CRA10 BATTLING HYPOXIA ON TWO FRONTS: THE CHALLENGE OF PULMONARY AVM IN A HEART FAILURE PATIENT

Zulkifli.S1
Hospital Pakar Sultanah Fatimah, Muar

Introduction

Patients with heart failure are susceptible to various respiratory complications, which can further exacerbate their condition. The coexistence of heart failure and pulmonary vascular anomalies, such as arteriovenous malformations (AVMs), poses a unique diagnostic and management dilemma.

Case Report

A 66-year-old man with a history of inferior-posterior myocardial infarction in 2021 and reduced ejection fraction heart failure (EF 40%) presented with recurrent episodes of decompensated congestive heart failure since 2021. In early 2024, he was admitted to the hospital with worsening shortness of breath, which was initially managed as a typical heart failure exacerbation.

Despite receiving standard treatment with diuretics and other heart failure medications, the patient was unable to wean off supplemental oxygen, with persistent hypoxemia (oxygen saturation 80-83% on room air). This was concerning, as his lung fields had cleared with diuresis, and his heart failure symptoms had improved with the inpatient management.

Further workup, including a CT angiogram of the chest, revealed a vascular anomaly in the patient's right lower lobe, suggestive of a pulmonary arteriovenous malformation (AVM). Pulmonary AVMs are abnormal, direct connections between the pulmonary arteries and veins, which can lead to right-to-left shunting and chronic hypoxemia.

The case was discussed in a multidisciplinary team meeting. The team considered coil embolization as a potential treatment for the pulmonary AVM. However, given the high-risk nature of the procedure and the patient's underlying heart condition, the team ultimately decided that the risks outweigh the benefits.

Conclusion

This case underscores the importance of maintaining a high index of suspicion for rare pulmonary vascular anomalies in heart failure patients with persistent hypoxia, and the need for a comprehensive, multidisciplinary approach to managing these complex patients.