No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Thoracic Aortic Aneurysm Presenting as Pulmonary Vein Stenosis: A Case Presentation and Review of the Literature
Abstract
We present the case of a 66-year-old woman presenting with pulmonary vein stenosis with a large descending thoracic aortic aneurysm. Pulmonary vein stenosis is a rare condition and can be caused by extrinsic compression, as well as by inflammatory diseases, congenital anomalies and related surgical repair, tuberculosis, and pulmonary veno-occlusive disease. With obstruction to pulmonary vein flow, the velocity increases and becomes continuous. The finding of turbulent antegrade flow in the left atrium through the use of transthoracic color flow Doppler and pulsed-Doppler warrants further investigation to evaluate known causes of pulmonary vein stenosis. We believe this is the first reported case of a patient with an aortic aneurysm causing pulmonary vein stenosis.
ResearchGate has not been able to resolve any citations for this publication.
Morphologic and morphometric studies were carried out on pulmonary vessels in lung tissue from 156 patients, for whom a diagnosis of primary pulmonary hypertension had been made. This material was collected from 51 medical centers. Chronic pulmonary thromboembolism can be recognized by organizing thrombi, patchy intimal fibrosis, and intra-arterial septa. The media is only slightly thicker than normal; in 31 of the 156 cases the vascular lesions corresponded to this pattern. Other conditions such as chronic pulmonary venous hypertension, pulmonary veno-occlusive disease, sarcoidosis, chronic bronchitis, and pulmonary schistosomiasis could also be classified from the morphologic criteria. The largest group comprised 110 cases showing medial hypertrophy, laminar intimal fibrosis, and often fibrinoid necrosis, arteritis, and plexiform lesions. These alterations suggest that they were initiated by vasoconstriction. In children the sex ratio is equal; in adults there are almost four females to one male. In these patients with vasoconstrictive primary pulmonary hypertension, various stimuli are likely to bring about vasoconstriction in the presence of a pronounced pulmonary vascular hyperreactivity. A review of 602 cases from the literature is given.
We describe a young woman who presented with a 6-month history of progressive pulmonary hypertension. At autopsy she was found to have noncaseating granulomas obliterating pulmonary veins, without granulomatous involvement of pulmonary arteries. Noncaseating granulomas were also present in the liver and hilar lymph nodes, confirming the diagnosis of sarcoidosis. To our knowledge this is the first reported case of pulmonary hypertension caused by sarcoidosis simulating pulmonary veno-occlusive disease.
Tracheal area at different lung volumes was measured using acoustic reflection technique, flow-volume curves, and lung volumes by body plethysmography in 24 healthy adults (14 men, 10 women) in order to study the relationship between tracheal area and lung volume, and between tracheal area and maximal expiratory flow rates. Each individual tracheal area was greatest at TLC and lowest at RV; this lung volume dependence was significantly greater in men than in women. When tracheal areas versus absolute lung volumes were plotted for the entire group and the linear regression analysis on the data was performed, no significant correlation between lung volume and tracheal area in men was found, but a highly significant correlation was found in women. Using the analysis proposed by Mead (Am Rev Respir Dis 1980; 121:339-42) in his assessment of dysanapsis, the ratio of tracheal area/lung volume versus lung volume was plotted and the slope was found to be negative (and close to -1) in men and positive in women. Therefore it was concluded that the relationship between tracheal area and lung volume is consistent with the hypothesis that in men and women lung parenchyma grows independently of the airways; furthermore, in women the airways grow faster than the lung parenchyma. In addition, in women there was good correlation between tracheal area and FEV1, as well as maximal expiratory flow rates at 50 and 25% of VC. For men, these correlations were less consistent and depended on the lung volume at which tracheal area was measured.
Obstruction to pulmonary venous return may be associated with a number of congenital cardiovascular abnormalities occurring both before and after surgery. Hemodynamic assessment by cardiac catheterization is often difficult. A noninvasive method for detection and quantitation of obstruction to systemic ventricular inflow would be clinically useful. Two-dimensionally directed pulsed and continuous wave Doppler echocardiography was performed before cardiac catheterization in 31 patients thought clinically to have possible obstruction to left ventricular inflow or pulmonary venous return. Primary diagnoses included transposition of the great arteries after the Mustard or Senning procedure in nine patients, total anomalous pulmonary venous connection in nine (in two after surgical repair), cor triatriatum in eight (in four after surgical repair), congenital mitral stenosis in four (in one after surgical repair) and mitral atresia in one. Severe obstruction was defined as a mean pressure gradient at catheterization of greater than or equal to 16 mm Hg at any level of the pulmonary venous return or of the systemic ventricular inflow. Severe obstruction was predicted if Doppler examination measured a flow velocity of greater than or equal to 2 m/s across any area of inflow obstruction. At catheterization, 12 patients (39%) had severe obstruction to left ventricular inflow or pulmonary venous return and all obstructions were correctly detected by Doppler echocardiography. The site of pulmonary venous obstruction was localized by two-dimensionally directed pulsed Doppler study. Patients with a lesser degree of obstruction had a lower Doppler velocity, but none had a maximal Doppler velocity of greater than or equal to 2 ms/s.(ABSTRACT TRUNCATED AT 250 WORDS)
Extraparenchymal pulmonary vein flow profiles were assessed by pulsed Doppler echocardiography in three groups of patients. Group I comprised 41 normal patients. Group II comprised 16 patients, 10 of whom had nonpulsatile pulmonary artery flow (5 with a right atrium to pulmonary artery Fontan procedure and 5 with a Glenn shunt). Six patients with pulsatile pulmonary artery flow had simultaneous Doppler and left atrial pressure measurements during cardiac catheterization. Group III comprised one patient with pulmonary vein obstruction, six with a large left to right shunt at ventricular level and two with pulmonary vascular disease. In Group I, biphasic forward pulmonary vein flow occurring during ventricular systole and diastole was observed in 26 subjects, 15 others had triphasic flow. In those with triphasic flow, the ventricular systolic component was divided into early and late. Reversed flow in the pulmonary veins during atrial systole was seen in 36 of the 41 subjects. The flow pattern in Group II was identical irrespective of the presence of pulsatile or nonpulsatile flow. The two periods of ventricular systolic flow occurred during the a to c and c to x descent, with the ventricular diastolic flow occurring during the y descent. Variations in waveform were mirrored in the left atrial pressure. Neither increased nor decreased pulmonary artery flow substantially altered the pattern. Pulmonary vein obstruction produced a distinctive pattern of high velocity turbulent flow. This technique demonstrates that extraparenchymal pulmonary vein flow is dependent on left atrial pressure events. It has major potential applications in patients who are prone to develop pulmonary vein obstruction.
Pulmonary vein stenosis was diagnosed preoperatively in 2 patients, aged 11 mth and 11 yr. The younger patient underwent repair of the right sided pulmonary vein stenoses with pericardial patch grafts. The veins thrombosed, and he died in the early postoperative period. In the older patient, both right and left sided pulmonary vein stenoses were repaired with saphenous vein grafts. Six mth after operation, restenosis of the pulmonary veins was proved at catheterization, and the patient died during repeat surgery. Techniques of diagnosis and surgical correction are discussed.
Stenosis or atresia of individual pulmonary veins is a rare condition that is usually fatal when untreated, even when only one side is involved. The lesion can be diagnosed at cardiac catheterization by the findings of (1) pulmonary artery hypertension, (2) elevated pulmonary capillary wedge pressure, (3) normal left atrial pressure, and (4) angiography of the main pulmonary artery showing either no filling or delay of emptying of one or more pulmonary veins. Occasionally, selective angiography of a pulmonary vein can demonstrate the lesion. The surgical approach to pulmonary vein stenosis must be flexible. The technique of repair will depend upon the local anatomy of each lesion. Those of the diaphragmatic type can be treated effectively by excision of the obstructing membrane. Increase of the vein's caliber can be effectively achieved by patch angioplasty. When segmental stenosis or atresia is present, it may be necessary to anastomose the vein directly to the left atrium. Relief of most types of extrapulmonary venous stenosis and atresia should be possible with currently available techniques. If relief of the obstruction is not possible, undrained pulmonary tissue should be excised whenever technically feasible.
The authors report a case of tuberculous myocarditis associated with miliary tuberculosis of the lungs, kidneys, adrenals, liver, spleen, and bone marrow. The paucity of cardiac symptoms and lack of physical findings in our case are stressed. Modern chemotherapeutic management of tuberculosis has diminished the number of patients with tuberculous myocarditis. Since the clinical diagnosis is extremely difficult, a high index of suspicion might be helpful in detecting this rare complication of tuberculosis.
Because of the complicated anatomy displayed by two-dimensional imaging of the heart, and the need to easily understand the image orientation, it is important that standard nomenclature and image orientations be adopted. The Committee believes that by adopting nomenclature and image orientation standards, the technique of two-dimensional imaging of the heart will be advanced and communication between laboratories will be improved. In addition, these standards should be helpful to those who are seeing two-dimensional images of the heart for the first time.
The purpose of this study was to determine, in an adult population, the percentage of patients in whom high quality pulmonary venous flow velocity recordings can be obtained using current transthoracic pulsed wave Doppler techniques. Pulmonary venous and mitral flow velocity variables obtained with a pulsed wave Doppler method were used for the indirect assessment of left ventricular (LV) diastolic function and LV filling pressures. The general clinical use of these methods, however, remains uncertain because the transthoracic success rate of obtaining all components of pulmonary venous flow velocity has been variable, and sometimes reported to be as low as 30% to 60%. Mitral and pulmonary venous flow velocity variables were obtained using pulsed wave Doppler signals in 200 consecutive adult patients (mean age 68.2 +/- 11.4 years) in normal sinus rhythm who were referred for echocardiographic study. Six cardiac sonographers and five ultrasound systems were used. The success rate for obtaining pulmonary venous systolic and diastolic flow velocity was 95%, reverse flow velocity at atrial contraction was 90%, and the duration of reverse flow at atrial contraction was 89%. In the 5% to 11% of patients in whom pulmonary flow velocities could not be adequately recorded, the most common reasons were depth limitations of the pulsed wave Doppler machine, marked cardiac enlargement, or left atrial wall motion artifact. The success rate also was influenced by the ultrasound equipment used, individual variation among sonographers, and even the type (impaired, pseudonormal, restricted) of associated mitral filling pattern. Given current machine technology, sonographer education, and daily practice, high quality, complete recordings of pulmonary venous flow velocity can be obtained in approximately 90% of adult patients using the precordial transthoracic Doppler technique. These results suggest that using these variables as an aid for evaluating LV diastolic function and filling pressures may have broader clinical applicability than previously appreciated.
Stenosis of individual pulmonary veins: Re-view of the literature and report of surgical case
- Rd Sade
- Md Freed
- Matthews
- Ec
Sade RD, Freed MD, Matthews EC, et al: Stenosis of individual pulmonary veins: Re-view of the literature and report of surgical case. J Thorac Cardiovasc Surg 1974;67:953
Diagno-sis and surgical treatment of bilateral pul-monary vein stenosis
- Sc Park
- Wh Neches
- Lenox
- Cc
Park SC, Neches WH, Lenox CC, et al: Diagno-sis and surgical treatment of bilateral pul-monary vein stenosis. J Thorac Cardiovasc Surg 1974;67:755
Pulmonary venous obstruction: Utility of transesophageal echocardiography Wagenvoort N: Primary pulmonary hypertension: A pathologic study of the lung vessels in 156 clinically diagnosed cases
- Ns Geither
- Rw Hull
- Dc Wortham
Geither NS, Hull RW, Wortham DC, et al: Pulmonary venous obstruction: Utility of transesophageal echocardiography. Am Heart J
Wagenvoort CA, Wagenvoort N: Primary pulmonary hypertension: A pathologic study of the
lung vessels in 156 clinically diagnosed cases.
Circulation 1970;42:1163-1184.