Pulmonary AVMs

[Should I be Worried?]

First let me thank the community here for providing an outlet for these sorts of questions (even if everything has to be considered carefully from some guy on the internet).

Onto the subject, I am a PPL using BasicMed and recently found out I have several pulmonary arteriovenous malformations (AVM). None of them are large enough to operate on, but they could grow with time to that stage. Brain AVMs were not found.

I have two questions:

Will this affect me at renewal time? I don't see anything that precludes recreational flying.

If I want to move to a second or first class medical down the line for some commercial flying what am I looking at?

Thanks again proactively for the help - as an otherwise healthy person, this has been a little jarring and removed the rose colored glasses of youth and I hope it won't affect this passion.

 

[bbchien]

What caused you to get the scans, in the first place?

 

[Cervieres]

A few questions:
1. About how old are you?
2. Has anyone in your family had a similar diagnosis? Did your doctor mention workup for HHT?
3. Assuming this was diagnosed on a CT scan, what was the wording of the report? Did the radiologist suggest possible AVMs or was the report more definitive. I ask because small AVMs can be difficult to accurately diagnose and characterize on CT.
4. Was a cardiac echo with a bubble test performed?

 

[Should I be Worried?]

Dr. Bruce, the scans were done as part of an HHT work up that Cervieres mentioned. My dad has dealt with pulmonary and brain AVMs and other complications related to it. I took the gene test and was positive. My other symptoms include minor and infrequent nose bleeds and anemia that is corrected with an iron supplement.


Cervieres, some answers below.
1. About how old are you?
Mid twenties
2. Has anyone in your family had a similar diagnosis? Did your doctor mention workup for HHT?
Yes, my father has HHT and I have the gene as well.
3. Assuming this was diagnosed on a CT scan, what was the wording of the report? Did the radiologist suggest possible AVMs or was the report more definitive. I ask because small AVMs can be difficult to accurately diagnose and characterize on CT.
It was more definitive and listed some sizes, all in the 2/3mm range if memory serves.
4. Was a cardiac echo with a bubble test performed?
Yes, bubbles were present with a 5/10 severity.

thanks to both of you

 

[Cervieres]

Dr. Bruce, the scans were done as part of an HHT work up that Cervieres mentioned. My dad has dealt with pulmonary and brain AVMs and other complications related to it. I took the gene test and was positive. My other symptoms include minor and infrequent nose bleeds and anemia that is corrected with an iron supplement.


Cervieres, some answers below.
1. About how old are you?
Mid twenties
2. Has anyone in your family had a similar diagnosis? Did your doctor mention workup for HHT?
Yes, my father has HHT and I have the gene as well.
3. Assuming this was diagnosed on a CT scan, what was the wording of the report? Did the radiologist suggest possible AVMs or was the report more definitive. I ask because small AVMs can be difficult to accurately diagnose and characterize on CT.
It was more definitive and listed some sizes, all in the 2/3mm range if memory serves.
4. Was a cardiac echo with a bubble test performed?
Yes, bubbles were present with a 5/10 severity.

thanks to both of you

Sounds like you received the the appropriate work up. I treat HHT in my practice, and as I’m guessing you already know, closing AVMs with feeding arteries <3mm is not indicated. The risk of hypoxia and stroke with paradoxical emboli with small AVMs is extremely low. I’m not an AME and can’t attest to what the FAA would say, but medical literature is in your favor. It might be worth contacting an HHT center to inquire if they have dealt with pilots or the FAA before. I can recommend a few if you don’t have one already.

 

[Aviator305]

It’s great that everyone asked the questions above, because I was unable to finish a response that I started last night.

The one thing that I have to add is regarding the 3mm threshold. This is based on very limited data (and I opine that the originator of this threshold overstated the strength of his findings), and over a decade or two after that presentation most specialized centers have come to realize that the risk of embolism is not dependent on the size of the feeding artery. This makes sense because there is no lower limit of size that an embolus can wreak havoc.

I absolutely second consultation with a specialized center. This is not coming from the perspective of just flying. I would recommend this even if you were not a pilot.

My 34 year old brother who is extremely fit just had an embolic stroke two months ago (it was a tiny dot on the MRI and he has no residual deficits), but at the time he presented he was driving and lost motor strength and consciousness. I mention this to just illustrate that unlikely things happen at the most inconvenient times. (For the docs wondering what his setup was: biceps tendon repair 6 weeks prior to episode..Workup found PFO)

 

[Should I be Worried?]

I did go to an HHT center. My doctor has a few pilots on the roster, but was not familiar with anything specific they went through for their medicals. He just provided test records and comments. I thought maybe there would be someone here with some experience.

I did double check the radiology report and everything was under 4mm.

Currently, my course of action is routine blood work to watch iron levels and hemoglobin levels for any indication of a bleed otherwise its life as normal for 5 years before another set of scans to check the AVMs.

My hope is that since they are inoperable this is a nonevent for a second class?

Thanks again to all.