IMAGES IN CARDIOLOGY
Late Onset of Hypoxemia Due to a Pulmonary Arteriovenous Malformation During Selective Estrogen Receptor Modulator Therapy
Antonio Rapacciuolo, MD, PhD,
Guido Carlomagno, MD,
Elisa Di Pietro, MD,
Valeria Fazio and
Serafino Fazio, MD
Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University, Naples, Italy
Manuscript received August 12, 2009;
accepted August 28, 2009.
A 76-year-old woman with unexplained hypoxemia and severe exertional dyspnea was admitted to our department. The symptoms had appeared during tamoxifen therapy after resection of breast carcinoma; history revealed recurrent upper gastrointestinal bleeding, epistaxis, and a granddaughter deceased because of a cerebral arteriovenous malformation. Chest computed tomography scan showed the presence of a highly vascularized nodule in the right lower lobe.
Right pulmonary artery angiography demonstrated a large pulmonary arteriovenous malformation (PAVM) (Online Video 1) with massive right-to-left shunt (A, B, C;
Online Video 2); this confirmed the diagnosis of hereditary hemorrhagic telangiectasia (1). The arrows point to the right upper pulmonary vein.
We decided to percutaneously close the PAVM. An occlusion test was performed before the procedure (D); O2 saturation rose from 87% to 96%. The PAVM was subsequently closed using a vascular occlusion device (E) with complete abolishment of the right-to-left shunt (F;
Online Video 3). It is likely that selective estrogen receptor modulator therapy may have been responsible for the enlargement of the PAVM in our patient (2).
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1. Haitjema T, Westermann CJ, Overtoom TC, et al. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). New insights in pathogenesis, complications, and treatment. Arch Intern Med 1996;156:714-719.[Abstract/Free Full Text]2. Battista MJ, Eichbaum MH, Hosch WP, et al. Extensive Osler-Rendu disease in a breast cancer patient: increasing hepatic arteriovenous malformations under endocrine therapy mimicking liver metastases Onkologie 2008;31:328-331.[Web of Science][Medline]
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