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Pulmonary Hypertension in a 45-Year-Old Woman With Recurrent Deep Venous Thromboses* FREE TO VIEW

Jeana D. O’Brien, MD, FCCP; Craig K. Reiss, MD
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*From the Division of Pulmonary and Critical Care Medicine, Division of Cardiology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO.

Correspondence to: Jeana D. O’Brien, MD, FCCP, Division of Pulmonary and Critical Care, Scott and White Clinic, 2401 S 31st St, Temple, TX 76508; e-mail: jobrien@bellnet.tamu.edu

Chest. 1999;116(2):560-563. doi:10.1378/chest.116.2.560
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A 45-year-old African-American woman was referred for evaluation of pulmonary hypertension. Five years before admission, the patient experienced gradually progressive dyspnea on exertion with recent onset of fatigue, two- to three-pillow orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema. Evaluation before referral included pulmonary function studies showing normal spirometry, mildly decreased total lung capacity and diffusion capacity, and exercise desaturation to 84%. A transthoracic echocardiogram was reported to show normal left ventricular function, mild mitral and tricuspid regurgitation, and elevated mean pulmonary arterial pressures.

There was also a history of atrial fibrillation, recurrent deep venous thromboses, and a hypercoagulable state, although details of this diagnosis were unavailable. Six years before admission, the patient had undergone placement of a Greenfield vena caval filter. Past surgeries include an abdominal hysterectomy and lumbar spinal disk surgery 7 years before admission.

She was a disabled former automotive spray painter who did not use tobacco, alcohol or other drugs. Current medications included furosemide, warfarin, captopril, digoxin, and nitrates.

The physical examination revealed an alert, obese woman in no distress. She weighed 118.2 kg and was 162.6 cm in height. She was afebrile with a heart rate of 106 beats per minute, a respiratory rate of 26 breaths per minute, and BP of 140/80 mm Hg. Room air O2 saturation was 94%.

Head, eye, ear, nose, and throat examination was normal. The neck was supple, short, and without lymphadenopathy. Cardiac examination showed jugular venous distension to the mandible, a prominent apical impulse, and right ventricular heave with pulmonary artery (PA) tap. The rhythm was irregularly irregular with a prominently wide split S2, and a grade 3/6 blowing holosystolic murmur across the precordium, which accentuated with inspiration. Examination of the lungs revealed minimal crackles in the bases with vesicular breath sounds. Soft bruits were heard over all lung fields. The abdomen was obese and nontender without hepatosplenomegaly. There was 2+ pitting edema to the knees with chronic stasis changes bilaterally, which was warm to the touch. There was no cyanosis or clubbing. There were no skin lesions noted, and neurologic examination was grossly intact.

The WBC count was 4.9/μL; hemoglobin level, 14.1 g/dL; hematocrit, 41%; platelet count, 153,000/μL; chemistry profile was normal except for bilirubin, 6.3 mg/dL, lactate dehydrogenase, 353 U/L, aspartate transaminase, 55 U/L, and alkaline phosphatase, 317 U/L. The results of arterial blood gas tests performed at rest with room air were the following: pH, 7.46; Pco2, 35 mm Hg; Po2, 78 mm Hg; prothrombin time, 17.1 s. ECG showed atrial fibrillation, right ventricular hypertrophy, and right axis deviation. Chest radiograph showed moderate cardiomegaly with pulmonary vascular and azygos vein prominence, mild volume overload, and enlargement of the PAs (Fig 1 ). Echocardiogram showed right atrial and right ventricular enlargement with paradoxical septal motion, moderate tricuspid regurgitation, no aortic or mitral valve disease, elevated mean PA pressures, and normal left ventricular function.

What is the most likely diagnosis in this patient?

This patient presented with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema, as well as an echocardiography report of pulmonary hypertension. Many symptoms of pulmonary hypertension overlap with those of congestive heart failure, particularly right-sided heart failure. Careful attention to the physical examination may help narrow the differential and direct further evaluation. Along with the estimation of PA pressures, echocardiography is useful to evaluate left ventricular function and look for valvular or pericardial disease.

In addition to symptoms and echocardiographic findings of pulmonary hypertension, our patient had physical examination characteristics of a high output state, uncharacteristic for most forms of pulmonary hypertension. This included warm hands and feet, brisk carotid upstrokes, and a “prominent” apical impulse. Patients with severe pulmonary hypertension commonly have cold hands and feet. She also had pulmonary bruits typically reported in association with chronic thromboembolic pulmonary hypertension. These bruits have been attributed to flow across “branch stenoses” at sites of embolic narrowing, but may also be caused by high flow in pulmonary arterioles.

The differential diagnosis significantly narrows when high output failure is suggested by the clinical examination, primarily to systemic arteriovenous (AV) shunts, hyperthyroidism, multiple myeloma, beri-beri, and severe anemia. Although our patient’s history suggested thromboembolic disease, increased attention to the examination findings of a high cardiac output state and notation of the abdominal bruit would have directed earlier evaluation toward abdominal arteriovenous fistula (AVF). A detailed history inclusive of surgeries, vascular procedures (including central lines), and penetrating trauma, as well as careful examination for scars and bruits, may further guide attention toward an acquired AV communication.

When systemic AV shunts are present, the clinical and hemodynamic aspects may vary depending on whether these shunts are congenital or acquired, or depending on their physical characteristics. Causes for acquired AV communications include the above-mentioned causes (penetrating trauma, surgery), Paget’s disease, chronic liver disorders, and myelofibrosis. In 1965, Holman described experimental and clinical evidence suggesting small to moderate fistulae with rigid borders typically remain stationary in size with no demonstrable deleterious effects on the heart or circulation. In contrast, fistulae with a distensible rim yield to the high arterial pressure and develop progressive dilatation, leading in time to cardiac dilatation. Depending on the size of the fistula and transfer of blood from a high- to a low-pressure system, this sequence of events may take years or may occur rapidly.

Although AVFs have long been known to potentially cause high output failure, marked pulmonary hypertension is rare. Although the pulmonary pressures increase to some extent because of increased left ventricular end-diastolic pressure from chronic volume overload, it has been suggested by Braunwald that, in some patients, there is additionally a reactive pulmonary hypertension because of the increased pulmonary blood flow. This was postulated years ago by Trell as being caused by precapillary vascular obstruction but has not been pathologically documented.

Our patient did not report onset of dyspnea until 2 years after the disk surgery with onset of symptoms of right heart failure even later. Although likely related to the small initial fistula size, in the setting of AVF, the heart has latent capacity to accept greater and greater volumes of blood without developing failure because of the lowered peripheral vascular resistance of the fistula circuit and concomitant hypertrophy. In a vicious cycle, there is also compensation for the blood diverted through the fistula circuit by gradual expansion of the total blood volume because of activation of the renin-angiotensin-aldosterone axis and effects of arginine-vasopressin. With fistula closure, the heart size regresses, and blood volume decreases to normal.

Treatment for most acquired AVF is surgical closure, which typically results in rapid improvement in symptoms and regression of pulmonary hypertension and cardiomegaly. The occurrence of AVF with pulmonary hypertension after spinal disk surgery has been reported with a review of the world literature by Machado-Atias and coworkers. This diagnosis was not initially considered in our patient because of the history of venous thrombosis. Increased attention to the clues provided on the physical examination may have further directed her initial evaluation.

Our patient was admitted with a diagnosis of pulmonary hypertension likely caused by recurrent thromboembolic disease. A ventilation/perfusion scan was performed, which was interpreted as a low likelihood ratio for pulmonary emboli with no segmental perfusion defects. Given the high clinical suspicion for pulmonary embolic disease, a pulmonary angiogram was performed. The right and left PAs were large, as were the major second- and third-order branch vessels, without evidence of thromboemboli. PA pressure measurements were the followng: right PA, 74/34 mm Hg (mean, 52 mm Hg); and left PA, 80/28 mm Hg (mean, 62 mm Hg).

After diuresis, the patient underwent a right heart catheterization with an oxyhemoglobin assessment as additional evaluation of pulmonary hypertension (Table 1 ). Thermodilution cardiac output was 15 L/min; BP, 124/77 mm Hg; heart rate, 81 beats per minute; arterial blood pH, 7.49; arterial Pco2, 41 mm Hg; arterial Po2, 69 mm Hg; arterial O2 content, 19.8 vol%; mixed venous O2 content, 17.8 vol%; and O2 saturation, 78%.

These oxyhemoglobin measurements suggested a shunt involving the lower inferior vena cava. Additional careful auscultation of the patient’s abdomen detected a bruit near the midline of the lower abdomen. An aortogram was performed, which demonstrated a large AVF between the right iliac vein and aorta. The fistula was believed to be caused by the patient’s lumbar disk surgery performed 7 years earlier, and did not appear related to the inferior vena cava filter. Surgical repair was performed.

The patient experienced rapid improvement in symptoms within the first weeks to months postoperatively. Two years later, she underwent cardiac catheterization to evaluate chest pain after a dual-isotope scan yielded abnormal findings. This revealed normal epicardial arteries and a normal left ventriculogram. Hemodynamic measurements were as follows: right atrial pressure, 4 mm Hg; right ventricular pressure, 40/7 mm Hg; PA pressure, 40/20 mm Hg; pulmonary capillary wedge pressure, 15 mm Hg; left ventricular end-diastolic pressure, 18 mm Hg; cardiac output, 8.1 L/min; and cardiac index, 3.7 L/min/μL. She has had continued clinical improvement since her initial presentation, with her only complaints being intermittent atypical chest pain.

  1. Careful physical examination can direct the diagnostic evaluation of patients with symptoms of pulmonary hypertension or congestive heart failure.

  2. Right heart catheterization with oxyhemoglobin assessment should be considered in any patient with pulmonary hypertension without apparent cause.

  3. Although commonly asymptomatic, systemic AV shunts may present as pulmonary hypertension or high output failure. Symptoms are typically reversible with surgical repair of the shunt.

  4. Spinal disk surgery is a well-established although infrequent risk factor for the occurrence of AVF.

Braunwald E. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia, PA: WB Saunders, 1997; 460

Holman E. Abnormal arteriovenous communications: great variability of effects with particular reference to delayed development of cardiac failure. Circulation 1965; 32:1001–1009

Machado-Atias I, Fornes O, Gonzalez-Bello R, et al. Iliac arteriovenous fistula due to spinal disk surgery. Tex Heart Inst J 1993; 20:60–65

Moser KM, Auger WR, Fedullo PF, et al. Chronic thromboembolic pulmonary hypertension: clinical picture and surgical treatment. Eur Respir J 1992; 5:334–342

Trell E. Pulmonary hypertension in shunt lesions. Klin Wochenschr 1974; 52:1043–1052

Wood P. Pulmonary hypertension. Br Med Bull 1952; 8:348–353

Table Graphic Jump Location
Table 1. Evaluation of Pulmonary Hypertension


Table Graphic Jump Location
Table 1. Evaluation of Pulmonary Hypertension


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