Respiratory variation in superior vena cava flow in patients with chronic obstructive pulmonary disease: estimation of pulmonary hypertension using Doppler flow index

Patients with chronic obstructive pulmonary disease (COPD) are difficult to assess by conventional transthoracic echocardiography (TTE) because of emphysematous lungs or mediastinal deviation. We hypothesized that superior vena cava (SVC) flow is related to pulmonary circulation and may be useful for the detection of pulmonary hypertension (PH) in patients with COPD that cannot been assessed by direct evaluation using the tricuspid regurgitant Doppler velocity. SVC Doppler flow velocities were examined in 46 patients with COPD and the pressure gradient between the right ventricular and right atrial pressure (RV-RADeltaP) was calculated by tricuspid regurgitant Doppler velocities. The patients were divided into 2 groups: 11 patients with PH (RV-RADeltaP > 25 mm Hg) were compared with 35 without PH. There was no significant difference in the maximal SVC peak systolic forward flow velocity during inspiration (INS) between these 2 groups. However, the minimal SVC peak systolic forward flow velocity during expiration (EXP) in the group with PH was significantly higher than that in the group without PH (37.4 +/- 20.0 cm/s vs 26.4 +/- 8.5 cm/s, P =.01). Linear regression analysis revealed a significant correlation between RV-RADeltaP and the EXP/INS ratio (r = 0.61, P <.001). In COPD patients with PH, the increased expiratory SVC systolic flow supplemented the preload for the impaired right ventricular filling flow caused by PH, thereby maintaining the transtricuspid driving pressure. Our observation suggests that respiratory variation in SVC systolic forward flow may be a sensitive Doppler flow index for evaluating severity of PH in patients with COPD that cannot been assessed by conventional TTE.

[Persistence of the left superior vena cava discovered during the implantation of a hemodialysis catheter]

A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. It is a persistent remnant of the left anterior cardinal vein that usually disappears in early embryological development as a result of compression between the left atrium and the hilum of the left lung. If it is not associated with other congenital cardiac anomalies it is usually asymptomatic but has important clinical implications in some situations. In this article, we describe a patient with bilateral SVC identified on a chest radiograph by a haemodialysis central venous catheter passing through it.

[Differential diagnosis of left-sided thoracic venous catheters: case report of a persistent left superior vena cava]

The differential diagnosis of left-sided thoracic central venous catheters is discussed in context with the cannulation of a persistent left superior vena cava. In this case the catheter tip was seen lying to the left of the spine on frontal chest X-ray. In addition to the descending aorta, differential diagnoses are a persistent left-sided superior vena cava as well as other smaller veins such as the left internal thoracic vein, the left superior intercostal vein, or the pericardiophrenic vein. The misplacement of a venous catheter in a pericardiophrenic vein may result in a fatal pericardial tamponade.

Prenatal diagnosis of partial anomalous pulmonary venous connection by detection of dilatation of superior vena cava in hypoplastic left heart. A case report

A 27-week fetus was given targeted fetal echocardiography due to an abnormal four-chamber view. A complex heart malformation was seen with two atria, a single ventricle, and aortic and mitral atresia. In addition to intracardiac findings, a dilated superior vena cava (SVC) was seen, suggesting a possible abnormal pulmonary venous connection to the SVC. An increased venous flow (up to 90 cm/s) was recorded as well. The course of pregnancy was uneventful and the baby was delivered vaginally at term. Cardiac surgery was planned but the baby died on 4th day of life. The autopsy findings confirmed both intracardiac anomalies as well as partial anomalous venous connection to SVC, with no apparent obstruction. This is the first report which stresses that dilatation of the fetal SVC may be suspicious for partial abnormal pulmonary venous connection during prenatal life.

Treatment of superior vena cava obstruction secondary to pacemaker wires with balloon venoplasty and insertion of metallic stents

AIMS

Pacemaker wires can result in stenosis of the superior vena cava and other central veins. The aim of this study is to demonstrate the safety and effectiveness of treating stenoses of the superior vena cava (SVC) and central veins with balloon venoplasty and metallic stent insertion in the presence of cardiac pacemaker wires.

METHODS AND RESULTS

Three patients were referred to the department after developing symptomatic SVC obstruction following implantation of a cardiac pacemaker several years earlier. They were examined with duplex ultrasound and venography, which revealed significant stenoses of the central veins. These patients subsequently underwent endovascular treatment which involved balloon dilation and stent insertion. The treatment was successful in all three patients, without any complications. Long-term patency of up to 4 years is recorded. No pacemaker function dysfunction was encountered.

CONCLUSION

SVC stenting is safe and effective in patients who develop the SVC obstruction after cardiac pacemaker insertion.

Persistent left superior vena cava identified after cannulation of the right subclavian vein

IMPLICATIONS

We report the case of a patient with a chest radiograph suggestive of intraarterial placement of a central venous catheter. On investigation, the catheter was located in a previously undiagnosed persistent left superior vena cava.

Diagnosis of an isolated persistent left side superior vena cava by contrast echocardiography compared with invasive angiographic study

BACKGROUND

The prevalence of left side superior vena cava (LSVC) is low and usually invasive angiography is necessary to validate its presence. Non-invasive echocardiographic study is important for the diagnosis and definition of associated lesions. The aim of this study is to demonstrate the clinical feasibility and accuracy of diagnosing LSVC by contrast echocardiography.

METHODS

Four cases were included in this study. They were aged from 41 to 75 years old, 1 male and 3 female, all in sinus rhythm, with mean heart rate 83 +/- 14 beat per minute. They all received transthoracic echocardiography and transesophageal echocardiography. Contrast material was rapidly infused from both left arm vein and right arm vein to evaluate the diagnostic value of contrast enhancement for LSVC. They also received invasive angiographic study as the diagnostic golden standard. An isolated persistent left side superior vena cava with drainage into the right atrium was considered to be present, supposing the following diagnostic criteria were met: (1) the presence of a dilated coronary sinus in parasternal long axis view of two-dimensional echocardiography; (2) earlier enhancement of the dilated coronary sinus than the right cardiac chambers after contrast material infusion into a left arm vein; (3) right cardiac chambers were enhanced earlier than the dilated coronary sinus after contrast material infusion into a right arm vein.

RESULTS

All 4 patients received the complete studies without any complications during the study procedures. Correct diagnostic yields could be obtained even with or without other associated cardiac lesions.

CONCLUSIONS

According to the experiences obtained from this study, contrast echocardiography is safe and highly informative for the definite diagnosis of left superior vena cava with drainage into coronary sinus. Correct diagnosis could be obtained by contrast echocardiography in all four cases within this study. The accuracy was 100%, if the above three echocardiographic diagnostic criteria were adopted.

Endovascular stent placement for venous obstruction after cardiac transplantation in children and young adults

Survival following cardiac transplantation in children and adults, including the group with complex congenital heart disease, has improved over the last decade secondary to medical and surgical advances in management. There have been rare reports of superior vena cava obstruction at anastomotic sites following transplantation. In patients following heart transplantation, venous stenosis can limit the ability to perform endomyocardial biopsies. We reviewed our experience in three patients who underwent cardiac transplantation and developed significant venous stenosis requiring intervention. All three were successfully treated by transcatheter implantation of endovascular stents. Endovascular stent implantation for venous obstruction in patients following cardiac transplantation was safe and effective, allowing improved ease of catheterization for future posttransplantation monitoring and surveillance.

A safe percutaneous method to recanalize sharp venous occlusions that resist the passage of guidewires

It is occasionally necessary to cross a sharp venous occlusion (a thin web of tissue without a lumen) and sometimes it is not possible to cross the stricture with a wire, so puncturing it with a sheathed needle is then required to enable stenting. Other methods have been reviewed; however, we think this balloon technique makes it a safer procedure.

Cor triatriatum sinistrum and persistent left superior vena cava: an original association

Cor triatriatum sinistrum is a rare congenital heart disease usually diagnosed in symptomatic children. Symptoms depend on the degree of obstruction to pulmonary venous return with pulmonary hypertension and other associated abnormalities. Persistent left superior vena cava is quite a common congenital heart disease (about 0.5% in healthy populations). It should be suspected every time a dilated coronary sinus is detected at the echo examination. Transthoracic and transoesophageal examinations visualize the site and the size of the fibrous membrane as well as the degree of obstruction, and allow the evaluation of pulmonary pressures that are very important clues for prognosis and therapy. This case report describes the clinical signs and the diagnostic ultrasound findings evaluated in comparison with magnetic resonance imaging, a well-defined gold standard in heart disease of this uncommon congenital association.

Using pullback pressure measurements to identify venous stenoses persisting after successful angioplasty in failing hemodialysis grafts

OBJECTIVE

We used pullback pressure measurements to identify venous stenoses persisting after angioplasty of failing hemodialysis grafts.

MATERIALS AND METHODS

Fifty angioplasty procedures were performed in 32 patients with elevated venous pressures at dialysis. Grafts were initially evaluated on digital subtraction angiography, and all stenoses measuring greater than 50% on angiography underwent angioplasty. In successful cases (residual stenosis < 30%), pullback pressure measurements were obtained from the superior vena cava to the graft to identify hemodynamically significant (> 10 mm Hg) stenoses. These lesions were then treated with repeated angioplasty.

RESULTS

Hemodynamically significant stenoses with a gradient range of 10-27 mm Hg (mean, 16 mm Hg) were found in nine (18%) of 50 procedures. All gradients occurred at sites of previous angioplasty. Repeated angioplasty of these stenoses performed with larger angioplasty balloons reduced gradients to less than 3 mm Hg in six stenoses and to 5 mm Hg in three stenoses. In this subgroup, primary patency was eight (89%) of nine stenoses at 1 month and 2 months and five (56%) of nine stenoses at 6 months. Using life table analysis, we found that primary patency of the entire population was 84% at 1 month, 66% at 2 months, and 47% at 6 months. The mean time between interventions was 6 months, and the thrombosis rate was 0.32 per year.

CONCLUSION

Pullback pressure measurements are a useful adjunct to angiography to evaluate the hemodynamic results of angioplasty in patients with failing hemodialysis grafts.

Atresia of the orifice of the coronary sinus after surgery

We describe a patient with a coronary arteriovenous fistula, atresia of the orifice of the coronary sinus, and persistence of the left superior caval vein. Depression of her ST segments was revealed by exercise electrocardiography long after the initial surgical reconstruction of the coronary sinus.

Comparison of venography and ultrasound for the diagnosis of asymptomatic deep vein thrombosis in the upper body in children: results of the PARKAA study. Prophylactic Antithrombin Replacement in Kids with ALL treated with Asparaginase

Deep vein thrombosis (DVT) in children occurs primarily in the upper body venous system. This prospective diagnostic study compared bilateral venography and ultrasound for detection of DVT in the upper venous system in 66 children with acute lymphoblastic leukemia. Results were interpreted by central blinded adjudication. Deep venous thrombosis occurred in 29% (19/66) patients. While 15/19 DVT were detected by venography (sensitivity 79%), only 7/19 were detected by ultrasound (sensitivity 37%). The 12 DVT detected by venography but not by ultrasound were located in the subclavian vein or more central veins. Three of 4 DVT detected by ultrasound but not by venography were in the jugular vein. We conclude that ultrasound is insensitive for DVT in the central upper venous system but may be more sensitive than venography in the jugular veins. A combination of both venography and ultrasound is required for screening for DVT in the upper venous system.

Diagnosis by ultrasonography of congestion of the caudal vena cava secondary to thrombosis in 12 cows

This paper describes the clinical, ultrasonographic, radiographic and postmortem findings in 12 cows with thrombosis of the caudal vena cava. The principal clinical signs were chronic bronchopneumonia and fever in 11 cows; one cow had epistaxis and one cow bled from the mouth; eight cows had anaemia and leucocytosis, and the clotting time for the glutaraldehyde test was markedly decreased in all the cows; in nine of the cows the activity of gamma-glutamyltransferase was high, suggesting chronic hepatic congestion. The most important ultrasonographic finding was congestion of the caudal vena cava attributable to thrombosis of the vein. In all the cows the caudal vena cava was round to oval on cross-section, rather than the normal triangular shape. The hepatic, splenic and portal veins were dilated in five, three and one cow, respectively. The results of radiography and endoscopy supported a diagnosis of bronchopneumonia, but there were radiographic changes in the diaphragmatic lung lobes that supported a diagnosis of vena caval disease in only four cows. Postmortem there was a thrombosis of the caudal vena cava in all the cows, and the thrombi were located in the thoracic, subphrenic and abdominal part of the caudal vena cava at the level of the liver in four, one and seven cows, respectively. In three cows, the thrombus was situated where a hepatic abscess had broken into the caudal vena cava, and in one cow it was at the site of a diaphragmatic abscess. In another cow, there was a fistula between the major bronchus of the right diaphragmatic lung lobe and the caudal vena cava where the thrombus was situated. Three cows had liver abscesses that had not broken into the caudal vena cava. There was severe bronchopneumonia in 11 of the cows, some of which also had multiple pulmonary abscesses.

Thrombectomy and SVC reconstruction due to infective thrombus

We report a case of thrombectomy and reconstruction of superior vena cava (SVC) in a patient presenting sepsis and SVC syndrome by infective thrombus. A 58-year-old woman presented sepsis and edema of the neck and left upper extremity during treatment of multiple organ failure. Sepsis by Serratia persisted in spite of appropriate antibiotic treatment. Computed tomography of the chest revealed thrombi that narrowed the SVC with obstruction of the left brachiocephalic vein. Removal of the infective thrombi followed by SVC reconstruction with autologous pericardial patch was performed. Postoperative period remained uneventful.

Surgical treatment of coronary sinus orifice atresia with hypoplastic left heart syndrome after total cavo-pulmonary connection

Atresia of the coronary sinus orifice is rare. We describe the surgical treatment of coronary orifice atresia in an infant with a persistent left superior vena cava after total cavo-pulmonary connection for hypoplastic left heart syndrome. The diagnosis was made by cardiac catheterization after total cavo-pulmonary connection at 8 months of age. After surgery, cardiac performance deteriorated. At reoperation, the coronary sinus was fenestrated to the left atrium. The patient survived surgical treatment of coronary sinus ostial atresia unroofed to the left atrium, guiding the placement of the fenestration with a probe placed through the open cardiac end of left superior vena cava.

[Persistent left superior vena cava with right-left shunt into the left atrium]

Persistent left superior vena cava with right-left shunt into the left atrium.

HISTORY AND CLINICAL FINDINGS

A 72-year-old patient was admitted to the hospital following bleeding into the basal ganglia secondary to a hypertensive crisis.

INVESTIGATIONS

The patient was found to suffer from marked hypoxaemia (pO2 49 mmHg) and erythrocytosis (Hb 18,5 g/dl). Subsequent investigations raised suspicion of a right-left shunt. This was verified by a contrast echocardiogram which was performed transthoracically by injection of echo-contrast material from the left. To improve imaging of the shunt a transoesophageal contrast-echocardiogram was carried out. This showed that the persistent left superior vena cava did not, as previously expected, lead directly into the left atrium, but had a connection to the left superior pulmonary vein. This anatomical variant, which so far to our knowledge has not been reported in the literature, could be confirmed by spiral computed tomography. Apart from an atrial septal aneurysm no other cardiac anomaly could be identified.

TREATMENT AND COURSE

Ligation of the left superior vena cava could have been a therapeutic option, but the patient declined operative intervention.

CONCLUSION

In cases of profound hypoxemia and erythrocytosis the differential diagnosis must include a persistent left superior vena cava with anomalous connection to the left atrium. Trans-thoracic and transoesophageal contrast-echocardiography is a simple and reliable method to diagnose persistent left superior vena cava as well as concomitant cardiac anomalies.

Gadolinium-enhanced three-dimensional magnetic resonance angiography of pulmonary and systemic venous anomalies

OBJECTIVE

The goal of this study was to evaluate the diagnostic value of gadolinium (Gd)-enhanced three-dimensional (3D) magnetic resonance angiography (MRA) in patients with congenital and acquired anomalies of the pulmonary and systemic veins.

BACKGROUND

Gadolinium-enhanced 3D MRA is a fast magnetic resonance imaging technique that has shown great promise in the evaluation of large and medium-sized arteries. However, its application to venous anomalies has not been studied in detail.

METHODS

The study retrospectively analyzed all patients who underwent Gd-enhanced 3D MRA examination from January 1998 through January 2001, were diagnosed with anomalies of the pulmonary or systemic veins and had additional diagnostic data available for comparison with the MRA findings.

RESULTS

Sixty-one patients (age 1 day to 60 years) were included. Image acquisition was completed in 29 +/- 6.9 s. Pulmonary venous anomalies were found in 37 patients, systemic venous anomalies in 17 patients and both pulmonary and systemic venous anomalies in 7 patients. Compared with available diagnostic information by other modalities, all known or suspected venous anomalies were imaged by 3D MRA. In three patients, catheterization did not detect anomalies of the pulmonary veins that were subsequently diagnosed by MRA. The 3D MRA diagnoses were followed by 10 interventional catheterization procedures and 15 operations. In 74% of patients, 3D MRA either diagnosed previously unsuspected venous anomalies (28%) or added new clinically important information (46%). The mechanism of pulmonary vein compression in eight patients was determined by MRA but not by other imaging modalities. Using a five-level grading system for MRA image quality (1 = nondiagnostic; 5 = excellent), the average grade was 4.6 +/- 0.6, with a 0.28 +/- 0.6 mean grade difference between two independent observers.

CONCLUSIONS

Gadolinium-enhanced 3D MRA is capable of rapidly and accurately diagnosing a wide spectrum of pulmonary and systemic venous anomalies and is a useful noninvasive alternative to diagnostic catheterization.