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Original Research: PULMONARY ARTERIOVENOUS MALFORMATIONS |

Grading of Pulmonary Right-to-Left Shunt With Transthoracic Contrast Echocardiography: Does It Predict the Indication for Embolotherapy?

Marco W. F. van Gent, MD; Martijn C. Post, MD, PhD; Repke J. Snijder, MD; Martin J. Swaans, MD; Herbert W. M. Plokker, MD, PhD; Cornelis J. J. Westermann, MD, PhD; Tim T. Overtoom, MD; Johannes J. Mager, MD, PhD
Author and Funding Information

*From the Departments of Cardiology (Drs. van Gent, Post, Swaans, and Plokker), Pulmonology (Drs. Snijder, Westermann, and Mager), and Radiology (Dr. Overtoom), St. Antonius Hospital, Nieuwegein, the Netherlands.

Correspondence to: Martijn C. Post, MD, PhD, Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands; e-mail: m.post@antonius.net


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1288-1292. doi:10.1378/chest.08-1266
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Rationale:  Pulmonary arteriovenous malformations (PAVMs) are associated with severe neurologic complications in patients with hereditary hemorrhagic telangiectasia (HHT). Therefore, screening is warranted. Transthoracic contrast echocardiography (TTCE) can effectively detect a pulmonary right-to-left shunt (RLS).

Objectives:  To determine prospectively the predictive value of TTCE grading to detect PAVMs on high-resolution CT (HRCT) scans of the chest and the indication for embolotherapy.

Methods:  Three hundred seventeen patients, referred for possible HHT, were screened for PAVMs. Patients who underwent both chest HRCT scanning and TTCE were included in the study (n = 281). For the purposes of this study we used a 3-point grading scale, and shunt grades 3 and 4 according to the classification model of Barzilai et al were combined. Embolotherapy was performed of all PAVMs judged large enough for treatment.

Results:  Echocardiographic criteria for a pulmonary RLS were present in 105 patients (41%) [mean (± SD) age, 43.7 ± 15.7 years; female gender, 63%]. Chest HRCT scan findings were positive in 55 patients (52%) in this group. The positive predictive value of shunt grade for the presence of PAVMs on chest HRCT scans was 22.9% for grade 1 (n = 35), 34.8% for grade 2 (n = 23), and 83.0% for grade 3 (n = 47), respectively. None of the patients with PAVMs seen on chest HRCT scans and a TTCE grade 1 (n = 8) or 2 (n = 8) were candidates for embolotherapy. Of 39 patients with TTCE grade 3 and PAVMs seen on chest HRCT scans, 26 patients (67%) underwent embolotherapy.

Conclusion:  An increased echocardiographic shunt grade correlates with an increased probability of PAVMs seen on chest HRCT scans. Only patients with a TTCE grade 3 displayed PAVMs on chest HRCT scans that were large enough for embolotherapy.


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