Anomalous pulmonary venous drainage: a pictorial essay with a CT focus

Delayed Diagnosis of Partial Anomalous Pulmonary Venous Return in an Adult With Pulmonary Hypertension

Partial anomalous pulmonary venous return (PAPVR) involving the left upper lobe pulmonary vein is an exceptionally rare congenital anomaly that, if untreated, can lead to pulmonary hypertension (PH). Its nonspecific clinical presentation often results in delayed diagnosis. We report the case of a 58-year-old woman who initially presented with progressive dyspnea and was diagnosed with group III pulmonary hypertension attributed to obstructive lung disease. Two years later, she returned with similar symptoms after discontinuing diuretic therapy. Further evaluation uncovered a previously undetected anomalous left pulmonary vein draining into the left innominate vein. This case highlights the diagnostic challenges of PAPVR, its role in contributing to PH, and the critical need for high clinical suspicion and comprehensive evaluation in patients with unexplained pulmonary hypertension.

A Cadaveric Study of Variations in Lung Fissures and Drainage Patterns of Pulmonary Veins at the Hilum With Its Clinical Implications

Introduction The human lungs are located in the pleural cavity, divided by fissures into lobes, facilitating respiration movements. It acts as a barrier to prevent the spread of infection to adjacent lobes. The pulmonary hilum in each lung contains pulmonary vessels, bronchial vessels, and the bronchus. Pulmonary venous drainage variations are expected to be significant in diagnostic and therapeutic procedures. The present study aims to study the variant pattern of the lung fissures and the drainage pattern of the right and left pulmonary veins at the pulmonary hilum. Methodology The descriptive study was conducted on 75 lungs in the Department of Anatomy after obtaining ethical approval from Vinayaka Mission's Medical College and Hospital, Karaikal, India. A few lung specimens were procured from the government hospital, Karaikal. All the lung specimens belonging to adults of unknown age and gender collected over three years were included in our study. Lungs with evident pathological conditions, damage, surgical resections, and metastatic disease were excluded from the study. The pattern of oblique and horizontal fissures and accessory fissures was studied on both the right and left lungs. These fissures were categorized based on the Craig and Walker classification, a widely accepted system in pulmonary anatomy. The hilar structures were dissected on both the right and left lungs, the pulmonary veins were picked up, the different drainage patterns of pulmonary veins at the hilum were studied, and the results were expressed in percentage. In addition, the presence of an accessory vein and anomalous unilateral single pulmonary vein was documented. Results Out of 35 right lungs, incomplete and absent oblique fissures were observed in 10 (28.57%) and four (11.43%), and incomplete and absent horizontal fissures were observed in 12 (34.29%) and seven (20%) of the specimens. Out of 40 left lungs, incomplete and absent oblique fissures were observed in 13 (32.5%) and three (7.5%) of the specimens. Superior and inferior accessory fissures were present in five (14.29%) and four (11.4%) of the right lungs, and the left minor fissures were seen in 15 (37.5%) of the specimens. Different patterns of pulmonary venous drainage were reported in our study, and variations were observed in 52% of the specimens. A single unilateral pulmonary vein was documented in two (5.71%) and 14 (35%), and the accessory vein was noted in seven (20%) and two (5%) of the right and left lungs, respectively. These findings underscore the importance of understanding the variant patterns of pulmonary veins and the presence of accessory veins in the context of cardio-thoracic surgeries. Conclusions As revealed by our study, the variations in the pulmonary veins and fissures are paramount in the surgical field. These findings will reassure and instill confidence in surgeons and radiologists, enabling them to diagnose and perform cardio-thoracic surgeries with a strong foundation of anatomical knowledge.

Mal-positioning of a dialysis catheter: One lumen with arterial blood and the other with venous blood?

Partial anomalous pulmonary vein drainage is a rare congenital defect, where the pulmonary vein drains into a systemic vein instead of draining into the left atrium. We present a case of a 63-year-old woman on hemodialysis who was found to have a right pulmonary vein with anomalous drainage to the superior vena cava after mal-positioning of a dialysis catheter, which demonstrated unexpected blood results from the different lumina of the catheter. Multiple imaging techniques were used to deal with this rare clinical situation. This is the first case reporting a mal-positioning of a left-side internal jugular vein tunneled catheter into a right-side pulmonary vein.

Nutrition in congenital heart disease: consensus document

INTRODUCTION

The prevalence of malnutrition among infants with congenital heart disease (CHD) is high. Early nutritional assessment and intervention contribute significantly to its treatment and improve outcomes. Our objective was to develop a consensus document for the nutritional assessment and management of infants with CHD.

MATERIAL AND METHODS

We employed a modified Delphi technique. Based on the literature and clinical experience, a scientific committee prepared a list of statements that addressed the referral to paediatric nutrition units (PNUs), assessment, and nutritional management of infants with CHD. Specialists in paediatric cardiology and paediatric gastroenterology and nutrition evaluated the questionnaire in 2 rounds.

RESULTS

Thirty-two specialists participated. After two evaluation rounds, a consensus was reached for 150 out of 185 items (81%). Cardiac pathologies associated with a low and high nutritional risk and associated cardiac or extracardiac factors that carry a high nutritional risk were identified. The committee developed recommendations for assessment and follow-up by nutrition units and for the calculation of nutritional requirements, the type of nutrition and the route of administration. Particular attention was devoted to the need for intensive nutrition therapy in the preoperative period, the follow-up by the PNU during the postoperative period of patients who required preoperative nutritional care, and reassessment by the cardiologist in the case nutrition goals are not achieved.

CONCLUSIONS

These recommendations can be helpful for the early detection and referral of vulnerable patients, their evaluation and nutritional management and improving the prognosis of their CHD.

Total Anomalous Pulmonary Venous Return in the Time of SARS-CoV-2-Case Report

The management of children with complex and life-threatening heart malformations became a clinical conundrum during the SARS-CoV-2 pandemic. The pathophysiological features of the new coronavirus infection have raised major dilemmas regarding the postoperative evolution of an infected patient, and the epidemiological limitations have tightened the criteria for selecting cases. We present the case of a newborn diagnosed with total anomalous pulmonary venous return (TAPVR) who underwent surgical repair of the defect with favorable outcome, despite a prior diagnosis of SARS-CoV-2 infection. We discuss the medical and surgical management of TAPVR, highlighting possible management difficulties brought by the SARS-CoV-2 pandemic.

Early and Late Outcomes of the Warden and Modified Warden Procedure

BACKGROUND

Operative repair of partial anomalous pulmonary venous connection (PAPVC) remains challenging due to risks of sinus node dysfunction, baffle obstruction, and superior vena cava (SVC) obstruction.

METHODS

Traditional or modified Warden procedures were performed in 75 of 318 consecutive patients (24%) with PAPVC repaired surgically at our institution during 1993 to 2021. Clinical characteristics, echocardiography data, operative details, and early and late outcomes were collected. Cumulative incidence of reintervention and Kaplan-Meier survival analysis are reported.

RESULTS

Median age was 39 years (interquartile range, 21-57 years). Fifty-nine (79%) had normal sinus rhythm preoperatively. Seventeen (23%) had intact atrial septa. Traditional and modified Warden procedures were performed in 15 (20%) and 60 (80%), respectively. Frequent concomitant procedures included 15 (20%) tricuspid valve repairs and 12 (16%) atrial fibrillation procedures. There were no early deaths. Postoperative complications included atrial fibrillation in 17 (23%), sinus node dysfunction in 15 (20%), pneumothorax in 3 (4%), pleural effusion in 2 (3%), and pacemaker implantation in 1 (1%). At hospital discharge, sinus node dysfunction persisted in 8 (11%). Over a median follow-up of 6 years (interquartile range, 4-10 years), baffle obstruction developed in 1 patient and SVC obstruction developed in 7. None required reoperation and 6 were treated with SVC stents. At 1, 5, and 10 years, the cumulative incidence of reintervention was 5%, 7%, and 14%, and survival was 99%, 94%, and 94%, respectively.

CONCLUSIONS

Traditional and modified Warden procedures can be performed with satisfactory early and late survival. Persistent sinus node dysfunction and need for permanent pacing are low. Late SVC obstruction is uncommon and can often be managed nonoperatively.

Left common pulmonary venous trunk-better be careful than sorry

Pulmonary vein abnormalities are very commonly encountered in general thoracic surgical practice. While performing a lobectomy, ideally all the pulmonary veins should be identified before ligating the corresponding vein. Failing to recognize a common pulmonary vein may lead to an unwarranted pneumonectomy which may end up morbid for the patient. In this report, we present a patient with left lower lobe bronchiectasis who underwent a left lower lobectomy and was identified to have a common left pulmonary venous trunk intra-operatively.

Is there an association between left atrial outpouching structures and recurrence of atrial fibrillation after catheter ablation?

Objective

The aim of this study was to investigate the impact of left atrial diverticula (LADs), left sided septal pouches (LSSPs) and middle right pulmonary veins (MRPVs) on recurrent atrial fibrillation (rAF) in patients undergoing laser pulmonary vein isolation procedure (PVI).

Material and methods

This retrospective study enrolled 139 patients with pre-procedural multiple detector computed tomography (MDCT) imaging and 12 months follow-up examination. LADs, LSSPs and MRPV were identified by two radiologists on a dedicated workstation using multiplanar reconstructions and volume rendering technique. Univariate and bivariate regression analyses with patient demographics and cardiovascular risk factors as covariates were performed to reveal independent factors associated with rAF.

Results

LADs were recorded in 41 patients (29%), LSSPs in 20 (14%) and MRPVs in 15 (11%). The right anterosuperior wall of the left atrium was the most prevalent location of LADs (68%). rAF occured in 20 patients, thereof, 15 exhibited an outpouching structure of the left atrium (LAD: 9, LSSP: 2 and MRPV: 3). Presence of an LAD (HR: 2.7, 95%CI: 1.0–8.4, p = 0.04) and permanent AF (HR: 4.8, 95%CI: 1.5–16.3, p = 0.01) were independently associated with rAF.

Conclusions

LAD, LSSP and MRPV were common findings on pre-procedural cardiac computed tomography. LADs were revealed as potential independent risk factor of rAF, which might be considered for treatment planning and post-treatment observation.

Pictorial Essay: Understanding of Persistent Left Superior Vena Cava and Its Differential Diagnosis

Persistent left superior vena cava (PLSVC) is a rare congenital, thoracic, and vascular anomaly. Although PLSVCs generally do not have a hemodynamic effect, several types of PLSVC and some cardiac anomalies may manifest with clinical symptoms. The presence of PLSVC can render catheterization via left subclavian access difficult when placing a pacemaker or central venous catheter. As such, recognizing a PLSVC that is typically incidentally discovered can prevent complications such as vascular injury. Differentiating vessels found in a similar location as PLSVC is necessary when performing thoracic vascular procedures. This pictorial essay explains the multi-detector CT findings of a PLSVC, and provides a summary of other blood vessels that require differentiation during thoracic vascular procedures.

Left superior vena cava or left vertical vein in supracardiac total anomalous pulmonary venous drainage - Does it make a difference?

What do we call a vascular structure that is in the left pneumopericardial space, drains systemic venous blood, and the total pulmonary venous return, into the right atrium, through a dilated coronary sinus (CS)? Can we preserve the CS drainage while correcting the total anomalous pulmonary venous connection?

Pulmonary Arteriovenous Malformation and Its Vascular Mimickers

Pulmonary arteriovenous malformation (AVM) is a congenital vascular disease in which interventional radiologists can play both diagnostic and therapeutic roles in patient management. The diagnosis of pulmonary AVM is simple and can usually be made based on CT images. Endovascular treatment, that is, selective embolization of the pulmonary artery feeding the nidus of the pulmonary AVM, and/or selectively either the nidus or draining vein, has become a first-line treatment with advances in interventional devices. However, some vascular diseases can simulate pulmonary AVMs on CT and pulmonary angiography. This subset can confuse interventional radiologists and referring physicians. Vascular mimickers of pulmonary AVM have not been widely known and described in detail in the literature, although some of these require surgical correction, while others require regular follow-up. This article reviews the clinical and radiologic features of pulmonary AVMs and their mimickers.

Midline crossing pulmonary vein: right upper lobe dual venous drainage, with partial anomalous venous return of the right lung into a persistent left superior vena cava

Introduction

We present a case of dual drainage of the right upper lobe of the lung into the left atrium and via partial anomalous venous pulmonary return (PAPVR) into a persistent left superior vena cava (SVC).

Discussion

It is only in the minority of PAPVR cases where the anomalous pulmonary veins cross the midline. We provide a review of current literature on this topic and an explanatory embryological model. Knowledge of embryonic development and possible anatomic variations, including the concept of dual venous drainage of the lung, leads to better interpretation of imaging, with more accurate description of the morphology at hand. High-resolution multidetector computed tomography (MDCT) helps to delineate the exact vascular anatomy. This will enhance a better understanding of and anticipation on the patient’s disease status, with more accurate planning of intervention, and possibly less complications.

The Pulmonary Venous Return from Normal to Pathological-Clinical Correlations and Review of Literature

Pulmonary veins carry oxygenated blood from lungs to the left atrium of the heart. The anatomy of the pulmonary veins is variable with some anatomic variants. In clinical practice the difference between the normal anatomy of pulmonary veins with its variants and abnormal anatomy is very important for clinicians. Variants of pulmonary veins may occur in number, diameter and normal venous return. We present a case report and a review of the literature with the pulmonary venous return that deviates from the usual anatomical configuration and ranges from normal variant drainage to anomalous pulmonary—systemic communication. Initially, it was considered as an anatomical variant of the pulmonary venous return associated with the persistence of the left superior vena cava. Upon detailed exploration it was established that it was an anomaly of the pulmonary venous return which led in time to the installation of its complications. Diagnosis can be difficult, sometimes missed, or only made late in adulthood when complications were installed. Knowledge of variant anatomy and anomalous pulmonary venous return play a crucial role in the diagnostically challenging patient.

Persistent left superior vena cava: clinical importance and differential diagnoses

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and may be a component of the complex cardiac pathologies. While it is often asymptomatic, it can lead to significant problems such as arrhythmias and cyanosis. Besides, it can cause serious complications during vascular interventional procedures or the surgical treatment of cardiac anomalies (CA). The clinical significance of PLSVC depends on the drainage site and the accompanying CA. In this article, we will describe the epidemiology, embryology, and anatomic variations of PLSVC. Possible accompanying CA and heterotaxy spectrum will be reviewed with the help of multidetector computed tomography (MDCT) images. Radiological pitfalls, differential diagnoses, and the clinical importance of PLSVC will be highlighted.

Surgical repair of an isolated left-sided partial anomalous pulmonary venous connection in an 18-month-old child

The isolated left-sided partial anomalous pulmonary venous connection is a rare congenital anomaly. Only 3% of cases have been reported with drainage from the whole left lung into the left innominate vein. This anomaly is often asymptomatic and may go undetected (particularly in non-referral centers) until adulthood when symptoms begin to manifest. Transthoracic echocardiography is the main diagnostic tool; however, computed tomography angiography, and magnetic resonance imaging are widely used nowadays. Herein, we present the case of an 18-month-old girl with the diagnosis of isolated left-sided partial anomalous pulmonary venous connection as the left pulmonary veins were draining into the left innominate vein via a vertical vein. The patient underwent surgical repair by anastomosing the vertical vein to the left atrial appendage using cardiopulmonary bypass and cardiac arrest. The patient was discharged on the fifth day without complications. The precise follow-up for 12 months showed improved clinical symptoms, and the successively performed TTE confirmed the excellent result of the operation.

Superior Vena Cava Inflow Following Repair for Anomalous Right Pulmonary Venous Drainage in Children

Risk of superior vena cava (SVC) obstruction following repair of anomalous right upper pulmonary veins in children is unclear. The incidence and outcome of subclinical obstruction remained unknown. Retrospective single institutional study (07/1993-02/2017) in a pediatric population (N = 42, median age 3.9-year, range 0.1-15.3 years). 33 (79%) children had repair without SVC translocation ("non-Warden") and 9 (21%) had Warden-type surgery. Echocardiographic SVC obstruction was defined as (I) turbulent flow across SVC and (II) continuous flow pattern without return to baseline velocity (0 m/s); severe obstruction was defined as loss of distinct biphasic profile ± mean gradient ≥ 5 mmHg. 3 (7%) patients required intra-operative revision due to obstruction (non-Warden: 1, Warden: 2). After discharge, 2 (5%) patients required reintervention (3 and 6-month post-op) for severe symptomatic obstruction (non-Warden: 1, Warden-type: 1). Both patients responded to balloon angioplasty with symptomatic resolution (one required repeat catheter reintervention). 10 (24%) patients had subclinical echocardiographic obstruction (2, 22% Warden vs. 8, 24% non-Warden; p = 1.0; 8 of 10 patients had mild gradient), which resolved and remained well without reintervention. At follow-up (mean 7.2-year, range 0-23 years), all patients were alive. Freedom from SVC reintervention at 10 and 20-year is 95% (97% at 10, 20-year in non-Warden and 89% at 5, 8-year in Warden-type group; log-rank p = 0.34). Surgical repair for anomalous right upper pulmonary veins is associated with risk of SVC obstruction in children. The need for reintervention for severe obstruction is rare at late follow-up. Patients with subclinical obstruction remain asymptomatic and demonstrate echocardiographic improvement.

Double drainage of pulmonary vein associated with atrial septal defect

We report the successful surgical treatment of a case of double drainage of the right upper pulmonary vein into the superior vena cava and left atrium in a 9-year-old girl.