Author: Sana Ullah, MB ChB, FRCA – Children’s Medical Center, Dallas TX
What is the MOST COMMON syndrome associated with pulmonary arteriovenous malformations ?
Correct!
Wrong!
Question of the Week 340
Pulmonary arteriovenous malformations (AVMs) are structurally abnormal blood vessels which form direct communications between the pulmonary arterial and pulmonary venous circulations, producing a right-to-left shunt bypassing the alveolar gas exchange regions and the normal filtering functions of the lungs. The most common cause of pulmonary AVMs is Osler-Weber-Rendu syndrome, which is also known as Hereditary Hemorrhagic Telangiectasia (HHT). Osler-Weber-Rendu is inherited in an autosomal dominant manner and affects approximately 1 in 5,000 to 8,000 people. In addition to AVMs, smaller telangiectatic vessels that are prone to bleeding are frequently found in nasal, mucocutaneous, hepatic, gastrointestinal and cerebral vascular beds.
Pulmonary AVMs can also develop after surgical palliation with the bidirectional cavopulmonary shunt and produce significant systemic desaturation. The purported mechanism is due to the lack of a “hepatic factor” that bypasses the pulmonary circulation after the bidirectional cavopulmonary shunt. Once the hepatic venous return is redirected back into the pulmonary circulation after Fontan completion, the pulmonary AVMs generally regress over a period of weeks to months.
The major clinical manifestations of pulmonary AVMs are recurrent bleeding manifesting as hemoptysis or hemothorax, systemic desaturation due to right-to-left shunting, ischemic strokes due to paradoxical thromboembolism, and cerebral abscesses resulting from bacteria in the blood that bypasses the filtering mechanism of the lungs. There is also an increased risk of pregnancy-related deaths in pregnant women with pulmonary AVMs. A rare but interesting phenomenon as a result of pulmonary AVMs is platypnea-orthodeoxia, which is best described as systemic desaturation and increased shortness of breath on standing up but improvement on lying flat. This is because most pulmonary AVMs are in the basal regions of the lungs thereby increasing the right-to-left shunt due to increased blood flow on assuming the upright posture.
Computed tomography of the chest is the gold-standard for diagnosis of pulmonary AVMs and offers better resolution than MRI. Contrast echocardiography using agitated saline injected into an arm vein and imaging the left side of the heart can also be used, but it lacks specificity even though it is highly sensitive. Transcatheter embolization is recommended for treatment of all pulmonary AVMs that are amenable to vessel access.
Scimitar syndrome is a rare variant of partial anomalous pulmonary venous return of a portion or the entirety of the right lung to the inferior vena cava. The abnormal venous channel forms a characteristic curved shadow on chest x-ray along the right heart border which resembles a sword known as a scimitar. Associated abnormalities include hypoplasia of the right lung, secondary dextroposition of the heart, and pulmonary sequestration of portions of the right. The sequestered lung does not take part in gas exchange and is prone to recurrent bleeding and infection. Management of Scimitar Syndrome is largely determined by the degree of volume overload to the heart and associated cardiac anomalies. Lung segments affected by sequestration may need to be resected.
Kartagener’s syndrome is an autosomal recessive disorder characterized by primary ciliary dyskinesis resulting in a triad of situs inversus totalis, chronic sinusitis, and bronchiectasis.
Alagille syndrome is an autosomal dominant disorder consisting of bile duct paucity and cholestasis, characteristic triangular facies, widespread vascular anomalies and congenital heart disease. The congenital heart disease often manifests as peripheral pulmonary arterial stenosis or hypoplasia, pulmonary valve stenosis, and/or Tetralogy of Fallot. Treatment of pulmonary arterial stenosis often requires a combination of surgical and transcatheter based techniques. Approximately 15% of patients eventually develop liver failure requiring transplantation. Many of these patients harbor a mutation in the JAG1 gene.
References
1. Shovlin CL. Pulmonary Arteriovenous Malformations. Am J Respir Crit Care Med. 2014; 190(11): 1217-1228.
2. Vida VL, Guariento A. A sword threatening the heart: The scimitar syndrome. JCTVS Techniques. 2020; 1: 75-80.
3. Tretter JT, McElhinney DB. Cardiac, Aortic, and Pulmonary Vascular Involvement in Alagille Syndrome. 2018. In: Kamath B., Loomes K. (eds) Alagille Syndrome. Springer, Cham. https://doi.org/10.1007/978-3-319-94571-2_6
4. Kamath BM, Spinner NB, Emerick KM, et al. Vascular anomalies in Alagille syndrome: A significant cause of morbidity and mortality. Circulation. 2004; 109:1354-1358.
Pulmonary AVMs can also develop after surgical palliation with the bidirectional cavopulmonary shunt and produce significant systemic desaturation. The purported mechanism is due to the lack of a “hepatic factor” that bypasses the pulmonary circulation after the bidirectional cavopulmonary shunt. Once the hepatic venous return is redirected back into the pulmonary circulation after Fontan completion, the pulmonary AVMs generally regress over a period of weeks to months.
The major clinical manifestations of pulmonary AVMs are recurrent bleeding manifesting as hemoptysis or hemothorax, systemic desaturation due to right-to-left shunting, ischemic strokes due to paradoxical thromboembolism, and cerebral abscesses resulting from bacteria in the blood that bypasses the filtering mechanism of the lungs. There is also an increased risk of pregnancy-related deaths in pregnant women with pulmonary AVMs. A rare but interesting phenomenon as a result of pulmonary AVMs is platypnea-orthodeoxia, which is best described as systemic desaturation and increased shortness of breath on standing up but improvement on lying flat. This is because most pulmonary AVMs are in the basal regions of the lungs thereby increasing the right-to-left shunt due to increased blood flow on assuming the upright posture.
Computed tomography of the chest is the gold-standard for diagnosis of pulmonary AVMs and offers better resolution than MRI. Contrast echocardiography using agitated saline injected into an arm vein and imaging the left side of the heart can also be used, but it lacks specificity even though it is highly sensitive. Transcatheter embolization is recommended for treatment of all pulmonary AVMs that are amenable to vessel access.
Scimitar syndrome is a rare variant of partial anomalous pulmonary venous return of a portion or the entirety of the right lung to the inferior vena cava. The abnormal venous channel forms a characteristic curved shadow on chest x-ray along the right heart border which resembles a sword known as a scimitar. Associated abnormalities include hypoplasia of the right lung, secondary dextroposition of the heart, and pulmonary sequestration of portions of the right. The sequestered lung does not take part in gas exchange and is prone to recurrent bleeding and infection. Management of Scimitar Syndrome is largely determined by the degree of volume overload to the heart and associated cardiac anomalies. Lung segments affected by sequestration may need to be resected.
Kartagener’s syndrome is an autosomal recessive disorder characterized by primary ciliary dyskinesis resulting in a triad of situs inversus totalis, chronic sinusitis, and bronchiectasis.
Alagille syndrome is an autosomal dominant disorder consisting of bile duct paucity and cholestasis, characteristic triangular facies, widespread vascular anomalies and congenital heart disease. The congenital heart disease often manifests as peripheral pulmonary arterial stenosis or hypoplasia, pulmonary valve stenosis, and/or Tetralogy of Fallot. Treatment of pulmonary arterial stenosis often requires a combination of surgical and transcatheter based techniques. Approximately 15% of patients eventually develop liver failure requiring transplantation. Many of these patients harbor a mutation in the JAG1 gene.
References
1. Shovlin CL. Pulmonary Arteriovenous Malformations. Am J Respir Crit Care Med. 2014; 190(11): 1217-1228.
2. Vida VL, Guariento A. A sword threatening the heart: The scimitar syndrome. JCTVS Techniques. 2020; 1: 75-80.
3. Tretter JT, McElhinney DB. Cardiac, Aortic, and Pulmonary Vascular Involvement in Alagille Syndrome. 2018. In: Kamath B., Loomes K. (eds) Alagille Syndrome. Springer, Cham. https://doi.org/10.1007/978-3-319-94571-2_6
4. Kamath BM, Spinner NB, Emerick KM, et al. Vascular anomalies in Alagille syndrome: A significant cause of morbidity and mortality. Circulation. 2004; 109:1354-1358.
