Author + information
- Received July 27, 2016
- Accepted August 11, 2016
- Published online October 24, 2016.
- Yasufumi Kijima, MD,
- Asim M. Rafique, MD and
- Jonathan M. Tobis, MD∗ ()
- Program in Interventional Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- ↵∗Reprint requests and correspondence:
Dr. Jonathan M. Tobis, Program in Interventional Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Factor Building, B-976, Los Angeles, California 90095.
A 71-year-old woman who had 2 strokes without significant atherosclerosis was referred to our institution for consideration of percutaneous patent foramen ovale (PFO) closure. There was no family history of hereditary hemorrhagic telangiectasia, and the patient had no telangiectasia or history of epistaxis. On right-heart catheterization, a J-tipped guidewire was unable to cross the interatrial septum. Selective angiography was performed to clarify the anatomy and confirmed the presence of a small PFO (Figure 1, Online Video 1). Despite the small size of the PFO, in the presence of recurrent stroke, the PFO was closed using a 25-mm GORE CARDIOFORM Septal Occluder (W. L. Gore & Associates, Flagstaff, Arizona). After device deployment, a repeat bubble contrast study was performed and demonstrated a persistent right-to-left shunt with intracardiac echocardiography. Selective angiography of the pulmonary artery was performed and revealed a pulmonary arteriovenous malformation (PAVM) with a feeding artery diameter of 6 to 7 mm (Figures 2A and 2B, Online Video 2A). This was closed using an 8-mm Amplatzer Vascular Plug IV (St. Jude Medical, St. Paul, Minnesota) (Figure 2C, Online Video 2B).
A PFO is an interatrial communication present in about 20% of the general population (1). Another etiology of a right-to-left shunt is a PAVM, which is formed by an abnormal communication between a branch pulmonary artery and vein. Approximately 70% to 90% of cases of PAVM are associated with hereditary hemorrhagic telangiectasia (2). This case of a small PFO associated with a PAVM is unusual because the patient did not have a history consistent with hereditary hemorrhagic telangiectasia, and thus a PAVM was not suspected.
Selective angiography demonstrated a small PFO associated with a large PAVM. We suspect that the PAVM was the primary etiology of the patient’s strokes. In patients who have undergone PFO closure, in whom there is still a large residual right-to-left shunt, the presence of a PAVM should be evaluated.
For supplemental videos and their legends, please see the online version of this article.
Dr. Tobis has served as a consultant for W. L. Gore & Associates and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 27, 2016.
- Accepted August 11, 2016.
- 2016 American College of Cardiology Foundation