Ann Thorac Surg 1998;65:267
© 1998 The Society of Thoracic Surgeons
Case Reports
Transesophageal Echocardiography in an Operation for Pulmonary Arteriovenous Malformation
Aubrey A. Almeida, MBBS,
Helen L. Thomson, FRACP,
Darryl J. Burstow, FRACP,
Robert K. W. Tam, FRACS
Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
Department of Echocardiography, The Prince Charles Hospital, Brisbane, Queensland, Australia
Accepted for publication September 8, 1997.
Dr Almeida, Department of Cardiothoracic Surgery, The Prince Charles Hospital, Rode Rd, Chermside, QLD, Australia, 4032 (e-mail: a.almeida@mailbox.uq.edu.au).
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Abstract
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Transesophageal echocardiography has been described as a useful tool in the diagnosis of pulmonary arteriovenous malformations. We describe a case in which intraoperative transesophageal echocardiography was used to aid localization and ensure complete surgical ligation.
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Introduction
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A 49-year-old man with known hereditary hemorrhagic telangectasia presented with two episodes of transient ischemic attacks. The first involved left hemiparesis, facial weakness, and dysarthria. The second involved right hemiparesis, facial weakness, and dysphasia. Physical examination after resolution of the transient ischemic attacks revealed telangectasia on the lower lip but no other abnormality. Chest roentgenography demonstrated a lesion in the right lower lobe, 3 cm in diameter. This was confirmed as an arteriovenous malformation on computed tomography.
A pulmonary angiogram was performed, which demonstrated the lesion; however, accurate assessment was not possible as selective injection caused the patient to become profoundly bradycardic, hypotensive, and sweaty. This was accompanied by ST changes on the electrocardiograph, which lasted 10 minutes. A further study and ablation was attempted 3 weeks after the first. The right femoral artery and vein were cannulated and the catheters positioned appropriately. Selective injection unfortunately resulted in a further hypotensive episode again accompanied by ST changes. The procedure was abandoned.
An operation was planned, and the patient underwent a right lateral thoracotomy through the fifth intercostal space. Intraoperative transesophageal echocardiography was performed, during which agitated blood and saline contrast was injected into the right heart. This demonstrated immediate opacification of the right atrium and, after three cardiac cycles, opacification of the left atrium (Fig 1),
which was consistent with a right-to-left shunt due to a pulmonary arteriovenous malformation. The oblique fissure was dissected and the ascending artery to the posterior segment of the upper lobe was identified. The feeding vessel arose from this structure, with drainage directly to the left atrium. The feeding vessel was ligated and divided. A repeat intraoperative transesophageal echocardiogram demonstrated no echo contrast in the left atrium, confirming complete ligation of the malformation (Fig 2).
The patient was discharged 3 days after the operation. The patient remains well at 15 months with no further transient ischemic attacks and a normal chest roentgenogram.
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Preligation transesophageal echocardiogram demonstrating microbubbles in the right atrium (A), and then appearing in the left atrium three cardiac cycles later (B). (LA = left atrium; RA = right atrium; LV = left ventricle; RV = right ventricle.)
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Postligation transesophageal echocardiogram three cardiac cycles after contrast injection demonstrating elimination of shunt.
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Comment
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Pulmonary arteriovenous malformation is well described in association with hereditary hemorrhagic telangectasia [1]. The malformations are often multiple, but solitary lesions are also described. Neurologic manifestations are not uncommon, occurring in 4% to 12% of cases [2]. Arteriography and embolization with various devices can be successfully used in the management in many cases, although long-term results are limited. Therapeutic embolization is associated with the risk of pulmonary infarction and pleurisy in about 11% of cases, systemic embolization, and arrhythmia [3]. Coronary spasm has been described during the procedure [4]. Recanalization is well recognized, occurring in 5% to 10% [3]. Because of this, surgical management is advised by some authors for all patients except those who are poor surgical risks and those whose lesions are too numerous to resect [5]. Operation, when performed, should aim to spare lung parenchyma.
Transesophageal echocardiography with echo contrast has been described as a tool in the diagnosis of arteriovenous malformations. The diagnosis relies on the transit of echo contrast in the form of agitated saline solution from the right to left atrium. Rapid transit is suggestive of atrial septal defects as a cause of the shunt, whereas transit after three or more cardiac cycles is characteristic of a pulmonary arteriovenous malformation [6].
This case highlights the usefulness of intraoperative transesophageal echocardiography in the management of this unusual condition. Echo-contrast intraoperative transesophageal echocardiography demonstrated that the surgeon had successfully ligated the feeding vessels and eliminated the shunt before completion of the operation. Without this information, a more extensive surgical procedure including lobectomy would have been required to eliminate the shunt with certainty.
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References
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- Rodes CB Cavernous hemangiomas of the lung with secondary polycythemia. JAMA 1938;110:1914-1915.[Abstract/Free Full Text]
- Yeung MD, Khan KA, Antecol DH, Walker DR, Shuaib A Transcranial Doppler ultrasonography and transesophageal echocardiography in the investigation of pulmonary arteriovenous malformation in a patient with hereditary hemorrhagic telangectasia presenting with stroke. Stroke 1995;26:1941-1945.[Abstract/Free Full Text]
- Haitjema TJ, Overtoom TTC, Westermann CJJ, Lammers JWJ Embolisation of pulmonary arteriovenous malformations: results and follow up in 32 patients. Thorax 1995;50:719-723.[Abstract/Free Full Text]
- Terry PB, White RI, Barth KH, et al. Pulmonary arteriovenous malformations: physiologic observations and results of therapeutic balloon embolization. N Engl J Med 1983;308:1197-1200.[Abstract]
- Puskas JD, Allen MS, Moncure AC, et al. Pulmonary arteriovenous malformations: therapeutic options. Ann Thor Surg 1993;56:253-258.[Abstract]
- Shub C, Tajik AJ, Seward JB, Dines DE Detecting intrapulmonary right-to-left shunt with contrast echocardiography: observations in a patient with diffuse pulmonary arteriovenous fistulas. Mayo Clin Proc 1976;51:81-84.[Medline]
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Abstract
Introduction
