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case_images: Pulmonary arteriovenous malformation. (A) Chest X-ray: increased vascular markings in the right lower lung (arrow). (B-D) Chest CT: pulmonary arteriovenous malformation (blue arrow) (B non-contrast; C, D contrast enhanced).
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case_images: An enlarged pulmonary vessel was noted in the right lower lung field (Figure 1A). Chest CT with contrast revealed a PAVM in the right middle lobe, with feeding and draining vessels ~4 mm in diameter (Figure 1B-D).
case_images: Bubble study before PFO closure. (A, B) Transthoracic echocardiography immediately after (A) and 3 cycles after (B) bubble injection. (C, D) Transoesophageal echocardiography immediately after (C) and 3 cycles after (D) bubble injection.
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case_images: TTE and TEE demonstrated significant right-to-left shunting. Transthoracic echocardiography with Valsalva manoeuvre showed grade 3 bubbles within three cardiac cycles, increasing to grade 4 after four cycles (Figure 2A and B; Supplementary material online, Video S1). Transoesophageal echocardiography revealed grade 3 bubbles within three cardiac cycles at rest and during abdominal compression release (Figure 2C and D; Supplementary material online, Video S2).
case_images: Intraoperative transoesophageal echocardiography and follow-up transthoracic echocardiography during patent foramen ovale and pulmonary arteriovenous malformation closure. (A) Intraoperative transoesophageal echocardiography: grade 3 bubble flow from the right upper pulmonary vein to the left atrium. (B) Intraoperative transoesophageal echocardiography: post-patent foramen ovale closure with occlusion device. (C) Transthoracic echocardiography post-patent foramen ovale closure, pre-pulmonary arteriovenous malformation closure: grade 4 left heart opacification >4 cycles after right heart. (D) Transthoracic echocardiography 4 months post-pulmonary arteriovenous malformation closure: no left heart bubble flow.
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case_images: Intraoperative bubble study revealed significant right-to-left shunting through both PFO and right lower pulmonary vein (Figure 3A; Supplementary material online, Video S3). A 25 mm Amplatzer  PFO Occluder (Abbott Medical Plymouth, MN, USA) was deployed (Figure 3B). One month post-PFO closure, bubble studies confirmed persistent shunting through the right lower pulmonary vein, suggesting PAVM (Figure 3C; Supplementary material online, Video S4). Follow-up evaluations at 7 months post-PFO closure and at 1 and 2 years post-procedures showed no significant residual shunting (Figure 3D; Supplementary material online, Video S5).
case_images: Pulmonary arteriovenous malformation closure procedure. (A) Selective angiography of pulmonary arteriovenous malformation before closure. (B) Selective angiography of pulmonary arteriovenous malformation after closure, showing no contrast passage. (C) Chest X-ray after pulmonary arteriovenous malformation closure.
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case_images: Percutaneous coil embolization of the PAVM was performed at another hospital 3 months after post-PFO closure (Figure 4A-C).