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The biological “scrabble” of pulmonary arteriovenous malformations: considerations in the setting of cavopulmonary surgery

Published online by Cambridge University Press:  21 January 2005

Robert M. Freedom ,
Shi-Joon Yoo  and
Donald Perrin
Robert M. Freedom
Affiliation:
The Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, The University of Toronto Faculty of Medicine, Toronto, Ontario, Canada The Division of Cardiology, Department of Diagnostic Imaging, The Hospital for Sick Children, The University of Toronto Faculty of Medicine, Toronto, Ontario, Canada The Division of Cardiology, Department of Pathology, The Hospital for Sick Children, The University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
Shi-Joon Yoo
Affiliation:
The Division of Cardiology, Department of Diagnostic Imaging, The Hospital for Sick Children, The University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
Donald Perrin
Affiliation:
The Division of Cardiology, Department of Pathology, The Hospital for Sick Children, The University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Abstract

Pulmonary arteriovenous fistulas are vascular malformations, which, by virtue of producing abnormal vascular connections proximal to the units of gas exchange, result in intrapulmonary right-to-left shunting. These malformations or fistulas reflect at least in part disordered angiogenesis, and less commonly recruitment and dilation of pre-existing vascular channels.1 Pulmonary arteriovenous fistulas occur in a number of diverse clinical settings. Such fistulas are a well-established feature of the Weber–Osler–Rendu complex, or hereditary haemorrhagic telangiectasia, an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasis, epistaxis, gastrointestinal haemorrhage, and arteriovenous malformations in the lung, brain, liver and elsewhere.2,3 They are also seen in the patient with acute or chronic liver disease, disease that is usually but not invariably severe, or those with non-cirrhotic portal hypertension. They may occur as congenital malformations, single or diffuse, large or small in isolation, and when large or extensive enough may result in hypoxaemia, clinical cyanosis, and heart failure.3 Cerebral vascular accidents are also a well-known complication of this disorder.3 An extensive literature has accumulated with regard to the pulmonary arteriovenous fistulas seen in the setting of the Weber–Osler–Rendu complex, and there is considerable information on the genetics, basic biology, clinical findings, complications and therapeutic interventions of these malformations in the setting of this syndrome.4 These issues, however, are not the primary considerations of this review, although some aspects of this fascinating disorder will be discussed later. Rather the focus will be on pulmonary arteriovenous malformations that develop in the setting of cavopulmonary surgery, and their relationship to the pulmonary arteriovenous fistulas occurring in the hepatopulmonary syndrome. The complex tapestry of these overlapping and intersecting clinical observations will be unfolded in the light of their chronology.

Keywords

AngiogenesisGlenn shunthepatopulmonary syndromehereditary haemorrhagic telangiectasiapulmonary arterial hypertension
Type
Continuing Medical Education
Information
Cardiology in the Young , Volume 14 , Issue 4 , August 2004 , pp. 417 - 437
Copyright
© 2004 Cambridge University Press

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