Abstract Introduction Pulmonary arteriovenous malformations (PAVMs) are a rare abnormal connection between a pulmonary artery and vein that bypasses the alveolar capillary bed. Most cases are congenital and associated with hereditary hemorrhagic telangiectasia. Acquired PAVFs after cardiac surgery are uncommon and may remain silent for years. This case describes a PAVM presenting almost two decades after cardiac surgery, where a post-surgical etiology remains a plausible explanation. Case Presentation A 66-year-old African American man presented with recurrent chest pain and hemoptysis. Over two months, he had six emergency visits and brief hospitalizations for similar symptoms. The description of his chest pain varied slightly, but he consistently described a sensation of “something jumping out of the chest,” localized to the mid-sternal region and radiating to the right mid-axillary line, often worsened by coughing. Previous evaluations, including serial cardiac biomarkers, electrocardiograms, and coronary CT angiography (CCTA), consistently showed no evidence of ischemia. Four days before this visit, he was seen for coughing up a golf-ball-sized blood clot and discharged after observation. Notably, retrospective review of a CT pulmonary angiogram performed one month earlier for pulmonary embolism evaluation showed the same lesion, though it was not initially characterized as a vascular malformation. A 2.3 × 1.4 cm spiculated nodule with a bronchus sign was also identified incidentallyHis medical history included mitral valve prolapse that required surgical repair in 2000. He underwent mechanical mitral valve replacement in 2005 due to infective endocarditis. Since then, he had been maintained on warfarin therapy.Initial labs on admission were unremarkable except subtherapeutic INR. A contrast chest CT angiogram revealed a PAVM arising from the right middle lobe adjacent to the prior thoracotomy site.. Pulmonary angiography confirmed a small right middle-lobe arteriovenous communication. However, the feeding artery of the AVM arising from the right middle lobe subsegmental could not be engaged so embolzation was not attempted. The patient was discharged in stable condition with referral to a tertiary center for multidisciplinary management. Discussion PAVM manifestations vary with shunt size and flow. Retrospective review showed the lesion had been present earlier but unrecognized, emphasizing how subtle radiographic features may escape detection when PAVM is not suspected. The lesion’s adjacency to the prior thoracotomy site raises suspicion for a postsurgical etiology, though confirmation is limited by the lack of earlier baseline imaging before cardiac surgery. Acquired PAVMs should be suspected in patients with prior cardiothoracic surgery presenting with recurrent hemoptysis or atypical chest pain. This abstract is funded by: None
San et al. (Fri,) studied this question.