PFO causing hemoptysis??

[jdh71]

Thought I'd drop this question in here and see what the collective consciousness of the SDN cardiology forum thinks about this.

I've got a young guy (30s) that I've been evaluating for hemoptysis. It's rather mild, but it's daily, and isn't associated with any other real pulmonary complaints, and the guys got normal PFTs. He has opacities on chest CT, though bronchs have been directly undiagnostic. So we ask ENT and GI to look around in the upper airway/GI track - nothing. We go looking for pulmonary AVMs with an echo bubble, and we get a report of early bubbles and PFO, otherwise normal heart and pressures. Now, my attending in clinic thinks that the PFO must be causing all the problems, but I think this is probably bull****. I can't find any case reports of this. I also don't see how it could really possibly happen outside of rather profound and symptomatic heart disease from chronic right to left shunting, which this young man does not have.

So I guess my question is have you ever seen this? Isolated PFO + hemoptysis without other good explanation? Could a guy get a transient increase in right side pressures enough to cause R-->L shunting and transient increase in left sided pressures enough to cause a mild hemoptysis??

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[TruthMD]

Thought I'd drop this question in here and see what the collective consciousness of the SDN cardiology forum thinks about this.

I've got a young guy (30s) that I've been evaluating for hemoptysis. It's rather mild, but it's daily, and isn't associated with any other real pulmonary complaints, and the guys got normal PFTs. He has opacities on chest CT, though bronchs have been directly undiagnostic. So we ask ENT and GI to look around in the upper airway/GI track - nothing. We go looking for pulmonary AVMs with an echo bubble, and we get a report of early bubbles and PFO, otherwise normal heart and pressures. Now, my attending in clinic thinks that the PFO must be causing all the problems, but I think this is probably bull****. I can't find any case reports of this. I also don't see how it could really possibly happen outside of rather profound and symptomatic heart disease from chronic right to left shunting, which this young man does not have.

So I guess my question is have you ever seen this? Isolated PFO + hemoptysis without other good explanation? Could a guy get a transient increase in right side pressures enough to cause R-->L shunting and transient increase in left sided pressures enough to cause a mild hemoptysis??

Anyone do a bronch?

I don't think it is from PFO... unless you telling me he is having left sided clots. Or if the PFO has or had a clot on the right sided that got dislodged and pushed in to lungs.

 

[jdh71]

Anyone do a bronch?

I don't think it is from PFO... unless you telling me he is having left sided clots. Or if the PFO has or had a clot on the right sided that got dislodged and pushed in to lungs.

Yes. I said the bronchs (multiple) have been negative.

You'd think a clot large enough to cause any hemoptysis would also be otherwise symptomatic.

 

[intcards]

How do you know it is a PFO? If the bubble study was performed on a TTE, it can be very difficult to differentiate PFO from ASD. You wouldn't even be able to directly visualize a sinus venosus ASD with a TTE. First, do a TEE to better characterize interatrial communication. Then do a right heart cath with saturation run. This will quantify the magnitude of left to right shunt (qp/qs), assess for anomalous pulmonary venous return which is often associated with ASD and can lead to elevated right heart pressures, and measure the degree of pulmonary hypertension under resting and exercise conditions. It would be hard to blame hemoptysis on a left to right shunt in the absence of pulmonary hypertension. I would not rely on echo derived pressures in this case, which are not always accurate and probably weren't measured after exercise. It's a lot of testing, but he is young and the symptoms are concerning. In all honesty, I would refer him to a cardiologist to help guide the testing and interpret the results. Good luck.

 

[jdh71]

How do you know it is a PFO? If the bubble study was performed on a TTE, it can be very difficult to differentiate PFO from ASD. You wouldn't even be able to directly visualize a sinus venosus ASD with a TTE. First, do a TEE to better characterize interatrial communication. Then do a right heart cath with saturation run. This will quantify the magnitude of left to right shunt (qp/qs), assess for anomalous pulmonary venous return which is often associated with ASD and can lead to elevated right heart pressures, and measure the degree of pulmonary hypertension under resting and exercise conditions. It would be hard to blame hemoptysis on a left to right shunt in the absence of pulmonary hypertension. I would not rely on echo derived pressures in this case, which are not always accurate and probably weren't measured after exercise. It's a lot of testing, but he is young and the symptoms are concerning. In all honesty, I would refer him to a cardiologist to help guide the testing and interpret the results. Good luck.

So what you are saying, before I refer this guy to cards for a million dollar work-up surrounding a PFO, is that do you think that a PFO (assuming it exists) could cause a mild daily hemoptysis in an otherwise asymptomatic person with basically normal TTE?

That's my question. I don't need a list of studies about how to look at a PFO. Do you buy it?

 

[punk]

Instead of going after actual cause of hemoptysis, a million dollar w/u for distinguishing b/w ASD versus PFO has been proposed.....amazing. Unless there is significant RA/RV enlargement on echo, a significant ASD or Anomalous pulmonary venous connection is highly unlikely. Try some non-cardiopulmonary causes of hemoptysis e.g. hereditary telengiectasias, small AVM in lungs may not be picked up by delayed appearance of bubbles...try pulmonary-renal syndromes e.g. Good pastures, autoimmune vasculitis etc.

 

[jdh71]

Instead of going after actual cause of hemoptysis, a million dollar w/u for distinguishing b/w ASD versus PFO has been proposed.....amazing. Unless there is significant RA/RV enlargement on echo, a significant ASD or Anomalous pulmonary venous connection is highly unlikely. Try some non-cardiopulmonary causes of hemoptysis e.g. hereditary telengiectasias, small AVM in lungs may not be picked up by delayed appearance of bubbles...try pulmonary-renal syndromes e.g. Good pastures, autoimmune vasculitis etc.

He doesn't have hereditary telengiectasia. Pulmonary-renal syndromes were basically ruled with his first visit a long time ago. This isn't amateur hour and I appreciate the rec's on the low hanging fruit. His beans are fine. If he has a vasculitis, it confined to the lungs and will need a biopsy to determine because common laboratory markers are negative for vasculitis and other rheumatological problems. He clearly has something weird. Or he's fooling the **** out of me. BEFORE I consider sending him for a VATS lung bx to sample the ground glass I see on CT chest, I'm trying to see if anyone thinks this "PFO" really needs more w/u given the clinical context. I really don't think so.

And I agree unless there is some rather interesting findings on the TTE there is no reason to think that his "PFO" (which aren't that uncommon actually) is causing enough left sided pressures to cause hemoptysis, especially since that guy is otherwise asymptomatic.

 

[Instatewaiter]

He doesn't have hereditary telengiectasia. Pulmonary-renal syndromes were basically ruled with his first visit a long time ago. This isn't amateur hour and I appreciate the rec's on the low hanging fruit. His beans are fine. If he has a vasculitis, it confined to the lungs and will need a biopsy to determine because common laboratory markers are negative for vasculitis and other rheumatological problems. He clearly has something weird. Or he's fooling the **** out of me. BEFORE I consider sending him for a VATS lung bx to sample the ground glass I see on CT chest, I'm trying to see if anyone thinks this "PFO" really needs more w/u given the clinical context. I really don't think so.

And I agree unless there is some rather interesting findings on the TTE there is no reason to think that his "PFO" (which aren't that uncommon actually) is causing enough left sided pressures to cause hemoptysis, especially since that guy is otherwise asymptomatic.

You should biopsy him. That will totally improve his hemoptysis.

But seriously, I'm assuming the ground glass has been reconfirmed? It's be a pity to biopsy a guy with a mild pneumonia that resolved prior to biopsy.

 

[jdh71]

You should biopsy him. That will totally improve his hemoptysis.

But seriously, I'm assuming the ground glass has been reconfirmed? It's be a pity to biopsy a guy with a mild pneumonia that resolved prior to biopsy.

I said this wasn't amateur hour.

GGO still there.

I sent the poor guy to cards to see if they buy it.

Got a 6mwt back on him and he has a significant oxygen desaturation, and his walk distance is below the LLN. Maybe he's got some pulmonary HTN the echo didn't see and get transient R --> L shunting with acute cardiogenic pulmonary edema with resultant mild hemotysis, but I still think it's a stretch.

If that's all turns out to be normal, then he probably gets a biopsy of the GGOs.

 

[Instatewaiter]

There is a known phenomena of non- pulm htn related exercise desaturations in pfos. You said nl pfts so i assume that means dlco was done. Perhaps this guy needs a rhc, shunt run etc in addition to lung biopsy. At outside hospital we can cath you...

 

[jdh71]

There is a known phenomena of non- pulm htn related exercise desaturations in pfos. You said nl pfts so i assume that means dlco was done. Perhaps this guy needs a rhc, shunt run etc in addition to lung biopsy. At outside hospital we can cath you...

exactly

yeah DLCO was normal, so vascular dz isn't crazy high on the diff, but whatever. let's prove it.