[A case of anomalous course of the pulmonary vein with a tracheobronchus]

A 28-year-old man was admitted to our hospital for further evaluation of a loop-like abnormal shadow in the middle lower lung field on chest X-ray film. Pulmonary angiograms demonstrated staining of the abnormal shadow during the venous phase. The abnormal vein descended from the right upper lobe to the middle lobe and then tortuously made a loop upward to drain into the left atrium. A part of the right apical vein was stenosed. The right apical segmental bronchus directly branched from the trachea. These observations indicate that the abnormalities may have originated in the prenatal period. Cases of anomalous course of the pulmonary vein are very rare.

[Surgical treatment of total anomalous pulmonary venous connection Darling type Ib using pedicled right atrial flap]

A one-month-old baby with total anomalous pulmonary venous connection (TAPVC) type Ib underwent a total correction with a pedicled right atrial (RA) flap, which was made by incising the RA wall in a quadrangular configuration. The common pulmonary vein (PV) was cut back into the left atrium (LA). Then the RA flap was sutured along the limbus of PV recess and atrial septal defect (ASD) to create a new pulmonary venous channel. The defect in the RA wall was directly closed without any prosthetic patch. Absorbable sutures (# 6-0 PDS) were used throughout. Postoperative course was uneventful and echocardiogram showed widely opened PV channel draining into the LA. We think that this procedure could be applied in various types of total and partial anomalous pulmonary venous connection, avoiding pulmonary venous obstruction on the assumption that the RA flap should grow.

Quantitative analysis of pulmonary vascular disease in total anomalous pulmonary venous connection in sixty infants

A quantitative analysis of small pulmonary arteries, pulmonary veins, and lymphatic vessels was conducted in autopsy cases of total anomalous pulmonary venous connection. The materials were obtained from 60 cases of total anomalous pulmonary venous connection without asplenia or pulmonary stenosis, ages ranging from 2 days to 19 months at the time of death (mean age 2.2 months). Pulmonary arterial pressure had been measured in 32 of these patients before death. Twenty cases of ventricular septal defect with pulmonary hypertension and 15 normal individuals were used as the control group. The mean thickness of the media of small pulmonary arteries and veins was 12.7 and 7.6 microns, respectively, in the total anomalous pulmonary venous connection cases, both values being significantly larger than those for normal and ventricular septal defect cases. No changes in thickness with aging were found. Medial thickness in the arteries and veins was greater in the cases of pulmonary venous obstruction than in those without such obstruction. The medial thickness of small pulmonary arteries in total anomalous pulmonary venous connection cases correlated with increased pulmonary arterial pressure. When the patients with the same pulmonary arterial pressure levels were compared, the medial thickness was always greater in those who had total anomalous pulmonary venous connection than in those who had ventricular septal defect. The medial thickness of pulmonary veins was also highly correlated with increased pulmonary arterial pressure in total anomalous pulmonary venous connection. The severity of the intimal lesions was milder in those who had total anomalous pulmonary venous connection than in those who had ventricular septal defect, suggesting the protective role of the thickened pulmonary arterial media against development of intimal lesions. Intimal fibrous thickening of pulmonary veins was not seen in the cases of ventricular septal defect, but it was present in 45% of the total anomalous pulmonary venous connection cases. Lymphangiectasia was characteristically present in 62% of the total anomalous pulmonary venous connection cases. Interstitial emphysema was often a complication of lymphangiectasia, and it led to eight postoperative deaths.

Value of transesophageal color Doppler echocardiography for detection of different types of atrial septal defect in adults

In 121 adults, the value of transthoracic and transesophageal color Doppler echocardiography for detection of different types of atrial septal defect (ASD) or of partial anomalous pulmonary venous return was analyzed. The 121 patients had a total of 129 defects with left-to-right atrial shunting (including eight patients with two types of defects). All of six cases with primum-type ASD were diagnosed correctly by both echocardiographic methods. Ninety-seven patients showed a secundum-type ASD during transesophageal echocardiography: by transthoracic echocardiography, only eight (20%) of the 40 small defects (diameter < 5 mm) were detected as compared with 15 (83%) of the 18 defects with a diameter of 5 to 10 mm and all 39 defects with a diameter > 10 mm. A sinus venosus--type ASD was evident by transesophageal echocardiography in 11 patients, of which only one (9%) was demonstrated by the transthoracic approach. Partial anomalous pulmonary venous return was seen by transesophageal echocardiography in 13 patients but missed in two other patients in whom anomalous pulmonary venous return was subsequently identified by surgery (both with anomalous return of the upper right pulmonary vein into the superior vena cava). By use of the transthoracic technique, partial anomalous venous return was detected in only two cases, both of which had "scimitar syndrome." Compared with transthoracic echocardiography, the transesophageal approach is clearly superior in the detection of small secundum-type ASD, sinus venosus--type ASD, and partial anomalous pulmonary venous return.

Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections. Comparison between the transpectoral and subpectoral approaches

A right submammarian incision with anterior thoracotomy was performed in 89 female patients to repair simple and complex forms of atrial septal defects. Patients' ages ranged from 8 to 38 years (mean 21.5 years). Seventy-seven had secundum-type atrial septal defects, one had the primum type, and 11 had an associated partial anomalous pulmonary venous connection. The patients were divided into two groups: 57 patients in group A, in whom, after a breast flap was elevated, a transpectoral approach was used to enter the chest; 32 patients in group B, in whom the pectoral muscle was not divided and a subpectoral approach was used. Aortic cannulation was accomplished without difficulty in all 89 patients. There were no early or late deaths in either group. Follow-up ranged from 24 to 108 months (mean 63.7 months) and included 86 patients, who were free of symptoms. In group A, however, among 54 patients examined, the volume of the right breast and pectoral muscle was smaller than the left in four patients (7.4%), and 21 (38.8%) had persistent right periareolar numbness. In 32 patients evaluated in group B, no difference was noted in the size of the breasts, and persistent numbness was present in four patients (12.5%). In summary, atrial septal defects or anomalous pulmonary venous connections can be safely repaired through a right submammarian thoracotomy in female patients. The subpectoral approach offers better results because breast asymmetry and paresthesias are significantly less prevalent (p less than 0.01).

Recurrence of brain abscess associated with asymptomatic arteriovenous malformation of the lung

On the basis of the data provided by literature the majority of patients with an arteriovenous malformation of the lung who develop a brain abscess suffer from hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber disease. Only nine cases of brain abscesses in which the arteriovenous malformation of the lung was isolated have been described and in all of these, clinical signs and/or alterations in the laboratory data were detected which can be attributed to the arteriovenous malformation itself. The case taken in this article would seem to be the first case of a recurrent brain abscess in a patient not suffering from Rendu-Osler-Weber with a completely asymptomatic arteriovenous malformation of the lung, both from the clinical point of view and from laboratory data. The authors stress the appropriacy of an angiographic pulmonary study in cases of recurrent brain abscesses, even where the chest X-ray has been negative.

Frequency and significance of intrapulmonary right-to-left shunting in end-stage hepatic disease

Intrapulmonary vascular abnormalities consisting of arteriovenous malformations and capillary dilatations have been described in patients with severe liver disease. These intrapulmonary vascular abnormalities can result in intrapulmonary right-to-left shunting and hypoxemia. Twenty-five of 53 patients (47%) with end-stage hepatic disease were found to have contrast echocardiographic evidence of intrapulmonary right-to-left shunting. There was no difference in mean age, gender distribution, or severity of hepatic disease in those with and without evidence of such shunting. Although there was no difference in mean partial arterial oxygen pressure (PaO2) values in the 2 groups (82 +/- 11 vs 76 +/- 11 mm Hg), the mean PaO2 value of those with at least 2+ left ventricular opacification (2 to 4+) was significantly lower (66 +/- 3 mm Hg, n = 8; p less than 0.01). Unexpectedly, patients with evidence of intrapulmonary shunting had a lower mortality rate before transplantation (3 of 25, 12%) than those without evidence of shunting (10 of 28, 36%) resulting in a significant difference in actuarial survival (p less than 0.05) by the end of the follow-up period. It is concluded that intrapulmonary right-to-left shunting occurs frequently in patients with end-stage liver disease and may be a marker of a positive biologic process that, in some way, leads to improved short-term survival.

[Pulmonary arteriovenous malformation with systemic blood supply]

A forty-eight year-old woman who had suffered from exertional dyspnea and cyanosis since her youth was found to have abnormal shadow in her right lower lung at the roentgenographic examination. Pulmonary angiography showed cavernous network between pulmonary artery and vein of the 8th, 9th, and 10th segments. Bronchial artery was dilated, supplying the cavernous lesion. From these findings this lesion was diagnosed as pulmonary arteriovenous malformation feeded by bronchial artery. Right lower lobectomy was performed. The effect of resection was confirmed by intraoperative arterial gas analysis before and after the excision. She has been doing well without any signs of recurrence for 3 years after the surgery.

Complete repair of total anomalous pulmonary venous connection in infancy

From 1983 to 1990, 20 infants underwent complete repair of isolated total anomalous pulmonary venous connection. Twelve were male; ages ranged from 1 day to 240 days (mean 32 days). The abnormal anatomic connection was supracardiac in nine, cardiac in four, mixed in five, and infradiaphragmatic in two. In seven patients the pulmonary venous drainage was obstructed. Corrective operations were performed 2.4 days after admission; after medical stabilization, seven patients underwent emergency operations, including extracorporeal membrane oxygenation in one. All operations were performed with the use of circulatory arrest (mean 33 minutes) and cardiopulmonary bypass (mean 54 minutes). There was one hospital death, which occurred in a premature infant (1.5 kg) who had supracardiac drainage. No preoperative risk factors correlated with a poor surgical outcome. Pulmonary hypertensive episodes were expectantly managed after the operation with 100% oxygen, sedation, and hyperventilation. Postoperative arrhythmias occurred predominantly in patients with intracardiac drainage. All survivors (mean follow-up of 42 months) are in sinus rhythm, receiving no medications, and are growing and developing normally. Surgical correction of total anomalous pulmonary venous connection in infancy can be performed at low risk with good results after aggressive preoperative stabilization and postoperative management.

Pulmonary circulation in pulmonary atresia associated with the asplenia cardiac syndrome

OBJECTIVE

The goal of this study was to determine the patterns of the pulmonary circulation in patients with pulmonary atresia and asplenia.

BACKGROUND

The asplenic cardiac syndromes characteristically have complex cardiac anomalies including pulmonary stenosis or atresia. Definition of the pulmonary artery circulation and pulmonary venous connections is needed for consideration of surgical procedures.

METHODS

In 35 patients, the sources of pulmonary blood flow, anatomic features of pulmonary arteries and pulmonary venous connections were determined from angiograms or autopsy specimens.

RESULTS

The main pulmonary artery was absent or hypoplastic in 91% of patients; most had a ductus arteriosus. The right and left pulmonary arteries were confluent in 90% and usually of normal size (right 71%, left 63%). Total anomalous pulmonary venous connections were present in 38%.

CONCLUSIONS

The anatomic features of the pulmonary arteries in pulmonary atresia associated with the asplenic cardiac syndrome are usually favorable for palliative surgical procedures. Total anomalous pulmonary venous connection may exist as a complicating factor.

Imaging of pulmonary venous pathway obstruction in patients after the modified Fontan procedure

To evaluate the efficacy of chest roentgenograms and echocardiograms in identifying pulmonary venous pathway obstruction in patients after the modified Fontan procedure, the records of 297 patients who underwent 307 Fontan procedures between 1984 and 1990 were reviewed. Twelve cases of pulmonary venous pathway obstruction documented by autopsy (3 cases) or cardiac catheterization (9 cases with an A wave gradient greater than or equal to 4 mm Hg) were found in 10 patients (mean age 43 +/- 28 months). The mechanisms of obstruction included narrow pulmonary vein ostia in six cases, narrow left atrial outlet in four and atrial baffle obstruction in three. Two causes of obstruction were present in one case. No patient had pulmonary venous congestion on chest roentgenograms. Pathway diameters indexed to 3 square root of body surface area with two-dimensional echocardiography were found to be 6.8 +/- 1.2 mm/3 square root of m2 in the subcostal frontal view, 7.9 +/- 0.6 mm/3 square root of m2 in the subcostal sagittal view and 6.5 +/- 1.7 mm/3 square root of m2 in the apical "four-chamber" view. These values differed significantly from those in 11 age-matched patients undergoing the Fontan procedure without pulmonary venous pathway obstruction documented by catheterization (p = 0.001). With pulsed Doppler ultrasound, there was a relatively narrow range of velocities distal to the obstruction (1.3 to 2.5 m/s). In five of the seven cases with pulsed Doppler measurements, flow was continuous and the Doppler spectral recordings were not phasic. Thus, in patients who have undergone the Fontan procedure and have pulmonary venous pathway obstruction 1) chest roentgenography cannot be used as a screening tool; 2) distal velocities as low as 1.3 m/s occur, usually with nonphasic, continuous forward flow; and 3) pathway diameters indexed to 3 square root of body surface area may be used as an output-independent parameter to cross-check Doppler data.

[Surgery versus detachable balloon embolization of pulmonary arteriovenous fistula: clinical experience]

We experienced 4 pulmonary arteriovenous fistula cases 2 of which were treated surgically and 2 were subjected to detachable balloon embolization therapy. Favorable results were obtained in the detachable balloon embolization therapy. In treating pulmonary arteriovenous fistula, if the lesion is in the position where the catheter can be reached easily and is composed of a single afferent-efferent vessel unit, it would be advisable to perform the embolization therapy first, and then to apply an operative procedure preserving lung tissue as much as possible.

Remnant of the common pulmonary vein mistaken for a left atrial mass: clarification by transoesophageal echocardiography

Faulty incorporation of the common pulmonary vein leaves it as a distinct structure posteriorly, into which the pulmonary veins empty. This "chamber" is separated from the anterior "fetal" left atrium (containing the left atrial appendage and communicating with the mitral valve) by a diaphragm, and is known as cor triatriatum, one of the rarest of cardiac malformations. Less pronounced but still incomplete regression of this vein would result in the persistence of a portion of the common pulmonary vein appearing as a mass along the lateral wall of the left atrium at the junction of the left atrial appendage and left upper pulmonary vein. In two patients, both referred for evaluation of a left atrial mass, transoesophageal echocardiography identified the "mass" as a remnant of the common pulmonary vein. Cardiologists need to be aware of this structural remnant and its possible variants so as to avoid misdiagnosis of this prominence as an atrial tumour or mass.

Unsuspected congenital heart disease in neonates receiving extracorporeal life support: a review of ninety-five cases from the Extracorporeal Life Support Organization Registry

The purpose of this study was to determine the frequency of patients with congenital heart disease who were given extracorporeal life support (ECLS) for respiratory failure. Underlying congenital heart disease "masked" by respiratory failure occurred in 2%. The most frequent pre-ECLS diagnosis that "masked" congenital heart disease was persistent fetal circulation. Of neonates with a pre-ECLS diagnosis of persistent fetal circulation, congenital heart disease was found in 56 (9%) of 623 patients.

Persistent pulmonary hypertension of the newborn due to alveolar capillary dysplasia

Three unrelated female term infants died when less than 1 month old from intractable pulmonary hypertension associated with deficient capillaries in airspace walls, anomalous small pulmonary veins in bronchiolar-arterial rays, and medial thickening in small pulmonary arteries together with peripheral muscularization. This complex vascular abnormality in the lungs has been termed alveolar capillary dysplasia and/or misalignment of lung vessels in seven previously reported cases. Each infant also showed abnormally immature parenchymal development in the lungs, as was noted in four of the seven prior cases. One had phocomelia; four of the seven prior cases had a variety of congenital anomalies. The primary pulmonary vascular anomaly is likely to be a failure of fetal lung vascularization dating from the second trimester and to be due to action of an unknown teratogen. Centroacinar veins may represent bronchial veins that do not normally develop beyond the ends of cartilaginous bronchi. Pulmonary arterial occlusive changes are interpreted as reactive to obstruction at the level of pulmonary arterioles.

[Repair of two cases of partial anomalous pulmonary venous return by draining total right pulmonary venous blood to the left atrium through dilated atrial septal defect]

Two cases of partial anomalous pulmonary venous return were reported in whom right pulmonary veins were totally drained to the coronary sinus and to the right atrium respectively. Re-routing of pulmonary veins was done by dilated atrial septal defect and making intra-atrial tunnel using equine pericardial patch. Postoperative courses were uneventful. MRI was useful to identify the pathway from right pulmonary veins to the left atrium.

Hemianomalous pulmonary venous connection of the left lung surgically corrected

Hemianomalous pulmonary venous connection is a rare congenital abnormality that leads to significant left-to-right shunt and complications related to that. Earlier surgical correction of this disorder was associated with the problem of stenosis at the anastomotic site with the left atrium. We describe the diagnosis of this abnormality in a 24-year-old woman and present the details of surgery to avoid the stenosis at the site of anastomosis.

[Assessment of Blalock-Taussig shunts in children with complex cardiac anomalies associated with reduced pulmonary blood flow and total anomalous pulmonary venous drainage]

Eleven patients with syndromes of asplenia and polysplenia associated with total anomalous pulmonary venous drainage (TAPVD) were underwent Blalock-Taussig (B-T) shunt operation for reduction of pulmonary blood flow. The age of patients at operation were 6 days to 5 years (average 19.5 +/- 18.7 month). There were seven patients in supracardiac type and four in cardiac type of TAPVD. All patients didn't present obstruction to pulmonary venous return (PVO) before B-T shunt operation. There were one early (9%) and two late deaths (20%) after surgery. Although the hospital death was related to perioperative errors. Two late deaths were not due to the PVO. One of infants had moderately pulmonary congestion and cardiac failure after shunt procedure. Two patients were measured pressure gradient (3 to 4 mmHg) between common pulmonary vein to atrium chamber before shunt procedure. Repeated catheterization revealed that 6 of them could be measured pressure gradient, 3 to 7 mmHg, and no patients had clinical sign of the PVO. Our results demonstrated that B-T shunt operation could be satisfactory for syndromes of asplenia and polysplenia associated with reduced pulmonary blood flow and TAPVD.

[Current problems in the diagnosis and surgical treatment of rare developmental defects of the lungs]

The author analyzes questions of diagnosis and surgical treatment of 168 patients with rare malformations of the lungs which made up 5.6% of the general amount of patients with surgical nonspecific diseases of the lungs and 36.1% among all defects of development of the lungs. It was established that diagnostics of rare defects of development of the lungs might be of full value but when using a complex of roentgenological, bronchiological and functional methods of examination. Surgical treatment of rare defects of the lung development is indicated to 86.1% of the patients and must be performed till the progressing of secondary alterations, when disturbances of ventilation and oxygenation are observed, there is blood flow shunt disturbances of hemodynamics of the pulmonary circus of blood circulation.

Diagnosis of pulmonary arteriovenous malformation by ultrafast chest computed tomography in Rendu-Osler-Weber syndrome with cerebral ischemia--a case report

Pulmonary arteriovenous malformations occur in 15-20% of patients with Rendu-Osler-Weber syndrome and can be the source of paradoxical emboli causing cerebral ischemia, septic emboli leading to brain abscesses, or polycythemia causing hyperviscosity and cerebral ischemia. The diagnosis of these malformations may be elusive, since classic clinical or radiologic findings may be absent in some patients. The authors report a patient with Rendu-Osler-Weber syndrome with cerebral ischemia who had normal findings from a pulmonary examination and chest roentgenogram. An ultrafast computed tomography scan of the chest demonstrated, however, a pulmonary arteriovenous malformation in the right upper lobe that was successfully resected. Ultrafast computed tomography of the chest is a relatively noninvasive method of screening for a pulmonary arteriovenous malformation in a patient with Rendu-Osler-Weber syndrome and otherwise unexplained neurologic symptoms.

Aberrant systemic artery-pulmonary venous fistula: diagnosis with Doppler imaging

A 6-year-old asymptomatic girl presented with a continuous murmur at two different locations. Using Doppler imaging modalities, a small patent arterial duct and an aberrant systemic artery arising near the coeliac axis, piercing the right hemidiaphragm, and connecting to the right lower pulmonary vein were identified. Angiography confirmed the diagnosis and revealed additional pulmonary abnormalities. Doppler examination helped in planning appropriate angiographic projections and sites of the contrast medium injection.