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Large pulmonary arteriovenous malformation diagnosed by cardiovascular magnetic resonance.

A 38-year-old woman was evaluated at our hospital because of a history of exertional dyspnea. The physical examination and chest radiographs were unremarkable. The patient underwent a comprehensive evaluation, including cardiovascular magnetic resonance (CMR). During bolus gadolinium administration, CMR angiography revealed a 2-cm pulmonary arteriovenous malformation (AVM), with 5-mm feeding and draining vessels, in the left lower lung (Fig. 1). Echocardiography showed preserved systolic function. After the intravenous injection of agitated saline, microbubbles appeared reproducibly within the left atrium and left ventricle after 6 cardiac cycles (typical), confirming the presence of a pulmonary AVM and distinguishing it from an atrial septal communication such as an atrial septal defect or a patent foramen ovale (Fig. 2). Exercise stress testing revealed no ischemia; however, the patient's oxygen saturation decreased from 94% to 80%. Angiography confirmed the findings of an AVM (Fig. 3). The AVM was closed with an AMPLATZER® vascular plug (AGA Medical Corporation; Plymouth, Minn) (Fig. 4), which produced substantial symptomatic improvement. 
 
 
 
Fig. 1 Volume-rendered, 3-dimensional reconstruction by cardiovascular magnetic resonance shows the pulmonary arteriovenous malformation (arrow) in the left lower lobe of the lung. 
 
 
 
 
 
Fig. 2 Two-dimensional echocardiogram (4-chamber view with agitated saline injection during the Valsalva maneuver) shows saline bubbles in the left ventricle (arrowhead) that suggest a pulmonary arteriovenous malformation. 
 
 
 
 
 
Fig. 3 Pulmonary angiogram shows the pulmonary arteriovenous malformation (arrow) in the left lower lobe of the lung before deployment of the AMPLATZER vascular plug. 
 
 
 
 
 
Fig. 4 Pulmonary angiogram shows the occluded pulmonary arteriovenous malformation in the left lower lobe of the lung after deployment of the AMPLATZER vascular plug.