There are a variety of cardiac and vascular hemoptysis sources (see Table 44.1). Among the primary cardiac hemoptysis sources, elevated pulmonary venous pressure leads to venous dilation and varix formation which may rupture and bleed during sudden pulmonary venous pressure increases (e.g., systolic or diastolic failure, cough, Valsalva). Hemoptysis is generally self-limited but can be rarely severe. In a similar fashion, localized pulmonary venous hypertension from pulmonary vein stenosis following atrial fibrillation radiofrequency ablation can result in massive hemoptysis. Similar to their tendency to bleed in other anatomic locations, pulmonary arteriovenous malformations can bleed spontaneously and cause massive hemoptysis.

A number of invasive procedures may be complicated by massive hemoptysis. Massive hemoptysis during bronchoscopy is rare and usually occurs in the setting of platelet dysfunction, thrombocytopenia, or coagulopathy when transbronchial biopsies are performed. Pulmonary artery catheter flotation may cause pulmonary artery rupture and has been reported to have a mortality rate greater than 50%. Avoiding balloon overinflation and insuring balloon deflation prior to catheter advancement can help avoid this potentially lethal complication.

A tracheal-innominate artery fistula (TIF) may develop in the chronic tracheostomy setting. A low tracheal insertion (below the recommended first to third tracheal rings) or a high innominate artery may predispose to TIF formation. One potential clue of TIF is the “sentinel bleed” – a small amount of fresh tracheal blood that appears usually 2 weeks or more after tracheostomy placement that can be a harbinger of a catastrophic, fatal bleed.

Massive hemoptysis is a known thoracic radiotherapy complication which more commonly occurs with endobronchial brachytherapy than external beam radiotherapy. Bleeding usually occurs from bronchovascular necrosis and erosion.

Massive hemoptysis may occur in the chest trauma setting. Blunt trauma can cause airway rupture with associated injury to the pulmonary or bronchial vasculature. Alternatively, fractured ribs can cause a lung laceration with hemoptysis and/or hemothorax. Similarly, penetrating trauma can directly lacerate the pulmonary, bronchial, or other major vascular structures, causing hemoptysis and/or hemothorax.

An important massive hemoptysis source to always consider is “pseudohemoptysis” or bleeding from a source other than the lung. Epistaxis and hematemesis are two common scenarios that can mimic hemoptysis and patients may be unable to differentiate the bleeding source. Therefore, if pseudohemoptysis is suspected, involving an otolaryngology or gastrointestinal specialist in the patient’s care can be crucial. Bone marrow transplant recipients can develop massive hemoptysis that is not necessarily temporally related to the transplant and is likely due to a microvascular chemotherapeutic injury.