A case of unusual branching and aberrant course of the segmental vein (V2) in the upper lobe of the right lung

Two right pulmonary veins emptying into the left atrium is the normal state. We describe a case observed at operation in which three pulmonary veins were present on the right side and emptied into the left atrium; a third vein arised from the dorsal part of the upper lobe and followed an abnormal extrapulmonary course. Right lower lobectomy and mediastinal lymph node dissection were carried out for a 73-year-old male with lung carcinoma. At operation, an aberrant branching vein arising from the upper lobe descended dorsally to the right main bronchus and emptied into the left atrium at the middle point between carina and inferior pulmonary vein. The intermediate bronchus lay between the anomalous vein and superior pulmonary vein. Conventional tomogram, CT scan and pulmonary angiogram showed that pulmonary arteries and bronchi were normal in their pattern of branching and distribution, and that the anomalous vein observed at operation was comprised of V2a and V2b according to the system of naming on Yamashita's. Infrequent variations of pulmonary veins are to be kept in mind to that operation may be performed in safety.     

Anomalous dual drainage of the right pulmonary veins in a patient with cor triatriatum: report of a case without scimitar sign

The majority of patients with partial anomalous drainage of pulmonary veins are asymptomatic during infancy and childhood. Patients with significant left-to-right shunt develop symptoms and benefit from early corrective surgery. Anomalous pulmonary veins draining into inferior vena cava is very rare and frequently encountered in association with scimitar syndrome. The purpose of this case report is to describe a non-scimitar patient with cor triatriatum who had anomalous dual drainage of right pulmonary veins into inferior vena cava/left atrium and anomalous connection of persistent left superior vena cava with a common pulmonary venous chamber. The patient underwent an operation with redirection of anomalous pulmonary venous drainage into left atrium and ligation of persistent left superior vena cava.     

A case of cor triatriatum with atrial septal defect in an adult]

A surgical treatment of a 54 year-old female with cor triatriatum was reported. Two dimensional echocardiography had demonstrated an abnormal septum in the left atrium. The abnormal septum had a 2 x 1 cm fenestration and existed between the left and right pulmonary veins. Preoperatively, we had misjudged the septum as ASD and misdiagnosed this case as PAPVC. During surgery we found that there was the accessory atrial chamber posterior to the true ASD. The accessory chamber received right pulmonary veins and connected to the left atrium. The left pulmonary veins connected to the left atrium normally behind the abnormal septum. We diagnosed this case as Lucas-Shmidt IIIA1 type cor triatriatum with ASD. The abnormal septum was resected, and the ASD was closed with a bovine pericardium. The postoperative course was uneventful and she was discharged 19 days after the operation.     

Primary osteosarcoma of left atrium: complete surgical excision

A patient with primary osteogenic sarcoma of the left atrium with clinical features of severe congestive heart failure is described. The operative procedure required excision of the posterior atrial wall in continuity with the left pulmonary veins. The resultant defect in the atrium was reconstructed with the left atrial appendage. The left pulmonary artery was ligated, and the lung was removed at a subsequent procedure. The patient survived operation but subsequently was found to have distant metastasis. He died seven months after the operation.     

心上型完全性肺静脉异位引流外科治疗24例临床分析

目的总结心上型完全性肺静脉异位引流的外科治疗经验。方法1995年7月至2004年6月,手术治疗心上型完全性肺静脉异位引流24例,其中男11例,女13例;年龄40d～35岁,其中6周岁以下23例,体重3．8～54．0kg。经右心房、房间隔切开左心房后壁和肺静脉共干吻合10例;横行切开双心房与肺静脉共干吻合8例;2例分别用人造血管补片和自体心包补片将垂直静脉入口和扩大的房间隔切口一并隔人左心房;1例行左心房后壁和肺静脉共干吻合的同时用自体心包补片将肺静脉共干人口和扩大的房间隔切口一并隔入左心房;3例行左心房顶和肺静脉共干吻合。术后呼吸机辅助呼吸,多巴胺、硝普钠辅助循环2～5d。结果手术死亡1例,死于低心排出量综合征;术后心包填塞1例,再次手术止血后治愈;心律失常6例,均治愈;急性肺水肿1例,二次手术重新开放垂直静脉延迟闭合治愈。术后随访3个月至7年,平均2．5年。术后2周严重室上性心律失常1例,治愈;远期因心包补片挛缩致肺静脉严重回流障碍二次手术1例,治愈;其余患者均未见远期并发症。结论心上型完全性肺静脉异位引流可采用不同的手术方法,正确的手术方法和对并发症的及时处理可以获得良好的治疗效果,单纯应用右心房内补片应选用合适的修补材料,左心房顶和肺静脉共干吻合法暴露好、操作简单、心律失常发生率低。     

A case report of total anomalous pulmonary venous drainage corrected with Vargas' method

A 50-day-old infant with Darling's type Ib of total anomalous pulmonary venous drainage (TAPVD) was operated on with the Vargas' method. Pulmonary veins drained separately into the right superior vena cava (SVC). A J-shaped right atriotomy was performed according to the Vargas' method. The posterior flap was sutured to the anterior border of a previously enlarged atrial septal defect, directing the pulmonary blood flow toward the left atrium. The right SVC was divided just above the site of drainage of pulmonary veins, the proximal end of the right SVC was closed, and the anastomosis between the distal end of the right SVC and the previously opened right atrial appendage was performed. However, pulmonary hypertension remained because of the restrictive orifices of pulmonary venous drainage into SVC, and then side-to-side anastomoses between pulmonary veins and left atrium had to be added. Eight months after the operation pulmonary hypertension progressed markedly, because the orifices of the anastomoses became severely stenotic. Re-operation was performed to create a large anastomosis between pulmonary veins and left atrium. The indication and the long-term prognosis of the Vargas' method were discussed.     

Surgical treatment of total anomalous pulmonary venous connection —Clinical aspects of pulmonary venous obstruction—

During November 1986 and May 1997, 19 patients with total anomalous pulmonary venous connection (TAPVC) underwent repair surgery. 20 operations including two reoperations were performed. 8 of 19 patients were classified as Darling type Ia, 5 as type IIa, 4 as type III and 2 patients were type IV. Two patients were operated under emergency circumstances within 24 hours after admission, 7 patients were after a short term stabilization of 4.4 days, and the other 11 patients received surgical treatment after a mean of 8.8 days as scheduled cases. For the anostomosis, the common pulmonary venous chamber or the vertical vein was connected with the left atrium in type Ia and III cases; in type IIa and IV cases the cut-back method was performed. Persistent pulmonary hypertension and post-operative pulmonary venous obstruction (PVO) affected the post-operative clinical course. Persistent pulmonary hypertension caused the death of one patient with type IIa and III each, just after operation. One type IV patient died 50 days after operation. The autopsy revealed post-operative obstructions of the remote parts of the pulmonary veins on the anostomosis site. Two patients (type IIa, III) successfully underwent reoperation due to PVO. Post-operative cardiac catheterization was performed after 12 month in 12 cases. Persistent pulmonary hypertension was found in 4 patients, and a type III patient was reoperated because of stenosis of the anostomosis site. The other three patients had persistent pulmonary hypertension without any demonstrable PVO. Persistent pulmonary hypertension and PVO are combined as TAPVC complex. The difficulty to reoperated patients with persistent pulmonary hypertension caused by PVO is one major problem. So preoperative prevention of PVO by normalization the morphologic changes of the pulmonary veins by using drugs could be a different view point in TAPVC therapy after the initial operation.     

Rheumatic mitral stenosis in association with partial anomalous pulmonary venous return

An unusual case is presented, in which mitral stenosis was accompanied by a persistent left superior vena cava communicating through a venous channel with the left pulmonary veins. The pulmonary veins were normally connected to the left atrium, but, due to elevation of the left atrial pressure from the mitral valve lesion, pulmonary venous blood was directed up the left superior vena cava to reach the right atrium. Although from an anatomical viewpoint this did not constitute true anomalous pulmonary venous drainage, the condition behaved as such haemodynamically. It was only at operation that the diagnosis was firmly established, but after mitral valvotomy the abnormal venous channel was obliterated by simple ligation without incident.     

Right hemi-reconstruction of the left atrium using two equine pericardial patches for recurrent malignant fibrous histiocytoma: Report of a case

We report a case of recurrent malignant fibrous histiocytoma (MFH) in the left atrium, treated by removal of the tumor and the right half of the left atrium, which was reconstructed with two equine pericardial patches. Postoperative echocardiography showed patent right pulmonary veins and a properly shaped left atrium. The patient survived for 3 years after the operation with no cardiac symptoms.     

Metastatic renal cell carcinoma extending to the left atrium through the inferior pulmonary vein

Metastatic renal cell carcinoma with involvement through the pulmonary veins to the left atrium is very rare. We report the case of a 70-year-old male with metastatic renal cell carcinoma to the right lower lobe of the lung abutting the inferior pulmonary vein with extension to the left atrium without pre-operative evidence. Surgical resection was achieved through a posterolateral thoracotomy. Lung masses that abut the pulmonary veins should prompt further investigation with a pre-operative transoesophageal echocardiogram to minimize unexpected intraoperative findings.     

Pulmonary metastasis with left intra-atrial extension of liposarcoma. Apropos of a case

The direct extension of a neoplastic thrombus of the pulmonary veins into the left atrium is extremely rare. The authors report the case of a pulmonary metastasis from a liposarcoma of the thigh extending into the pulmonary veins and prolapsing into the left atrium. The patient was successfully treated by tumorectomy under cardiopulmonary bypass then by left upper lobectomy.     

Modified Fontan operation for a single ventricle with a nonconfluent pulmonary artery]

A 8-year-old boy with a double inlet right ventricle with a non-confluent pulmonary artery was operated on with a modified Fontan operation. He had right isomerism, right aortic arch, bilateral superior caval veins, and left-sided inferior caval vein. Hepatic veins were separately drained to the right-side atrium. Left Blalock-Taussig shunt and right central shunt operations had been previously performed. Firstly, we had reconstructed the central pulmonary artery with a 16 mm porcine pericardial roll to unify the nonconfluent pulmonary arteries. Secondly, about 2 months after the first operation, we performed a modified Fontan operation. Systemic venous return from the inferior caval vein and the hepatic veins were drained to a reconstructed pericardial roll with an intraatrial Gore-Tex graft, and bilateral superior caval veins were also anastomosed to the roll. The structure of the pulmonary arterial system is one of the most important factors to determine the outcome of a modified Fontan operation. Even if the central pulmonary artery is absent, however, a modified Fontan operation is applicable for the patient whose peripheral pulmonary arteries have enough growth.     

A resected case of lung cancer with an extrapericardial single trunk formed by the left pulmonary veins

We successfully performed left lower lobectomy in a lung cancer patient with anatomical variation in which left superior and inferior pulmonary veins were connected to the left atrium after foaming an extrapericardial single trunk. When indicating lobectomy, confirming the presence of such anatomical variation is clinically significant to prevent the development of pulmonary edema in the residual lung due to improper division of the single trunk as well as preventing subsequent possibly essential completion pneumonectomy.     

肺及部分左心房切除术治疗中心型肺癌

为探讨肺及部分左心房切除术在治疗侵及左心房的ＩＩｂ期肺癌的效果。对１９８３年２月至１９９４年１０月期间诊断为侵及左心房的ＩＩＩｂ期肺癌病人分为手术组２６例、探查组１４例。两组于围术期均行强化化疗和术后放、化疗。结果本组无手术死亡，探查组生存２～７个月，平均１３４天；切除组除５例术后１０～５８个月死于癌转移外，余２１例无癌生存６～８５个月。作者认为，肺叶或全肺切除并部分左心房切除能明显延长侵及左心房的ＩＩｂ期肺癌的生存时间。     

A case of concomitant surgery of advanced valvular disease and lung cancer under cardiopulmonary bypass

We successfully performed a concomitant operation in a patient with severe valvular heart disease with a giant left atrium and a pulmonary cancer. The operation was done via a median sternotomy under cardiopulmonary bypass. The patient was a 62-year-old man with congestive heart failure, NYHA class III. The CT ratio was 76%, and the volume of the left atrium estimated by a CT scan was above 900 ml. An abnormal shadow was recognized in the left upper lung field. Mitral valve replacement with St. Jude Medical valve (31 mm), and tricuspid annuloplasty with a Bex Reducer were performed. After an autonomous cardiac rhythm and a decrease in the size of the left atrium were confirmed, we went on to remove the upper lobe of the left lung under cardiopulmonary bypass. Twelve months postoperatively, the patient was doing well. For a complex case such as the present one, we recommend lobectomy via a median sternotomy using cardiopulmonary bypass as the technique of choice. This method assures good hemodynamic control and provides improved visibility of the pulmonary hilus.     

Epicardial pulmonary vein isolation by cryoablation as concomitant cardiac operation to treat nonvalvular atrial fibrillation

Since Ha?ssagere and colleagues reported that a rapid firing focus in or close to the pulmonary veins could be the cause of atrial fibrillation, a transcutaneous catheter technique directed at isolating these foci has been developed. How should patients with nonvalvular atrial fibrillation who require cardiac operation be managed? We developed an epicardial technique that uses cryoablation to isolate the left atrial posterior wall and pulmonary veins and used it to treat a patient. Because cryoablation is achieved epicardially, the technique does not require atriotomy and does not prolong aortic cross-clamp time. Isolation of the left atrium was confirmed by electrophyscologic studies, and the patient remains in sinus rhythm 16 months after operation. This concomitant procedure allows treatment of patients with nonvalvular atrial fibrillation.     

A unique pulmonary venous abnormality: with associated pulmonary arterial anomaly and arteriovenous malformation.

A man aged 29 was first seen at the age of 11, when he was found to have a congenital anomaly of the pulmonary veins which follow an abnormal course to the hilum. On the left side, two large veins descend peripherally before turning medially towards the left atrium; on the right, several smaller veins follow a similar circuitous route from the periphery, before uniting into two main veins which enter the left atrium. The proximal pulmonary arteries are normal in their pattern of branching and distribution but are dilated and tortous and taper abruptly: the left lower lobe artery is abnormally large almost down to the diaphragm. There is also a systemic arterio/pulmonary venous fistula. There is no haemodynamic disturbance, but gas transfer is slightly impaired, and there is slight arterial desaturation. The congenital anomaly is unique. Reported cases described as having pulmonary venous varices are a heterogeneous group, but one patient described as such shows resemblances to our case.     

Lung cancer with an extrapericardial single trunk as the left pulmonary vein; report of a case

A left lower lobectomy was successfully performed in a lung cancer patient with anatomical variation in which the left superior and inferior pulmonary veins were connected to the left atrium after forming an extrapericardial single trunk. This variation is surgically important because ligation and division of the left inferior pulmonary vein may result in blockage of upper lobe vein drainage at the time of a left lower lobectomy. The ligation of the pulmonary vein leads to severe lung edema, which may cause infection, respiratory distress, or postoperative complications that could be life-threatening. Surgeons must always pay attention to this variation when performing a left lower lobectomy.     

Surgical cure of automatic atrial tachycardia by partial left atrial isolation

Partial left atrial isolation was performed in a 16-year-old girl with persistent atrial tachycardia refractory to antiarrhythmic agents for 3 years. Intraoperative atrial epicardial and endocardial mapping showed that the earliest atrial activation occurred in an area lateral to the junction of the right superior pulmonary vein and the left atrium. An incision isolating the right half of the left atrial body containing the area of the earliest atrial activation and both right pulmonary veins from the remainder of the left atrium was made. The incision was then reapproximated. An excision encircling the interatrial septum containing the upper anterior portion of the septum with early activation was also made, and the atrial septal defect was repaired with a pericardial patch. The patient has been in sinus rhythm and free of arrhythmia for a follow-up period of 12 months.     

Total anomalous drainage of pulmonary veins into the coronary sinus (clinical aspects, diagnosis and surgical treatment)]

Total anomalous drainage of the pulmonary veins into the coronary sinus is a complicated congenital heart disease which takes a particularly severe course at early age. Its diagnosis is based on the discovery of overfilling of pulmonary circulation on radiography in a cyanotic patient, atrial septal defect and distended coronary sinus on echocardiography, and, in some cases, anomalous drainage of the pulmonary veins into the coronary sinus. The final diagnosis may be established during selective pulmonary arteriography. Operations were performed on 12 patients with this pathological condition under extracorporeal circulation and hypothermia with good results. In patients over one year of age the operation consisted in widening the atrial septal defect with resection of the part of the interatrial septum between the defect and the superior border of the coronary sinus and closure of the newly formed defect with a graft and transposition of the coronary sinus and the abnormally draining pulmonary veins into the left atrium. In patients under one year of age the interatrial septum was not resected.