SESSION TYPE: Cardiovascular Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Massive hemoptysis in patients with complex congenital heart disease can present multiple challenges regarding etiology and management. These challenges stem from the presence of significant anatomical and physiological changes in the lung vascularization. We report the case of massive hemoptysis associated with an unusual etiology in a patient with pulmonary atresia.
CASE PRESENTATION: A 31-year-old woman with a history of complex chronic cyanotic heart disease consisting of pulmonary atresia, ventricular septal defect, non-confluent pulmonary arteries and multiple aorto-pulmonary collaterals presented to the emergency department after having hemoptysis in massive amounts, totaling close to 4 liters. She reported another episode of minor hemoptysis 4 days prior when she also coughed up a metallic piece. Another metallic piece was noted during the massive hemoptysis episode. Her past surgical history was significant for bilateral unifocalization, Blalock-Taussig shunt and stenting of the left lower and right pulmonary arteries. Her prior significant hemoptysis episodes required a right lower lobe wedge resection for aspergilloma and multiple embolizations of a left upper lobe bronchial artery. Upon arrival to the emergency department, she was intubated for emergent bronchoscopy, which revealed massive amounts of blood in her airways. A possible source of bleeding was noted in the right lower lobe. After a failed attempt at bleeding control during bronchoscopy, she was sent to Interventional Radiology for angiography and possible embolization. Although no active bleeding source was identified, clinical judgment dictated a coil embolization of the prominent enlarged bronchial collaterals supplying the right lower lobe. Afterwards, she recovered uneventfully without any recurrent episode of hemoptysis during her hospitalization.
DISCUSSION: Massive hemoptysis is a potentially fatal complication following palliative surgical interventions for pulmonary atresia. Thrombosis in the small pulmonary vessels, relative hypoplasia of the pulmonary arterial wall, and the increased size and tortuosity of the bronchial arteries are the most likely factors leading to rupture of bronchopulmonary collaterals, the most common etiology of hemoptysis in these patients. Infections and platelet disorders are other causative or contributing factors. Recent advances in Interventional Radiology techniques allowed these patients to benefit from embolizations of the bleeding bronchopulmonary collaterals.
CONCLUSIONS: Massive hemoptysis is a well known complication in patients with corrective surgery for pulmonary atresia. In our case most likely an erosion of a surgical clip or vascular stent into the airways caused massive hemoptysis, which was successfully managed by coil embolization of the putative bronchial collaterals.
1) Haroutunian, LM, Neill, CA, Pulmonary complications of congenital heart disease: Hemoptysis. The American heart journal, 84(4), 540-559.
DISCLOSURE: The following authors have nothing to disclose: Radu Neamu, Christopher Parks, Micah Fisher
No Product/Research Disclosure InformationEmory University School of Medicine, Atlanta, GA