. [PMID: 37455534 DOI: 10.4274/tjar.2022.221106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.
Collapse
Affiliation(s)
| | | | - Joseph Cahill
- Department of Cardiothoracic Surgery, Albany Medical Center, New York, United States
| | - Imran Ramzan Sunesara
- Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, United States
| | - Patrick Chan
- Department of Cardiothoracic Surgery, Albany Medical Center, New York, United States
| | - Chanderdeep Singh
- Department of Cardiothoracic Surgery, Albany Medical Center, New York, United States
| | - Thomas Fabian
- Department of Cardiothoracic Surgery, Albany Medical Center, New York, United States
| | - Alexander D Shapeton
- Department of Anaesthesia, Critical Care and Pain Medicine, Tufts University Faculty of Medicine, Boston, United States
| | - Sridhar Reddy Musuku
- Department of Anaesthesiology and Perioperative Medicine, Albany Medical Center, New York, United States
| |
Collapse
|
2
|
Liu J, Duan X, Yin J, Yang H, He R, Zhao S. Effective long-term sirolimus treatment in hypoxemia mainly due to intrapulmonary right-to-left shunt in a patient with multiple vascular anomalies. Orphanet J Rare Dis 2023; 18:124. [PMID: 37226169 DOI: 10.1186/s13023-023-02732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs), particularly where feeding artery/arteries to PAVMs ≥ 3 mm can be treated with embolization. The treatment for hypoxemia resulting from multiple small or diffuse PAVMs remains unclear.We report a girl aged 5 years and 10 months presented with cyanosis and decreased activity after exercise (83-85% of pulse oxygen saturation, SpO2). She had 1 skin lesion on her face and 1 suspected hemangioma on her left upper extremity at birth and that gradually disappeared spontaneously. Physical examination revealed clubbed fingers, and abundant vascular networks on her back. Contrast-enhanced lung CT (slice thickness:1.25 mm) with vascular three-dimensional reconstruction and abdominal CT revealed increased bronchovascular bundles, increased diameter of the pulmonary artery and ascending aorta, and intrahepatic portosystemic venous shunts due to patent ductus venosus. Echocardiography revealed increased diameter of aortic and pulmonary artery. Transthoracic contrast echocardiography was highly positive (bubble appearing in the left ventricle after 5 cardiac cycles). Abdominal doppler ultrasound revealed hepatic-portal venous shunt. Magnetic resonance imaging, artery and vein of the brain revealed multiple malformations of venous sinuses. The patient received sirolimus for 2 years and 4 months. Her condition improved significantly. SpO2 gradually increased to 98%. Her finger clubbing gradually normalized.Our report implicates sirolimus might be a potential treatment option in persistent hypoxemia mainly due to intrapulmonary right-to-left shunt even small multiple or diffusive PAVMs in pediatric patients with multiple cutaneous and visceral vascular anomalies.
Collapse
Affiliation(s)
- Jinrong Liu
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Xiaomin Duan
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jie Yin
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Haiming Yang
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Ruxuan He
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Shunying Zhao
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
| |
Collapse
|
3
|
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.
Collapse
|
4
|
Lim KH, Kim SM, Park SJ, Kim EK, Chang SA, Lee SC, Park SW, Choe YH. Significance of transesophageal contrast echocardiography with the agitated saline test for diagnosing pulmonary arteriovenous malformations. Front Cardiovasc Med 2022; 9:975901. [PMID: 36158804 PMCID: PMC9497879 DOI: 10.3389/fcvm.2022.975901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives This study evaluated the diagnostic value of transesophageal contrast echocardiography (TECE) with the agitated saline test for diagnosing pulmonary arteriovenous malformations (PAVMs) in comparison with chest CT or pulmonary angiography. Background Although transthoracic contrast echocardiography (TTCE) is the recommended screening test for diagnosing PAVMs, it has low specificity and positive predictive value. TECE is expected to offer improved sensitivity and specificity compared with TTCE, but no studies have reported the diagnostic accuracy and clinical significance of TECE in detecting PAVMs. Methods and results In total, 1,809 patients underwent TECE with the agitated saline test to evaluate symptoms of a suspected right to left shunt. Patients with hereditary hemorrhagic telangiectasia (HHT) were excluded. A total of 387 patients showed transpulmonary bubble passage, indicating a PAVM. Among them, 182 patients had additional chest CT or pulmonary angiography. Those patients were divided into two groups according to the presence of a PAVM in the radiologic imaging. A total of 18 patients (9.8%) were confirmed for the PAVM group. Only 13 patients required embolization for their PAVMs. The TECE with saline test results were divided into four grades according to the number of bubbles: grade 1 (n = 91), grade 2 (n = 47), grade 3 (n = 35), and grade 4 (n = 9). None of the patients in the PAVM group had grade 1 shunts in their TECE results. The positive predictive values for the presence of a PAVM according to the TECE grade scale were 10.6% for grade 2, 22.8% for grade 3, and 55.6% for grade 4. Conclusion TECE with a grade scale is a useful method for initially diagnosing PAVMs in non-HHT patients with a suspected right to left shunt. The findings of this study also suggest that patients with a small grade (<10 bubbles) shunt in their TECE findings should be spared unnecessary radiation exposure from CT scans or pulmonary angiography.
Collapse
Affiliation(s)
- Kyung Hee Lim
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Busan, South Korea
| | - Sung Mok Kim
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Sung-Ji Park,
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
5
|
Hvelplund T, Lange B, Bird SD, Korsholm M, Kjeldsen AD. A retrospective cohort study on European Reference Network for Rare Vascular Diseases 5 outcome measures for Hereditary Haemorrhagic Telangiectasia in Denmark. Orphanet J Rare Dis 2022; 17:8. [PMID: 34991676 PMCID: PMC8734368 DOI: 10.1186/s13023-021-02160-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder characterized by several clinical symptoms including epistaxis, arteriovenous malformations (AVM), and telangiectasia. In 2018, European Reference Network for Rare Vascular Diseases (VASCERN) recommended five outcome measures for HHT-patients to guide health care providers, some with limited experience in treating HHT, and thereby maximizing the number of HHT-patients receiving good care. The outcome measures cover the following aspects: (1) 90% of the patients should receive a pulmonary AVM (PAVM) screening; (2) 90% of the patients should receive written advice on nosebleed; (3) 70% should be assessed for iron deficiency; (4) 100% of the patients should receive written advice on antibiotic (AB) prophylaxis prior to dental and surgical procedures, and (5) 100% of relevant patients should receive written advice on pregnancy. We have introduced the outcome measures as Benchmarks in our HHT-centre and wanted to evaluate the extend of implementation we have achieved. We constantly struggle to secure the best possible treatment of our HHT-patients. Methods The study was a non-interventional retrospective study. Data was collected manually from patient records and from the Danish HHT-database. Results A total of 180 HHT-patients were included, all diagnosed in the period from January 1st, 2016, to December 31st, 2020. All patients were screened for PAVM. We could confirm that 66% of patients who had epistaxis received thoroughly advice. Assessment for iron deficiency was performed in 80% of the adult patients. Thoroughly advice on AB prophylaxis was documented in 75%. Thoroughly advice on pregnancy was documented in 80% of female patients 15–45 years of age. There were no significant differences over time for any of the outcome measures. Conclusions The Danish HHT-centre reached the target threshold for outcome measures 1 and 3. It could not be documented that the target thresholds for outcome measures 2, 4, and 5 were achieved. As information and education are a very important part of HHT care, focus on and documentation that all patients receive the relevant advice must be a priority in order to ensure best care.
Collapse
Affiliation(s)
- Troels Hvelplund
- Research Unit for ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws Vej 4, 1st Floor, 5000, Odense C, Denmark.,University of Southern Denmark, Odense, Denmark.,Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Bibi Lange
- Research Unit for ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws Vej 4, 1st Floor, 5000, Odense C, Denmark
| | - Susanne Djernes Bird
- Research Unit for ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws Vej 4, 1st Floor, 5000, Odense C, Denmark
| | - Malene Korsholm
- Research Unit for ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws Vej 4, 1st Floor, 5000, Odense C, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Anette Drøhse Kjeldsen
- Research Unit for ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws Vej 4, 1st Floor, 5000, Odense C, Denmark. .,University of Southern Denmark, Odense, Denmark. .,Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark.
| |
Collapse
|
6
|
Ohuchi H, Mori A, Nakai M, Fujimoto K, Iwasa T, Sakaguchi H, Kurosaki K, Shiraishi I. Pulmonary Arteriovenous Fistulae After Fontan Operation: Incidence, Clinical Characteristics, and Impact on All-Cause Mortality. Front Pediatr 2022; 10:713219. [PMID: 35757115 PMCID: PMC9218217 DOI: 10.3389/fped.2022.713219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Fontan operation is a surgical procedure used in children with univentricular hearts. Pulmonary arteriovenous fistulae (PAVF) is a major complication after a Fontan operation. However, the incidence and related clinical pathophysiology of PAVF remain unclear. PURPOSE This study aimed to clarify the incidence of PAVF, its clinical characteristics, and its influence on all-cause mortality. METHODS AND RESULTS We serially assessed the presence of PAVF using pulmonary artery angiography and/or contrast echocardiography during catheterization in 391 consecutive patients who underwent the Fontan procedure and compared the results with the Fontan pathophysiology and all-cause mortality. PAVF developed in 36 patients (9.2%), including 30 diffuse- and six discrete-PAVF types. The PAVF-free rates at 1, 5, 10, 15, 20, and ≥25 years after Fontan operation were 97, 96, 93, 88, 87, and 83%, respectively. The mean arterial blood oxygen saturation (SaO2) in patients with diffuse PAVF at each corresponding postoperative stage were 90, 91, 91, 91, 89, and 88%, respectively, indicating lower SaO2 levels than those in patients without PAVF (all p < 0.01). However, there was no difference in the SaO2 levels between patients with discrete PAVF and those without PAVF. During a median follow-up period of 2.9 years after the last catheterization, 31 patients, including 12 patients with PAVF, died. Patients with PAVF, especially those with diffuse PAVF, had a higher mortality rate (p = 0.01) than those without PAVF (hazard ratio: 3.6, 95% confidence interval: 1.6-7.8, p = 0.0026). CONCLUSION Patients who underwent Fontan surgery had an increased incidence of PAVF as they aged. Discrete PAVF did not influence SaO2 or mortality, whereas the presence of diffuse PAVF caused hypoxia and was associated with all-cause mortality.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan.,Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Aki Mori
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuto Fujimoto
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toru Iwasa
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
7
|
Deng Y, Huang X, Wang G, Cao J, Wang S, Li Y, Wang Y, Ye J, Zhang P, Chen X, Luo Y, He K. Applicability of Transthoracic Contrast Echocardiography for the Diagnosis and Treatment of Idiopathic Pulmonary Arteriovenous Malformations. Front Cardiovasc Med 2021; 8:656702. [PMID: 34322523 PMCID: PMC8311437 DOI: 10.3389/fcvm.2021.656702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/21/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: To explore the preferred test to screen for pulmonary arteriovenous malformations (PAVMs) and to predict the probability of interventional embolization. Methods: We performed a retrospective observational study evaluating patients with idiopathic PAVMs from 2009 to 2019. After clinical evaluation, a total of 105 patients were studied, including 71 patients with positive digital subtraction pulmonary angiography (DSPA) findings and 34 with negative DSPA findings. The following patient data were assessed: blood test, chest radiograph, transthoracic contrast echocardiography (TTCE), and DSPA findings. Results: The majority of patients with idiopathic PAVMs were female (66.2% with positive DSPA findings). We found a good κ-coefficient of 0.77 with strong consistency for inter observer agreement concerning the pulmonary right-to-left shunt (RLS) grade on TTCE, which was superior to conventional chest radiographs. The positive predictive value (PPV) of the radiographic features for PAVMs on DSPA was 0.83 (95% CI 0.64-1.0) and 0.44 for the possibility of embolization (95% CI 0.19-0.70). The PPV of the shunt grade of PAVMs on DSPA was 0.14 (95% CI 0.01-0.29) for grade 1, 0.74 (95% CI 0.60-0.88) for grade 2, and 0.97 (95% CI 0.92-1.0) for grade 3. The PPVs of pulmonary shunt grades 2 and 3 on TTCE for the possibility of embolization for PAVMs were 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively. Conclusion: TTCE is the preferred screening test for PAVMs. The pulmonary RLS grade on TTCE not only identifies the likelihood of PAVMs but also predicts the probability for embolization.
Collapse
Affiliation(s)
- Yujiao Deng
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin Huang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Guangyi Wang
- Department of Cardiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jian Cao
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Shengshu Wang
- Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second Medical Center of Chinese PLA General Hospital, Institute of Geriatrics, Beijing, China
| | - Yue Li
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yiru Wang
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | | | | | - Yukun Luo
- Department of Ultrasound, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Kunlun He
- Translational Medicine Research Center, Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
8
|
Bechsgaard T, Midtgaard A, Jakobsen E, Kjeldsen AD. Successful treatment of massive haemoptysis in a young woman with anastomosis of right internal mammary artery to right superior pulmonary vein fistula. BMJ Case Rep 2021; 14:14/5/e240739. [PMID: 34035019 DOI: 10.1136/bcr-2020-240739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 21-year-old, otherwise healthy, female patient was admitted with haemoptysis. Chest X-ray and CT found a consolidated right middle pulmonary lobe. Catheter angiography of ascending aorta visualised two hypertrophic and tortuous branches of the right internal mammary artery with a fistula to the right superior pulmonary vein. The inflow was embolised with coils. Catheter angiography of descending aorta found hypertrophic right bronchial arteries and right phrenic artery supplying a web-like network of vessels, which drained to the right superior pulmonary vein with discrete filling of an accessory right middle pulmonary vein. CT angiography with a catheter for contrast administration in the ascending aorta was performed for characterisation. After two additional episodes of haemoptysis, right middle lobe lobectomy was performed. Perioperatively pulmonary artery blood supply to the right middle pulmonary lobe was absent and an atretic accessory middle pulmonary vein was seen. The patient was discharged 7 days afterwards without sequelae.
Collapse
Affiliation(s)
| | | | - Erik Jakobsen
- Cardiac, Thoracic, and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | | |
Collapse
|
9
|
Krečak I, Gardijan B, Brkičić J, Grubišić‐Čabo R, Gverić‐Krečak V. Cryptic brain abscess - do not forget hereditary hemorrhagic teleangiectasia! Am J Hematol 2021; 96:640-642. [PMID: 33502016 DOI: 10.1002/ajh.26111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine General Hospital of Šibenik‐Knin County Šibenik Croatia
| | - Bojan Gardijan
- Department of Neurology General Hospital of Šibenik‐Knin County Šibenik Croatia
| | - Jasminka Brkičić
- Department of Infectious Diseases General Hospital of Šibenik‐Knin County Šibenik Croatia
| | - Robert Grubišić‐Čabo
- Department of Internal Medicine General Hospital of Šibenik‐Knin County Šibenik Croatia
| | - Velka Gverić‐Krečak
- Department of Internal Medicine General Hospital of Šibenik‐Knin County Šibenik Croatia
| |
Collapse
|
10
|
Droege F, Kuerten CHL, Kaiser C, Dingemann J, Kaster F, Dahlfrancis PM, Lueb C, Zioga E, Thangavelu K, Lang S, Geisthoff U. [Hereditary hemorrhagic telangiectasia: symptoms and diagnostic latency]. Laryngorhinootologie 2021; 100:443-452. [PMID: 33761571 DOI: 10.1055/a-1408-5160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Patients with hereditary hemorrhagic Telangiectasia (HHT) suffer from a rare and systemic disease which is characterized by vascular malformations leading to a variety of different symptoms. MATERIAL AND METHODS A retrospective review of patients who were referred to our new HHT Center of Excellence (HHT COE) for evaluation and treatment between April 2014 and August 2019 was performed. RESULTS 235 patients were treated at the West German HHT Center. 83 % of these were diagnosed with definite HHT (235/282, 83 %) and 9 % with possible HHT (26/282). The average latency between first manifestation and definite diagnosis of HHT was 18 years. Several initial symptoms were direct or indirect signs of bleeding (224/241, 93 %). In 83 % of the patients HHT was reported having caused their degree of disability. Older, female patients and those with severe epistaxis suffered from chronic iron deficiency anemia, took iron preparations (148/261, 57 %) and received 9 blood transfusions on average (± standard deviation: 41, minimum - maximum: 0-400, number of patients: 218). 10 % of all patients tolerated anticoagulant or antiplatelet agents. 74 % of patients with HHT used nasal creams/sprays/oils (177/238) and reported fewer bleedings compared to patients without nasal care (ESS: T-Test: 3.193; p = 0.003; anemia: Chi-square: 5.173; p = 0.023). CONCLUSIONS The diagnostic latency of HHT was almost two decades. Patients with HHT particularly suffered from recurrent epistaxis, which was mostly treated with nasal care and coagulative therapies. Antiplatelet or anticoagulant agents can be used in patients with HHT with caution if indicated.
Collapse
Affiliation(s)
- Freya Droege
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Christina Kaiser
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Julia Dingemann
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Friederike Kaster
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Carolin Lueb
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Eleni Zioga
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Stephan Lang
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Urban Geisthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Philipps-Universität Marburg, Germany
| |
Collapse
|
11
|
Ammonia Predicts Hepatic Involvement and Pulmonary Hypertension in Patients With Hereditary Hemorrhagic Telangiectasia. Clin Transl Gastroenterol 2020; 11:e00118. [PMID: 31977452 PMCID: PMC7056052 DOI: 10.14309/ctg.0000000000000118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION: Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is common and can be associated with severe clinical consequences, including portal hypertension, cardiac failure, and encephalopathy. However, there are no reliable clinical predictors of hepatic involvement and its associated complications, limiting appropriate identification of these patients. In this work, we define the utility of serum ammonia and liver biochemical tests (LFTs) in predicting hepatic HHT involvement and its complications. METHODS: We performed a retrospective study examining a well-characterized cohort of patients with HHT. Clinical characteristics, laboratory tests, liver imaging, transthoracic echocardiography assessment of right ventricular systolic pressure (RVSP), and history of other HHT-related outcomes were assessed. Patients were followed for the development of encephalopathy. RESULTS: Of 45 patients with definite HHT, 18 (40%) had elevated ammonia levels. An elevated ammonia associated with the presence of hepatic arteriovenous malformations (AVMs) on imaging (P < 0.03) and when combined with elevated liver tests increased the sensitivity for hepatic AVMs by 18% (55% for LFTs vs 73% for LFTs plus ammonia). Furthermore, an elevated serum ammonia in patients with HHT associated with an elevated RVSP (>35 mm Hg), providing an 80% sensitivity and 71% specificity for predicting the presence of pulmonary hypertension. In contrast, there was no association with an elevated serum ammonia and encephalopathy over a total of 859 months of follow-up. DISCUSSION: Elevated ammonia in a cohort of patients with HHT was associated with the presence of hepatic AVMs and elevated RVSP, but no other complications of HHT, including encephalopathy.
Collapse
|
12
|
Bernard S, Churchill TW, Namasivayam M, Bertrand PB. Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots. J Am Soc Echocardiogr 2020; 34:S0894-7317(20)30615-5. [PMID: 34756394 DOI: 10.1016/j.echo.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 02/08/2023]
Abstract
Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.
Collapse
Affiliation(s)
- Samuel Bernard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
13
|
Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia. J Interv Cardiol 2020; 2020:1462140. [PMID: 32982607 PMCID: PMC7492935 DOI: 10.1155/2020/1462140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 07/30/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure. Background TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure. Methods All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately. Results In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE. Conclusion Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.
Collapse
|
14
|
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: 27] [Impact Index Per Article: 6.8] [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.
Collapse
|
15
|
Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
Collapse
Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
| |
Collapse
|
16
|
DePietro DM, Curnes NR, Chittams J, Ferrari VA, Pyeritz RE, Trerotola SO. Postembolotherapy Pulmonary Arteriovenous Malformation Follow-Up: A Role for Graded Transthoracic Contrast Echocardiography Prior to High-Resolution Chest CT Scan. Chest 2019; 157:1278-1286. [PMID: 31794700 DOI: 10.1016/j.chest.2019.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-resolution chest CT (HRCT) scan is recommended after pulmonary arteriovenous malformation (PAVM) embolotherapy to assess for PAVM persistence and untreated PAVM growth. Graded transthoracic contrast echocardiography (TTCE) predicts the need for embolotherapy in PAVM screening. This study sought to determine whether postembolotherapy graded TTCE can similarly predict the need for repeat embolotherapy. METHODS Thirty-two patients (8 men and 24 women; mean age, 51.1 ± 12.6 years) with prior PAVM embolotherapy and follow-up HRCT scan were prospectively enrolled. Patients underwent graded TTCE using a validated three-point quantitative grading scale. TTCE grade and HRCT findings were compared. RESULTS Median time between most recent HRCT scan and TTCE was 7 days (interquartile range, 0-272 days). Thirty patients (94%) had no PAVMs requiring repeat embolotherapy on HRCT scan. Two patients (6%) had PAVMs requiring repeat embolotherapy (feeding artery [FA] ≥ 3 mm), one with untreated PAVM growth and one with treated PAVM persistence. TTCE was positive in 88% of patients (n = 28). All patients (n = 4, 12%) with negative TTCE had no visible PAVMs on HRCT scan. Nine patients (32%) had grade 1 shunt, 10 (35%) had grade 2 shunt, and nine (32%) had grade 3 shunt. No patients with grade 1 shunt had PAVMs amenable to repeat embolotherapy on HRCT scan. All patients (n = 2) with PAVMs requiring repeat embolotherapy (FA ≥ 3 mm) had grade 3 shunt. TTCE grade was significantly associated with PAVM FA diameter (P < .001). CONCLUSIONS Postembolotherapy graded TTCE can predict the need for repeat embolotherapy on HRCT scan. Patients with negative TTCE and grade 1 shunt may not require HRCT follow-up and can potentially be followed with serial graded TTCE. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02936349; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Daniel M DePietro
- Department of Radiology, Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA
| | - Nicole R Curnes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Chittams
- Biostatistics Consulting Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Victor A Ferrari
- Department of Medicine, Cardiovascular Division and Penn HHT Center of Excellence, Philadelphia, PA
| | - Reed E Pyeritz
- Department of Medicine, Division of Medical Genetics and Penn HHT Center of Excellence, Philadelphia, PA
| | - Scott O Trerotola
- Department of Radiology, Division of Interventional Radiology and Penn HHT Center of Excellence, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disease characterized by telangiectasia and arteriovenous malformations (AVMs). To date, five genetic types of HHT and one combined juvenile polyposis syndrome and HHT are known. Clinical and genetic screening of patients suspected with HHT is recommended to confirm the diagnosis and to prevent complications associated with HHT. The aim of this article is to give an overview of the evidence and to formulate a recommendation for clinicians concerning screening for HHT. RECENT FINDINGS Complications of HHT such as stroke, brain abscess and intracranial hemorrhage are caused by pulmonary and cerebral AVMs (CAVMs) and can often be prevented by screening and treatment when possible. Screening and treatment of these AVMs will result in an increased life expectancy comparable with that of the general population as opposed to unscreened and untreated HHT patients. SUMMARY Screening of HHT patients and their first-degree relatives is recommended to prevent severe complications including stroke, brain abscess and intracranial hemorrhage.
Collapse
|
18
|
Meier NM, Foster ML, Battaile JT. Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations: clinical aspects. Cardiovasc Diagn Ther 2018; 8:316-324. [PMID: 30057878 DOI: 10.21037/cdt.2017.12.07] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder of blood vessel formation resulting in mucocutaneous telangiectasias and visceral arteriovenous malformations. Nearly half of patients with HHT will have pulmonary arteriovenous malformations (PAVM) that place them at risk for potentially fatal complications that can occur when blood bypasses the pulmonary capillary circulation or as a result of PAVM rupture. Other manifestations of HHT outside the lung may increase the rate and severity of PAVM complications, creating unique clinical challenges. Management hinges on timely screening and diagnosis, followed by treatment of amenable PAVMs with transcatheter embolization in conjunction with medical management and prophylactic measures to treat and prevent complications. The purpose of this review is to highlight the clinical manifestations of PAVMs specific to patients with HHT and to detail screening and treatment strategies that can reduce the risk of developing life-threatening complications.
Collapse
Affiliation(s)
- Nathaniel M Meier
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael L Foster
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John T Battaile
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
19
|
Fernandopulle N, Mertens L, Klingel M, Manson D, Ratjen F. Echocardiography Grading for Pulmonary Arteriovenous Malformation Screening in Children with Hereditary Hemorrhagic Telangiectasia. J Pediatr 2018; 195:288-291.e1. [PMID: 29274888 DOI: 10.1016/j.jpeds.2017.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/12/2017] [Accepted: 11/17/2017] [Indexed: 01/09/2023]
Abstract
Transthoracic contrast echocardiography (TTCE) has high sensitivity but low specificity in screening for pulmonary arteriovenous malformations (pAVMs) in children with hereditary hemorrhagic telangiectasia (HHT). Here we describe characteristics of TTCE that might be used to reduce the need for confirmatory computed tomography scans in children with HHT.
Collapse
Affiliation(s)
- Nigel Fernandopulle
- University of Toronto, Toronto, Ontario, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Klingel
- Department of Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Manson
- University of Toronto, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- University of Toronto, Toronto, Ontario, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
| |
Collapse
|
20
|
Tonelli AR, Naal T, Dakkak W, Park MM, Dweik RA, Stoller JK. Assessing the kinetics of microbubble appearance in cirrhotic patients using transthoracic saline contrast-enhanced echocardiography. Echocardiography 2017; 34:1439-1446. [PMID: 28840954 DOI: 10.1111/echo.13662] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The number of cardiac cycles that need to be reviewed by echocardiography before a significant intrapulmonary shunt can be excluded remains unclear. METHODS We retrospectively identified patients with cirrhosis who underwent technetium-99 m-labeled macroaggregated albumin scanning. The kinetics of bubble appearance after the injection of agitated saline during transthoracic echocardiograms were assessed in these patients. RESULTS For the 64 eligible patients, the mean ± SD age was 56 ± 9 years. The median (IQR) shunt fraction by radionuclide scanning was 7.7% (2.8%-19.9%). Microbubbles were seen in the left atrium (LA) and left ventricle (LV) at a median (IQR) of 4 (2-5) and 4 (2-5) beats, respectively. The number of heart cycles before microbubbles appeared in the LA or LV was inversely associated with the nuclear scanning shunt fraction (R = -0.42, P = .001, R = -0.46, P < .001, respectively). If no microbubbles were detected by heart cycle 7, the shunt fraction was uniformly less than 3%. Patients with arterial oxygen <60 mm Hg, compared to ≥60 mm Hg, had earlier appearance of microbubbles in the left heart chambers (2.6 ± 1.9 vs 4.0 ± 2.3 beats, P = .046). CONCLUSIONS In patients with advanced cirrhosis suspected of having hepatopulmonary syndrome, a greater shunt fraction during nuclear scanning was associated with more pronounced hypoxemia and a prompt and more intense appearance of microbubbles in the left-sided heart chambers. Patients with a shunt fraction above 3% have microbubbles in the LA or LV at some point during the first seven heart cycles.
Collapse
Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tawfeq Naal
- Pathobiology Department, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Margaret M Park
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James K Stoller
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Education Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
21
|
Ohuchi H, Miyazaki A, Negishi J, Hayama Y, Nakai M, Nishimura K, Ichikawa H, Shiraishi I, Yamada O. Hemodynamic determinants of mortality after Fontan operation. Am Heart J 2017. [PMID: 28625386 DOI: 10.1016/j.ahj.2017.03.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Elevated central venous pressure (CVP), low cardiac output, and mild hypoxia are common early and late after Fontan operations. However, the association of these characteristics with late mortality is unclear. We aimed to elucidate the hemodynamic determinants of mortality after Fontan operation. METHOD We evaluated early (group early; 0.5-5years postoperatively, n=387) and late (group late; ≥15years postoperatively, n=161) Fontan hemodynamics that included CVP (mm Hg), cardiac index (CI; L/min per m2), systemic ventricular end-diastolic volume index (mL/m2), ejection fraction (EF; %), and arterial blood oxygen saturation (%). We examined the effect of these variables on 5-year all-cause mortality. RESULTS Mortality was higher in group late than in group early (17 vs 11, P<.0001). In both groups, higher CVP (hazard ratio [HR]1.46 and 1.38, respectively; P<.001-.0001) and lower arterial blood oxygen saturation (HR 1.12, P<.001 for both) were associated with increased mortality. Greater end-diastolic volume index (HR per 20: 1.73) and lower EF (HR per 10%: 3.38) were associated with increased mortality only in group early (P<.0001 for both). In contrast, only in group late was higher CI associated with increased mortality (HR 2.50, 95% CI 1.30-4.55, P<.01). Seven patients in group late with both high CVP (≥14) and CI (≥3.0) had the highest mortality (HR 18.1, 5.55-52.4, P<.0001). CONCLUSIONS Elevated CVP and low arterial blood oxygen saturation correlate with mortality in both early and late Fontan survivors. End-diastolic volume index and EF are associated with mortality only in the earlier cohort, whereas interestingly, elevated cardiac output is associated with increased mortality in the later cohort.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Hayama
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michikazu Nakai
- Department of Preventive Medicine and Epidemiologic Informatics, Center for Cerebral and Cardiovascular Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, Center for Cerebral and Cardiovascular Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| |
Collapse
|
22
|
Figueiredo ACPCT, Mata-Machado N, McCoyd M, Biller J. Neurocutaneous Disorders for the Practicing Neurologist: a Focused Review. Curr Neurol Neurosci Rep 2016; 16:19. [DOI: 10.1007/s11910-015-0612-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
23
|
The Role of TEE in Diagnosing Hepatopulmonary Syndrome and Cryptogenic Cirrhosis. Case Rep Cardiol 2016; 2016:9029606. [PMID: 27656299 PMCID: PMC5021868 DOI: 10.1155/2016/9029606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/17/2016] [Indexed: 11/18/2022] Open
Abstract
In the vast majority of cases, ongoing hypoxemia in a cirrhotic patient is usually hepatopulmonary syndrome (HPS) until proven otherwise; in this case, HPS was suspected prior to any known diagnosis of cirrhosis. This is the first reported case in the literature whereby HPS and cirrhosis were diagnosed after the fact, rather than with the preexisting knowledge of liver cirrhosis.
Collapse
|
24
|
Duke JW, Elliott JE, Lovering AT. Clinical consideration for techniques to detect and quantify blood flow through intrapulmonary arteriovenous anastomoses: lessons from physiological studies. Echocardiography 2015; 32 Suppl 3:S195-204. [PMID: 25693624 DOI: 10.1111/echo.12839] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Intrapulmonary arteriovenous anastomoses (IPAVA) are large diameter (>50 μm) vascular conduits, present in >95% of healthy humans. Because IPAVA are large diameter pathways that allow blood flow to bypass the pulmonary capillary network, blood flow through IPAVA (QIPAVA) can permit the transpulmonary passage of particles larger than pulmonary capillaries. IPAVA have been known to exist for over 50 years, but their physiological and clinical significance are still being established; although, currently suggested roles for QIPAVA include allowing emboli to reach the systemic circulation and providing a source of shunt. Studying QIPAVA is an important area of research and as the suggested roles become better established, detecting and quantifying QIPAVA may become significantly more important in the clinic. Several techniques that can be used to quantify and/or detect QIPAVA in animals, ex vivo human/animal lungs, and intact healthy humans; microspheres, radiolabeled macroaggregated albumin particles, and saline contrast echocardiography, are reviewed with limitations and advantages to each. The current body of literature using these techniques to study QIPAVA in animals, ex vivo lungs, and healthy humans has established conditions when QIPAVA is present, such as during exercise or with arterial hypoxemia and conditions when QIPAVA is absent, such as at rest or during exercise breathing 100% O2 . Many of these physiological studies have direct application to patient populations and we discuss each of these findings in the context of their potential to influence the clinical utility, and interpretation, of the results from these techniques highlighted in this review.
Collapse
Affiliation(s)
- Joseph W Duke
- Division of Exercise Physiology, Ohio University, Athens, Ohio
| | | | | |
Collapse
|
25
|
Yanna-Schulze A. Carotid ultrasound for pulmonary arteriovenous malformation screening. Open Med (Wars) 2015; 10:285-293. [PMID: 28352707 PMCID: PMC5152993 DOI: 10.1515/med-2015-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/04/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In patients with hereditary hemorrhagic telangiectasia (HHT), pulmonary arteriovenous malformations (PAVMs) can cause serious neurological complications. Our aim was to evaluate the potential of contrast-enhanced Doppler ultrasound (CE-US) of the common carotid artery as a screening test for detection of PAVMs. METHODS A total of 124 consecutive patients with HHT or a positive family history underwent screening for PAVMs with CE-US and thoracic contrast-enhanced magnetic resonance angiography (CE-MRA). CE-US was performed after receiving (D)-galactose microparticulate, and CE-MRA with gadobenate dimeglumine. Twenty-five patients with confirmed PAVMs were referred to conventional pulmonary catheter angiography (PA). Findings on CE-US and CE-MRA were evaluated using contingency tables and McNemar's test. RESULTS Using CE-MRA as the reference test, CE-US had a sensitivity of 100%, a specificity of 87%, and a negative predictive value of 100%. In 25 patients who underwent PA, PAVMs that had been diagnosed on CE-US and CE-MRA were confirmed. Of the PAVMs detected by CE-MRA, 24% were not identified on PA. CONCLUSION CE-US is a simple, minimally invasive screening method that can easily be performed in different settings. CE-US can predict PAVMs with high probability of success. CE-US may be a simple alternative to transthoracic echocardiography in the assessment of PAVMs in certain HHT-patients.
Collapse
|
26
|
Velthuis S, Buscarini E, Gossage JR, Snijder RJ, Mager JJ, Post MC. Clinical implications of pulmonary shunting on saline contrast echocardiography. J Am Soc Echocardiogr 2015; 28:255-63. [PMID: 25623000 DOI: 10.1016/j.echo.2014.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 02/07/2023]
Abstract
Pulmonary right-to-left shunting can be encountered using transthoracic contrast echocardiography (TTCE) with agitated saline. Diseases associated with pulmonary shunting on saline TTCE include hereditary hemorrhagic telangiectasia (HHT), hepatopulmonary syndrome, and some congenital heart defects after partial or complete cavopulmonary anastomosis. Furthermore, small pulmonary shunts on saline TTCE are also documented in a proportion of healthy individuals. Pulmonary shunting carries the risk for severe neurologic complications due to paradoxical embolization. In HHT, additional chest computed tomography is recommended in case of any pulmonary shunt detected on saline TTCE, to evaluate the feasibility for transcatheter embolotherapy of pulmonary arteriovenous malformations. Furthermore, antibiotic prophylaxis is advised in case of any pulmonary shunt on saline TTCE to prevent brain abscesses after procedures with risk for bacteremia. The present review provides an overview of important aspects of pulmonary shunting and its detection using saline TTCE. Furthermore, advances in understanding the clinical implications of different pulmonary shunt grades on saline TTCE are described. It appears that small pulmonary shunts on saline TTCE (grade 1) lack any clinical implication, as these shunts cannot be used as a diagnostic criterion for HHT, are not associated with an increased risk for neurologic complications, and represent pulmonary arteriovenous malformations too small for subsequent endovascular treatment. This implies that additional chest computed tomography could be safely withheld in all persons with only small pulmonary shunts on saline TTCE and sets the stage for further discussion about the need for antibiotic prophylaxis in these subjects. Besides further optimization of the current screening algorithm for the detection of pulmonary arteriovenous malformations in HHT, these observations can be of additional clinical importance in other diseases associated with pulmonary shunting and in those healthy individuals with documented small pulmonary shunts on saline TTCE.
Collapse
Affiliation(s)
- Sebastiaan Velthuis
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.
| | | | - James R Gossage
- Department of Medicine, Georgia Regents University, Augusta, Georgia
| | - Repke J Snijder
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
27
|
Velthuis S, Vorselaars VM, Westermann CJ, Snijder RJ, Mager JJ, Post MC. Pulmonary Shunt Fraction Measurement Compared to Contrast Echocardiography in Hereditary Haemorrhagic Telangiectasia Patients: Time to Abandon the 100% Oxygen Method? Respiration 2015; 89:112-8. [DOI: 10.1159/000368416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022] Open
|
28
|
Lovering AT, Duke JW, Elliott JE. Intrapulmonary arteriovenous anastomoses in humans--response to exercise and the environment. J Physiol 2015; 593:507-20. [PMID: 25565568 DOI: 10.1113/jphysiol.2014.275495] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 12/05/2014] [Indexed: 12/17/2022] Open
Abstract
Intrapulmonary arteriovenous anastomoses (IPAVA) have been known to exist in human lungs for over 60 years. The majority of the work in this area has largely focused on characterizing the conditions in which IPAVA blood flow (Q̇IPAVA ) is either increased, e.g. during exercise, acute normobaric hypoxia, and the intravenous infusion of catecholamines, or absent/decreased, e.g. at rest and in all conditions with alveolar hyperoxia (FIO2 = 1.0). Additionally, Q̇IPAVA is present in utero and shortly after birth, but is reduced in older (>50 years) adults during exercise and with alveolar hypoxia, suggesting potential developmental origins and an effect of age. The physiological and pathophysiological roles of Q̇IPAVA are only beginning to be understood and therefore these data remain controversial. Although evidence is accumulating in support of important roles in both health and disease, including associations with pulmonary arterial pressure, and adverse neurological sequelae, there is much work that remains to be done to fully understand the physiological and pathophysiological roles of IPAVA. The development of novel approaches to studying these pathways that can overcome the limitations of the currently employed techniques will greatly help to better quantify Q̇IPAVA and identify the consequences of Q̇IPAVA on physiological and pathophysiological processes. Nevertheless, based on currently published data, our proposed working model is that Q̇IPAVA occurs due to passive recruitment under conditions of exercise and supine body posture, but can be further modified by active redistribution of pulmonary blood flow under hypoxic and hyperoxic conditions.
Collapse
Affiliation(s)
- Andrew T Lovering
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | | | | |
Collapse
|
29
|
Latino GA, Kim H, Nelson J, Pawlikowska L, Young W, Faughnan ME. Severity score for hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2014; 9:188. [PMID: 25928712 PMCID: PMC4302697 DOI: 10.1186/s13023-014-0188-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022] Open
Abstract
Background A disease severity score in hereditary hemorrhagic telangiectasia (HHT) would be a useful tool for assessing burden of disease and for designing clinical trials. Here, we propose the first known HHT severity score, the HHT-score. Methods Demographics and disease characteristics were collected for the first 525 HHT patients recruited to the HHT Project of the Brain Vascular Malformation Consortium (BVMC). HHT-score was calculated based on presence of: organ arteriovenous malformations (maximum 3 points); chronic bleeding (maximum 2 points); and severe organ involvement (maximum 2 points). Points were summed and patients categorized as having mild (0–2), moderate (3–4) or severe (5–7) disease. The occurrence of “any adverse outcome” was evaluated for association with HHT-score categories. Results The frequency of “any adverse outcome” was significantly different across the three groups (49.6% in mild, 65.8% in moderate and 89.5% in severe, p < 0.001). Adjusting for age and gender, the risk of “any adverse outcome” was higher in the moderate (OR = 1.84, 95% CI: 1.15-2.95, p = 0.011) and severe groups (OR = 9.16, 95% CI: 1.99-42.09, p = 0.004) compared to the mild. Conclusions We have taken the first steps toward creating a global measure of disease severity in HHT. While the initial results are promising, further validation of the HHT-score is still required.
Collapse
Affiliation(s)
- Giuseppe A Latino
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA. .,Institute for Human Genetics, University of California, San Francisco, USA.
| | - Jeffrey Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA.
| | - Ludmila Pawlikowska
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA. .,Institute for Human Genetics, University of California, San Francisco, USA.
| | - William Young
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA.
| | - Marie E Faughnan
- Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada. .,Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Canada.
| | | |
Collapse
|
30
|
Angriman F, Ferreyro BL, Wainstein EJ, Serra MM. Pulmonary Arteriovenous Malformations and Embolic Complications in Patients With Hereditary Hemorrhagic Telangiectasia. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
31
|
Angriman F, Ferreyro BL, Wainstein EJ, Serra MM. Pulmonary arteriovenous malformations and embolic complications in patients with hereditary hemorrhagic telangiectasia. Arch Bronconeumol 2014; 50:301-4. [PMID: 24629762 DOI: 10.1016/j.arbres.2013.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/08/2013] [Accepted: 08/10/2013] [Indexed: 11/19/2022]
Abstract
Patients with hereditary hemorrhagic telangiectasia (HHT) and pulmonary arteriovenous malformation (PAVM) face higher risk of embolic complications. It is not clear whether poor outcomes are related to PAVM severity or pulmonary symptoms. Furthermore, there is currently no available data on HHT patients in Argentina. We conducted a cross sectional study in a teaching hospital in Buenos Aires, Argentina. We describe baseline characteristics of HHT and compare the prevalence of embolic complications in patients with significant PAVM compared to patients without significant PAVM. One hundred and eight consecutive patients were included. Significant PAVM was defined as: contrast echocardiography grade 2 or greater; bilateral PAVM or feeding artery bigger than 3mm; or previous PAVM treatment. Primary composite outcome was defined as: cerebrovascular accident, cerebral abscess or peripheral embolism. 20% of participants had embolic complications, the most frequent one was stroke. Embolic complications were associated with significant PAVM and respiratory symptoms.
Collapse
Affiliation(s)
- Federico Angriman
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina.
| | - Bruno L Ferreyro
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Esteban J Wainstein
- Departamento de Medicina Respiratoria, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo M Serra
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina; Unidad de THH, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
32
|
Ischaemic strokes in patients with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia: associations with iron deficiency and platelets. PLoS One 2014; 9:e88812. [PMID: 24586400 PMCID: PMC3929507 DOI: 10.1371/journal.pone.0088812] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/13/2014] [Indexed: 01/24/2023] Open
Abstract
Background Pulmonary first pass filtration of particles marginally exceeding ∼7 µm (the size of a red blood cell) is used routinely in diagnostics, and allows cellular aggregates forming or entering the circulation in the preceding cardiac cycle to lodge safely in pulmonary capillaries/arterioles. Pulmonary arteriovenous malformations compromise capillary bed filtration, and are commonly associated with ischaemic stroke. Cohorts with CT-scan evident malformations associated with the highest contrast echocardiographic shunt grades are known to be at higher stroke risk. Our goal was to identify within this broad grouping, which patients were at higher risk of stroke. Methodology 497 consecutive patients with CT-proven pulmonary arteriovenous malformations due to hereditary haemorrhagic telangiectasia were studied. Relationships with radiologically-confirmed clinical ischaemic stroke were examined using logistic regression, receiver operating characteristic analyses, and platelet studies. Principal Findings Sixty-one individuals (12.3%) had acute, non-iatrogenic ischaemic clinical strokes at a median age of 52 (IQR 41–63) years. In crude and age-adjusted logistic regression, stroke risk was associated not with venous thromboemboli or conventional neurovascular risk factors, but with low serum iron (adjusted odds ratio 0.96 [95% confidence intervals 0.92, 1.00]), and more weakly with low oxygen saturations reflecting a larger right-to-left shunt (adjusted OR 0.96 [0.92, 1.01]). For the same pulmonary arteriovenous malformations, the stroke risk would approximately double with serum iron 6 µmol/L compared to mid-normal range (7–27 µmol/L). Platelet studies confirmed overlooked data that iron deficiency is associated with exuberant platelet aggregation to serotonin (5HT), correcting following iron treatment. By MANOVA, adjusting for participant and 5HT, iron or ferritin explained 14% of the variance in log-transformed aggregation-rate (p = 0.039/p = 0.021). Significance These data suggest that patients with compromised pulmonary capillary filtration due to pulmonary arteriovenous malformations are at increased risk of ischaemic stroke if they are iron deficient, and that mechanisms are likely to include enhanced aggregation of circulating platelets.
Collapse
|
33
|
Velthuis S, Buscarini E, van Gent MWF, Gazzaniga P, Manfredi G, Danesino C, Schonewille WJ, Westermann CJJ, Snijder RJ, Mager JJ, Post MC. Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: a striking association. Chest 2014; 144:542-548. [PMID: 23429940 DOI: 10.1378/chest.12-1599] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND A pulmonary right-to-left shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). METHODS We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary shunt grading on TTCE (grade 0, no microbubbles; grade 1, < 30 microbubbles; grade 2, 30-100 microbubbles; grade 3, > 100 microbubbles) was performed according to contrast opacification of the left ventricle. Cerebral complications were defined as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confirmed by appropriate imaging techniques. RESULTS A pulmonary RLS was present in 530 out of 1,038 patients (51.1%; mean age, 44.3 ± 15.6 years; 58.6% women). The presence of a cerebral manifestation (n = 51) differed significantly among pulmonary shunt grades on TTCE: 1.4%, 0.4%, 6.5%, and 20.9% for grades 0, 1, 2 and 3, respectively. A pulmonary shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95% CI, 0.05-4.13; P = .47), whereas pulmonary shunt grade 2 (OR, 4.78; 95% CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95% CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. CONCLUSIONS The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.
Collapse
Affiliation(s)
- Sebastiaan Velthuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | | | - Marco W F van Gent
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Guido Manfredi
- Department of Gastroenterology, Maggiore Hospital, Crema, Italy
| | | | | | | | - Repke J Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
34
|
Velthuis S, Vorselaars VMM, van Gent MWF, Westermann CJJ, Snijder RJ, Mager JJ, Post MC. Role of transthoracic contrast echocardiography in the clinical diagnosis of hereditary hemorrhagic telangiectasia. Chest 2013; 144:1876-1882. [PMID: 23907523 DOI: 10.1378/chest.13-0716] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) can be diagnosed according to the four clinical Curaçao criteria, including the presence of pulmonary arteriovenous malformations (PAVMs). In the past few years, transthoracic contrast echocardiography (TTCE) replaced chest high-resolution CT (HRCT) imaging for the screening of PAVMs. The objective of this study was to determine whether the presence of any pulmonary shunt on TTCE can be accepted as a new clinical Curaçao criterion in diagnosing HHT. METHODS Between 2004 and 2012, we included 487 first-degree relatives of known HHT-causing mutation carriers who underwent both TTCE and chest HRCT imaging to screen for PAVMs. A quantitative three-point grading scale was used to differentiate among minimal, moderate, or extensive pulmonary shunt on TTCE (grade 1-3). Genetic testing was performed in all people and considered the gold standard for the diagnosis of HHT. RESULTS Chest HRCT imaging demonstrated PAVMs in 114 of 218 patients (52.3%) with a pulmonary shunt on TTCE. The addition of any pulmonary shunt on TTCE to the current clinical Curaçao criteria increased the number of positive criteria in 92 of 487 individuals (18.9%), which increased the sensitivity in diagnosing HHT from 88% to 94% at the expense of a decreased specificity from 74% to 70%. Accepting only pulmonary shunt grades ≥ 2 on TTCE as a diagnostic criterion for HHT enhanced the number of positive criteria in 30 (6.2%) individuals, which led to an increased sensitivity of 90% with no decrease in specificity (74%). CONCLUSIONS The addition of only pulmonary shunt grades ≥ 2 on TTCE to the current clinical Curaçao criteria increases its sensitivity without affecting specificity in the diagnosis of HHT.
Collapse
Affiliation(s)
- Sebastiaan Velthuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | | | - Marco W F van Gent
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Repke J Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
35
|
Elliott JE, Nigam SM, Laurie SS, Beasley KM, Goodman RD, Hawn JA, Gladstone IM, Chesnutt MS, Lovering AT. Prevalence of left heart contrast in healthy, young, asymptomatic humans at rest breathing room air. Respir Physiol Neurobiol 2013; 188:71-8. [PMID: 23648476 DOI: 10.1016/j.resp.2013.04.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/01/2013] [Accepted: 04/23/2013] [Indexed: 10/26/2022]
Abstract
Our purpose was to report the prevalence of healthy, young, asymptomatic humans who demonstrate left heart contrast at rest, breathing room air. We evaluated 176 subjects (18-41 years old) using transthoracic saline contrast echocardiography. Left heart contrast appearing ≤3 cardiac cycles, consistent with a patent foramen ovale (PFO), was detected in 67 (38%) subjects. Left heart contrast appearing >3 cardiac cycles, consistent with the transpulmonary passage of contrast, was detected in 49 (28%) subjects. Of these 49 subjects, 31 were re-evaluated after breathing 100% O2 for 10-15min and 6 (19%) continued to demonstrate the transpulmonary passage of contrast. Additionally, 18 of these 49 subjects were re-evaluated in the upright position and 1 (5%) continued to demonstrate the transpulmonary passage of contrast. These data suggest that ~30% of healthy, young, asymptomatic subjects demonstrate the transpulmonary passage of contrast at rest which is reduced by breathing 100% O2 and assuming an upright body position.
Collapse
Affiliation(s)
- Jonathan E Elliott
- University of Oregon, Department of Human Physiology, Eugene, OR 97403-1240, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Al-Saleh S, Dragulescu A, Manson D, Golding F, Traubici J, Mei-Zahav M, Maclusky IB, Faughnan ME, Carpenter S, Ratjen F. Utility of contrast echocardiography for pulmonary arteriovenous malformation screening in pediatric hereditary hemorrhagic telangiectasia. J Pediatr 2012; 160:1039-43.e1. [PMID: 22196589 DOI: 10.1016/j.jpeds.2011.11.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 09/30/2011] [Accepted: 11/14/2011] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the utility of transthoracic contrast echocardiography (TTCE) as a screening tool for pulmonary arteriovenous malformations (PAVMs) in children with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN This was a single-center study of children who underwent baseline screening for PAVMs using both TTCE and chest computed tomography (CT) for evaluation of HHT. The CT and TTCE results were prospectively reviewed independently by 2 radiologists and 2 cardiologists blinded to the study results. RESULTS Both intraobserver and interobserver agreement for interpreting TTCE results were excellent (κ = 0.97 and 0.92, respectively) and higher than the interobserver agreement for CT interpretation (κ = 0.75). The sensitivity and specificity of TTCE to predict PAVMs were 1 and 0.82, respectively, and the positive predictive and negative predictive values were 0.39 and 1, respectively. CONCLUSION TTCE is a sensitive test for PAVMs in children with suspected HHT and can be a useful initial screening tool in pediatric HHT.
Collapse
Affiliation(s)
- Suhail Al-Saleh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Relation between migraine and size of echocardiographic intrapulmonary right-to-left shunt. Am J Cardiol 2011; 107:1399-404. [PMID: 21371682 DOI: 10.1016/j.amjcard.2010.12.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 12/31/2010] [Accepted: 12/31/2010] [Indexed: 11/21/2022]
Abstract
An increased prevalence of intrapulmonary right-to-left shunt (RLS) has been shown in patients with migraine. The aim of this study was to determine whether the size of intrapulmonary RLS was associated with migraine with aura (MA+) and migraine without aura (MA-) in subjects screened for hereditary hemorrhagic telangiectasia. A total of 462 consecutive subjects were screened for hereditary hemorrhagic telangiectasia and underwent transthoracic contrast echocardiography. A pulmonary shunt was established when contrast appeared in the left atrium after 4 cardiac cycles. Shunt size was assessed semiquantitatively as small (<30 microbubbles), moderate (30 to 100 microbubbles), or large (>100 microbubbles). A headache questionnaire was completed by 420 subjects (91%). Two independent neurologists diagnosed migraine according to the International Headache Society criteria. Of 420 screened subjects (mean age 43.4 ± 15.4 years, 61.4% women), 44 (10.5%) had MA+ and 45 (10.7%) had MA-. MA+ was an independent predictor for an intrapulmonary RLS (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.36 to 6.47, p=0.006) in multivariate analysis. MA- was not correlated with RLS (OR 1.21, 95% CI 0.56 to 2.64, p=0.60). When comparing patients with MA+ to those without migraine in a multivariate analysis, the presence of an intrapulmonary shunt predicted MA+ (OR 2.5, 95% CI 1.2 to 5.2, p=0.01), as did female gender (OR 3.15, 95% CI 1.29 to 7.65, p<0.01). The correlation of MA+ and RLS could be entirely attributed to large intrapulmonary shunts (OR 7.61, 95% CI 3.11 to 18.61, p<0.001), as small (OR 0.6, 95% CI 0.13 to 2.78, p=0.52) and moderate (OR 1.33, 95% CI 0.35 to 5.02, p=0.68) shunts did not appear to be risk factors for MA+. In conclusion, patients with large intrapulmonary RLS have an increased risk for MA+.
Collapse
|
38
|
Van den Branden BJ, Post MC, Plokker HW, ten Berg JM, Suttorp MJ. Patent foramen ovale closure using a bioabsorbable closure device: safety and efficacy at 6-month follow-up. JACC Cardiovasc Interv 2011; 3:968-73. [PMID: 20850098 DOI: 10.1016/j.jcin.2010.06.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 06/10/2010] [Accepted: 06/27/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to assess the mid-term safety and efficacy of percutaneous patent foramen ovale (PFO) closure using a bioabsorbable device (BioSTAR, NMT Medical, Boston, Massachusetts). BACKGROUND Closure of PFO in patients with cryptogenic stroke has proven to be safe and effective using different types of permanent devices. METHODS All consecutive patients who underwent percutaneous PFO closure with the bioabsorbable closure device between November 2007 and January 2009 were included. Residual shunt was assessed using contrast transthoracic echocardiography. RESULTS Sixty-two patients (55% women, mean age 47.7 ± 11.8 years) underwent PFO closure. The in-hospital complications were a surgical device retrieval in 2 patients (3.2%), device reposition in 1 (1.6%), and a minimal groin hematoma in 6 patients (9.7%). The short-term complications at 1-month follow-up (n = 60) were a transient ischemic attack in the presence of a residual shunt in 1 patient and new supraventricular tachycardia in 7 patients (11.3%). At 6-month follow-up (n = 60), 1 patient without residual shunt developed a transient ischemic attack and 1 developed atrial fibrillation. A mild or moderate residual shunt was noted in 51.7%, 33.9%, and 23.7% after 1-day, 1-month, and 6-month follow-up, respectively. A large shunt was present in 8.3%, 3.4%, and 0% after 1-day, 1-month, and 6-month follow-up. CONCLUSIONS Closure of PFO using the bioabsorbable device is associated with a low complication rate and a low recurrence rate of embolic events. However, a relatively high percentage of mild or moderate residual shunting is still present at 6-month follow-up.
Collapse
Affiliation(s)
- Ben J Van den Branden
- Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. antoniusziekenhuis.nl
| | | | | | | | | |
Collapse
|
39
|
Van Den Branden BJL, Post MC, Plokker HWM, Ten Berg JM, Suttorp MJ. Percutaneous atrial shunt closure using the novel Occlutech Figulla device: 6-month efficacy and safety. J Interv Cardiol 2010; 24:264-70. [PMID: 21198853 DOI: 10.1111/j.1540-8183.2010.00619.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The Occlutech Figulla Occluder is a new innovative device for percutaneous closure of a patent foramen ovale (PFO) and an atrial septum defect (ASD). We describe the safety and efficacy of this new device at 6-month follow-up. METHODS All 82 consecutive patients (51% female, mean age 49.0 ± 13.6 years) who underwent percutaneous PFO (n = 48) or ASD (n = 34) closure between October 2008 and October 2009 were included. RESULTS Implantation success was 100%. The in-hospital complications were two new onset supraventricular tachycardia (SVT) (2.4%, both ASD patients), nine minimal groin hematoma's (11.0%, 4 PFO and 5 ASD patients), and one transient ST elevation during the procedure (1.2%, ASD patient). During 6 months follow-up (n = 79), no major complications or reoccurrences of cerebral thrombo-embolic events did occur. Seven patients (8.9%, 6 PFO and 1 ASD patient) experienced a new SVT. One patient developed a recurrent cerebral hemorrhage 5 months after ASD closure, which appeared not to be related to the procedure. Using contrast transthoracic echocardiography 6 months after PFO closure (n = 45), a residual shunt was present in 30.2% of the patients (small 25.6%, moderate 4.6%, severe 0%). In the ASD group (n = 34), a residual shunt was observed in 32.5% (small 17.7%, moderate 14.7%, severe 2.9%). CONCLUSION The Occlutech Figulla Occluder appears to be easy to use, effective, and safe for percutaneous closure of PFO and ASD. We report a low complication rate but a relative high percentage of small residual shunts 6 months after closure.
Collapse
Affiliation(s)
- Ben J L Van Den Branden
- Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | | | | | | | | |
Collapse
|
40
|
Abstract
Hereditary haemorrhagic telangiectasia, inherited as an autosomal dominant trait, affects approximately 1 in 5000 people. The abnormal vascular structures in HHT result from mutations in genes (most commonly endoglin or ACVRL1) whose protein products influence TGF-ß superfamily signalling in vascular endothelial cells. The cellular mechanisms underlying the generation of HHT telangiectasia and arteriovenous malformations are being unravelled, with recent data focussing on a defective response to angiogenic stimuli in particular settings. For affected individuals, there is often substantial morbidity due to sustained and repeated haemorrhages from telangiectasia in the nose and gut. Particular haematological clinical challenges include the management of severe iron deficiency anaemia; handling the intricate balance of antiplatelet or anticoagulants for HHT patients in whom there are often compelling clinical reasons to use such agents; and evaluation of apparently attractive experimental therapies promoted in high profile publications when guidelines and reviews are quickly superseded. There is also a need for sound screening programmes for silent arteriovenous malformations. These occur commonly in the pulmonary, cerebral, and hepatic circulations, may haemorrhage, but predominantly result in more complex pathophysiology due to consequences of defective endothelium, or shunts that bypass specific capillary beds. This review will focus on the new evidence and concepts in this complex and fascinating condition, placing these in context for both clinicians and scientists, with a particular emphasis on haematological settings.
Collapse
Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, UK and HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
| |
Collapse
|
41
|
Balza OR, García-Guereta L, Vidal MDR, Marín MJDC, Pajares MP. [Rendu-Osler-Weber syndrome: an rare cause of hypoxemia in children]. An Pediatr (Barc) 2010; 73:272-6. [PMID: 20813596 DOI: 10.1016/j.anpedi.2010.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 03/21/2010] [Accepted: 06/10/2010] [Indexed: 11/28/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia or Rendu-Osler-Weber syndrome is a rare genetic autosomic dominant disorder with an estimated prevalence of one in 3000-5000 individuals. This multisystemic vascular dysplasia is determined by the mutation of two main genes which are endoglin (ENG) or HHT1 and ALK1 or HHT2. These mutations induce the vascular disorders which cause recurrent epistaxis and eventually multiple telangiectasias and arteriovenous visceral malformations (AVM). We report the case of an 11-year-old boy who developed severe hypoxaemia due to multiple pulmonary arteriovenous malformations.
Collapse
|
42
|
Van den Branden B, Luermans J, Post M, Plokker H, ten Berg J, Suttorp M. The BioSTAR(r) device versus the CardioSEAL(r) device in patent foramen ovale closure: comparison of mid-term efficacy and safety. EUROINTERVENTION 2010; 6:498-504. [DOI: 10.4244/eij30v6i4a83] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
43
|
Laurie SS, Yang X, Elliott JE, Beasley KM, Lovering AT. Hypoxia-induced intrapulmonary arteriovenous shunting at rest in healthy humans. J Appl Physiol (1985) 2010; 109:1072-9. [PMID: 20689088 DOI: 10.1152/japplphysiol.00150.2010] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Intrapulmonary arteriovenous (IPAV) shunting has been shown to occur at rest in some subjects breathing a hypoxic gas mixture [fraction of inspired oxygen (FI(O(2))) = 0.12] for brief periods of time. In the present study we set out to determine if IPAV shunting could be induced at rest in all subjects exposed to hypoxia for 30 min. Twelve subjects (6 women) breathed four levels of hypoxia (FI(O(2)) = 0.16, 0.14, 0.12, and 0.10) for 30 min each in either an ascending or descending order with a 15-min normoxic break between bouts. Saline contrast echocardiography was used to detect IPAV shunt and a shunt score (0-5) was assigned based on contrast in the left ventricle with a shunt score ≥ 2 considered significant. Pulmonary artery systolic pressure (PASP) was determined using Doppler ultrasound. The total number of subjects demonstrating shunt scores ≥ 2 for FI(O(2)) = 0.16, 0.14, 0.12, and 0.10 was 1/12, 7/12, 9/12, and 12/12, respectively. Shunt scores were variable between subjects but significantly greater than normoxia for FI(O(2)) = 0.12 and 0.10. Shunt scores correlated with peripheral measurements of arterial oxygen saturation (SpO(2)) (r(w) = -0.67) and PASP (r(w) = 0.44), despite an increased shunt score but no increase in PASP while breathing an FI(O(2)) = 0.12. It is unknown how hypoxia induces the opening of IPAV shunts, but these vessels may be controlled via similar mechanisms as systemic vessels that vasodilate in response to hypoxia. Despite intersubject variability our results indicate significant IPAV shunting occurs at rest in all subjects breathing an FI(O(2)) = 0.10 for 30 min.
Collapse
Affiliation(s)
- Steven S Laurie
- Department of Human Physiology, University of Oregon, Eugene, Oregon 97403, USA
| | | | | | | | | |
Collapse
|
44
|
van Gent MWF, Post MC, Snijder RJ, Westermann CJJ, Plokker HWM, Mager JJ. Real prevalence of pulmonary right-to-left shunt according to genotype in patients with hereditary hemorrhagic telangiectasia: a transthoracic contrast echocardiography study. Chest 2010; 138:833-9. [PMID: 20154077 DOI: 10.1378/chest.09-1849] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Transthoracic contrast echocardiography (TTCE) can detect pulmonary right-to-left shunting (RLS) and is used to screen for pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT). We studied the prevalence and size of pulmonary RLS in HHT type 1, HHT type 2, and HHT-negative controls, and its positive predictive value (PPV) and negative predictive value (NPV) for PAVMs that can be treated by embolotherapy. METHODS In 343 consecutive persons referred for possible HHT as first-degree family members of index patients a TTCE and chest CT scan were performed. All persons were offered genetic analysis. RESULTS An HHT-causing mutation was confirmed in 92 (mean age 41 ± 15 y; 59% female) HHT1 relatives and in 97 (mean age 47 ± 14 y; 52% female) HHT2 relatives. TTCE showed a pulmonary RLS in 78 (85%) HHT1- and 34 (35%) HHT2-related mutation carriers, respectively (P < .0001). In HHT1 relatives, 29 of 53 (55%) PAVMs and in HHT2 relatives three of 17 (18%) PAVMS were treated, resulting in a PPV of TTCE for treatable PAVMs of 36.3% and 8.3%, respectively. The accompanying NPV was 100%. A minimal, moderate, or large shunt was present in 12 (13%), 24 (26%), and 42 (46%) HHT1-related, and in 20 (21%), 6 (6%), and 8 (8%) HHT2-related mutation carriers, respectively (P for trend < .0001). A large shunt predicted treatable PAVMs in 55.8% of HHT1 relatives and 37.5% of HHT2 relatives. TTCE was positive in four (6%) of 63 persons without HHT. CONCLUSIONS A pulmonary shunt on TTCE is more prevalent and larger in HHT1- compared with HHT2-related mutation carriers. Shunt grading is helpful to predict treatable PAVMs, particularly in the HHT2 group. TTCE is also positive in a small fraction of persons without HHT.
Collapse
Affiliation(s)
- Marco W F van Gent
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | | | | | | |
Collapse
|