Author + information
- Received January 5, 2014
- Accepted January 16, 2014
- Published online September 1, 2014.
- Basil (Vasilios) D. Thanopoulos, MD, PhD∗ ( )( and )
- George Papaioannou, MD
- ↵∗Reprint requests and correspondence:
Dr. Basil D. Thanopoulos, Department of Interventional Pediatric Cardiology, Iatrikon Medical Center, Distomou 5-7, 15125, Athens, Greece.
A 65-year-old woman with a history of multiple (1 to 2/year since 45 years of age) transient ischemic attacks was referred to our department with the multislice computed tomography (MSCT) diagnosis of pulmonary arteriovenous fistula (PAVF) for catheter closure (Figure 1A). Two weeks prior to admission, the patient had a cryptogenic stroke with cardiac magnetic resonance confirmation that was characterized by dysarthria and unilateral body weakness despite treatment with aspirin and Coumadin (Bristol-Myers Squibb, New York, New York). Blood tests and transesophageal echocardiography with color Doppler study were negative for thrombophilia and patent foramen ovale, respectively. Due to the patient’s speech disturbance, it was not possible to perform a bubble test during Valsalva maneuver. Cardiac catheterization confirmed the MSCT findings demonstrating a PAVF between the right pulmonary artery and right upper pulmonary vein (Figures 1B and 1C, Online Video 1). The PAVF was successfully closed with a 6-mm Amplatzer vascular plug II (St. Jude Medical, St. Paul, Minnesota) (Figure 1D, Online Video 2). The patient went home a week after the procedure in stable condition on aspirin 5 mg/kg daily. One year later, an MSCT demonstrated complete closure and no recanalization of the fistula (Figure 1E). Complete resolution of her neurological symptoms was observed at 1-year follow-up. The patient did not have any further episodes of transient ischemic attacks or stroke during a follow-up period of 2 years.
Paradoxical embolism in patients with isolated PAVF is rare with few reported cases in the literature (1–3). Late appearance of microbubbles in the left atrium during transesophageal echocardiography with Valsalva bubble test is highly suggestive of PAVF in patients with cryptogenic stroke (4). However, it should be noted that this test is difficult or not possible to perform in patients with dysarthria or disturbance of consciousness. Our case emphasizes the importance of MSCT in the initial evaluation and the post-closure follow-up of patients with PAVF-related cryptogenic stroke.
For accompanying videos, and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 5, 2014.
- Accepted January 16, 2014.
- American College of Cardiology Foundation
- Kimura K.,
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