Applicability of Transthoracic Contrast Echocardiography for the Diagnosis and Treatment of Idiopathic Pulmonary Arteriovenous Malformations

Abstract

Objective: To explore the preferred test to screen for pulmonary arteriovenous malformations (PAVMs) and to predict the probability of interventional embolization.Methods: We performed a retrospective observational study evaluating patients with idiopathic PAVMs from 2009 to 2019. After clinical evaluation, a total of 105 patients were studied, including 71 patients with positive digital subtraction pulmonary angiography (DSPA) findings and 34 with negative DSPA findings. The following patient data were assessed: blood test, chest radiograph, transthoracic contrast echocardiography (TTCE), and DSPA findings.Results: The majority of patients with idiopathic PAVMs were female (66.2% with positive DSPA findings). We found a good κ-coefficient of 0.77 with strong consistency for inter observer agreement concerning the pulmonary right-to-left shunt (RLS) grade on TTCE, which was superior to conventional chest radiographs. The positive predictive value (PPV) of the radiographic features for PAVMs on DSPA was 0.83 (95% CI 0.64–1.0) and 0.44 for the possibility of embolization (95% CI 0.19–0.70). The PPV of the shunt grade of PAVMs on DSPA was 0.14 (95% CI 0.01–0.29) for grade 1, 0.74 (95% CI 0.60–0.88) for grade 2, and 0.97 (95% CI 0.92–1.0) for grade 3. The PPVs of pulmonary shunt grades 2 and 3 on TTCE for the possibility of embolization for PAVMs were 0.21 (95% CI, 0.05–0.36) and 0.87 (95% CI, 0.79–0.99), respectively.Conclusion: TTCE is the preferred screening test for PAVMs. The pulmonary RLS grade on TTCE not only identifies the likelihood of PAVMs but also predicts the probability for embolization.

Significance of transesophageal contrast echocardiography with the agitated saline test for diagnosing pulmonary arteriovenous malformations

“…Moreover, the lower the TECE grade scales, the more often they are microscopic level PAVMS that are undetectable on radiologic. Several studies about the diagnostic value of TTCE in PAVMs published that the lower TTCE grade scale was associated with a lower prevalence of radiologic detectable PAVM ( 9 , 10 ). Since this study included relatively many patients with a small grade of TECE, low PPV was reported.…”

“…Previous studies have already established effective screening tests for PAVM diagnosis in asymptomatic HHT patients. Transthoracic contrast echocardiography (TTCE) has high sensitivity (93–100%) for detecting PAVMs ( 3 , 8 – 10 ). Because complications associated with PAVMs also occur in even asymptomatic patients without HHT and because PAVMs can be effectively treated by percutaneous transcatheter embolization ( 11 ), the diagnosis of PAVMs that form an intrapulmonary right-to-left shunt in patients without HHT is important.…”