Pulmonary vein stump thrombus: an early complication following upper division segmentectomy of the left lung

We report a rare case of a pulmonary vein stump thrombus detected by a contrast-enhanced computed tomography for transient syncope 2 days after upper division segmentectomy of the left lung for metastatic pulmonary tumor. The thrombus disappeared without embolic events after anticoagulation with intravenous heparin followed by oral warfarin. Considering this case and previous reports, thoracic surgeons should be aware of pulmonary vein stump thrombus, a latent source of systemic embolization, after pulmonary resection, especially lobectomy or segmentectomy of the left upper lobe. This possible serious complication can occur at any time from the early postoperative period.     

Incidental partial anomalous pulmonary venous connection in left lung cancer

We present the case of a 79-year-old woman with partial anomalous pulmonary venous connection (PAPVC), discovered incidentally during upper left division segmentectomy for primary lung cancer. The left superior pulmonary vein originated from the hilum of the upper left lobe and flowed into the left brachiocephalic vein. The left inferior pulmonary vein was connected normally, and neither atrial septal defect nor other anomalous condition was present. Upper left lobectomy with ligation of the anomalous connected vein was performed, as the lingual segment was anatomically difficult to retain. Although this type of PAPVC is extremely rare, it is advisable to exercise caution when performing lung resection with the potential for PAPVC in mind.     

Incidental partial anomalous pulmonary venous connection in left lung cancer.

We present the case of a 79-year-old woman with partial anomalous pulmonary venous connection (PAPVC), discovered incidentally during upper left division segmentectomy for primary lung cancer. The left superior pulmonary vein originated from the hilum of the upper left lobe and flowed into the left brachiocephalic vein. The left inferior pulmonary vein was connected normally, and neither atrial septal defect nor other anomalous condition was present. Upper left lobectomy with ligation of the anomalous connected vein was performed, as the lingual segment was anatomically difficult to retain. Although this type of PAPVC is extremely rare, it is advisable to exercise caution when performing lung resection with the potential for PAPVC in mind.     

Torsion after left lower lobectomy and cerebral infarction following the re-exploratory thoracotomy: a case report

A 38-year-old man had a left lower lobectomy for pulmonary carcinoid. Following the operation, torsion of the left residual upper lobe occurred. Re-explosive thoracotomy was performed on the second postoperative day. The left upper lobe showed a clockwise 180-degree rotation. Pneumonectomy was not done. After the re-thoracotomy, the patient developed right hemiplegia. Head CT showed a cerebral infarction due to the thrombus of pulmonary vein that was released after the repair of the torsion.     

Bilateral partial anomalous pulmonary venous connection; report of a case

We have experienced a case of bilateral partial anomalous pulmonary venous connection with a fossa ovalis type of atrial septal defect and pulmonary stenosis. The right upper pulmonary vein returned to the superior vena cava and the left upper pulmonary vein returned to the left innominate vein via the vertical vein. The atrial septal defect was enlarged and the right upper pulmonary vein was baffled into the left atrium with an equine pericardial patch. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Pulmonary commissurotomy was also done for concomitant pulmonary stenosis. Postoperative course of the patient was excellent with constantly normal sinus rhythm. Angiography 2 weeks after operation showed no evidence of pulmonary venous obstructions on both sides.     

Neonatal repair of left atrial diverticulum with gigantic thrombus without cardiopulmonary bypass

A 5-day-old neonate with coarctation of the aorta, hypoplastic aortic arch, large apical muscular ventricular septal defect, and patent ductus arteriosus developed pulmonary over-circulation and systemic hypoperfusion underwent bilateral pulmonary artery banding through median sternotomy as a part of hybrid stage I palliation. At operation, left atrial diverticulum with gigantic thrombus formation at the base of the left atrial appendage was incidentally detected by intraoperative direct echocardiography, and therefore, was successfully resected with the whole thrombus inside it without use of cardiopulmonary bypass. Histopathological finding was compatible with diverticulum. The patient was free from atrial arrhythmia and recurrent thrombus formation.     

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.     

A case of ligating both upper and anomalous lower left pulmonary veins in the left upper lobectomy

A 53-year-old male was anesthetized for left upper lobectomy under one-lung ventilation using a double-lumen endobronchial tube in the lateral position. When the upper left pulmonary vein was ligated, Pao2/FIo2 ratio (PF ratio) was elevated despite the one-lung ventilation. After the operation, the patient was repositioned onto spine position and massive bleeding occurred from the anomalous lower left pulmonary vein, which was ligated during the operation. The lower left pulmonary vein was restored and the bleeding stopped. Because the pulmonary shunt flow from the lower left pulmonary vein had stopped, the PF ratio was unusually elevated. We urge anesthesiologists to pay attention to the arterial blood gas data even when it is better than expected.     

Successful surgical treatment of total left anomalous pulmonary venous return with intact atrial septum--a case report

A successful repair of total left anomalous pulmonary venous return with intact atrial septum is reported. A 7-year-old girl was admitted for evaluation of cardiac murmur which was first noted at 3 months of age. She had been followed up on suspicion of ASD, without any subjective symptoms. Physical examination on admission revealed a systolic ejection murmur at left sternal border. Chest X-ray showed mild cardiomegaly and increased pulmonary vascularity. ECG showed right axis deviation and incomplete right bundle branch block. Selective pulmonary arteriography delineated anomalous return of all left pulmonary veins to RA via vertical vein, left brachiocephalic vein, and SVC, and documented the absence of an atrial septal defect. Ratio of pulmonary to systemic blood flow was 2.2. Vertical vein was anastomosed to left atrial appendage under cardiopulmonary bypass. Postoperative cardiac catheterization showed no difference of wedge pressure between bilateral PA. The patient is up and well 1 years and 6 months after operation.     

Fontan procedure for DORV with mitral atresia and anomalous hepatic vein connection to the left atrium--advantage of leaving right to left shunt in situ

A 5-year-old boy with double outlet right ventricle, mitral atresia, pulmonary stenosis and anomalous hepatic vein drainage into left atrium underwent Fontan procedure leaving hepatic venous-left atrial connection. Systemic venous-left atrial connection provided enough filling volume of the systemic ventricle despite of high pulmonary resistance. Extra cardiac shunt between the systemic vein and left atrium would be the second best in fontan operation for cases with high pulmonary resistance.     

Acute post-cardiopulmonary bypass left atrial thrombosis after mitral valvuloplasty and left atrial thrombectomy

A patient with mitral stenosis and multiple left atrial thrombi underwent valvuloplasty and thrombectomy. While closing the sternum after completing the cardiopulmonary bypass, a new left atrial thrombus was detected by transesophageal echocardiography. We used heparin for the prevention of new thrombus formation and closed the wound after meticulous bleeding control. Three months later, there was no residual thrombus in the left atrium according to the echocardiographic study.     

The initial division of left renal vein in left renal cancer with intracaval tumor thrombus: a case report

A 30-year-old female was admitted to our hospital with a 3-month history of general fatigue and one month history of left flank mass. Computed tomography revealed a huge left renal tumor (20 × 13 × 10 cm) with intracaval tumor thrombus. The tumor thrombus extended into the right atrium. The left renal vein (lt-RV) was expanded 3.5 cm in diameter by the tumor thrombus. The tumor was surrounded by a tortuous dilated capsular vein. The strategic issue was how to ligate the left renal artery (lt-RA) behind the expanded lt-RV. We first divided the lt-RV occluded by the tumor thrombus using a Linear Cutter? and then divided the lt-RA before the dissection of the tumor to avoid excessive bleeding. Even transarterial embolization of lt-RA were to be performed,the tumor was too large to dissect without division of lt-RV and lt RA. After the left kidney was removed,the lower half of the tumor thrombus was excised,clamping the inferior vena cava,three right renal arteries,two right renal veins,and the lumber vein. Finally,we removed the upper half of the tumor thrombus extending to the right atrium through atriotomy and cavotomy under an extracorporeal cardiovascular bypass. Operation time was 9 h 22 m,and total blood loss was 1670 ml. Convalescence was uneventful except for abdominal lymphocele.     

An anomalous segmental vein of the left upper lobe of the lung: preoperative identification by three-dimensional computed tomography pulmonary angiography

A number of variations in the pulmonary arteries and veins have been documented, and the information is very important for performing a safe lung resection. This report describes a case of an anomalous segmental vein of the left upper lobe of the lung. The patient was a 75-year old male who was suspected to have lung cancer in the left upper lobe. A contrast-enhanced computed tomography showed a vessel behind the left lower bronchus. A three-dimensional computed tomography angiography demonstrated that it was an anomalous vein for the apicoposterior segment of the left upper lobe of the lung, draining into the left inferior pulmonary vein. The aberrant vein was readily identified during surgery and was divided without injury, and a left upper lobectomy was successfully performed. Aberrant pulmonary veins for the superior segment of the right upper lobe of the lung are rarely observed, and the same kind of anomaly on the left side has not been reported.     

Left partial anomalous pulmonary venous connection found during a lobectomy for lung cancer: Report of a case

We report herein the case of a 68-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found during an operation for primary lung cancer. The preoperative clinical findings did not suggest a vascular shunt, and intraoperatively the anomalous vein was seen to drain only from the left upper lobe into the left innominate vein. The lower pulmonary vein connected normally, and there was no atrial septal defect nor any other anomalous condition. A left upper lobectomy with ligation of the anomalous connected vein was performed uneventfully. This type of PAPVC is extremely rare, and is especially noteworthy because there were no clinical signs.     

Pulmonary venous anastomosis in lung transplantation without donor left atrium. Experimental and clinical results

Single lung transplantation now is a therapeutic option for some patients with end-stage lung disease. Cyclosporine immunosuppression and refinements in bronchial anastomosis have been responsible for recent successes. Since 1953, the usual pulmonary venous anastomosis, both in experimental animals and in humans, has been an atrium-to-atrium connection. This technique may limit the availability of usable donor lungs, since the donor heart, along with the atrium, is usually harvested for another recipient. Although techniques can be developed to allow both transplant teams to harvest atrial tissue, this study was undertaken to determine if, in fact, anastomosis with donor left atrium is necessary. Twenty-four dogs were anesthetized and a left thoracotomy performed. After heparinization (3 mg/kg), the pulmonary artery and left atrium were occluded. One of four different pulmonary venous anastomoses was performed at 3.5x magnification: superior pulmonary vein end to end (group I), inferior pulmonary vein end to end (group II), superior pulmonary vein implantation into left atrium (group III), and left atrium-to-left atrium anastomosis as control (group IV). Everting mattress sutures of 7-0 polypropylene were used in groups I, II, and III and 6-0 in group IV. Average crossclamp time for group I, group II, and group IV was 20 minutes. The average crossclamp time for group III was 10 minutes. All anastomoses were patent at the time of 1-week reevaluation. Gross and microscopic examination demonstrated establishment of an intimal lining; organized nonocclusive thrombus was present in only one anastomosis. We conclude that atrium-to-atrium anastomosis is not necessary for a successful single lung transplantation, and that transplantation of a single lobe is feasible. The best alternative is implantation of the pulmonary vein into the left atrium, which will easily allow use of the heart and both lungs from a single donor to different recipients. We have used this anastomosis in one patient without difficulty.     

Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation

OBJECTIVE: Pulmonary vein isolation is curative in selected patients with atrial fibrillation. The objective of this study was to assess the feasibility and safety (midterm results) of video-assisted thoracoscopic epicardial pulmonary vein isolation. METHODS: Twenty-seven patients (22 male patients) with atrial fibrillation (18 paroxysmal, 4 persistent, and 5 permanent; average age, 57 years) underwent bilateral video-assisted thoracoscopic off-pump epicardial pulmonary vein isolation and exclusion of the left atrial appendage. All patients had had unsuccessful drug therapy or were intolerant to antiarrhythmic drug therapy or were intolerant to warfarin. The approach included two 10-mm ports and one 5-cm working port (non-rib spreading) bilaterally. Pulmonary vein isolation was achieved bilaterally by using a bipolar radiofrequency device. The left atrial appendage was excised with a surgical stapler. RESULTS: Bilateral pulmonary vein isolation and left atrial appendage excision was performed successfully in all patients. There were no conversions to sternotomy or thoracotomy. All patients were extubated in the operating room. Postoperative complications in 3 patients were minor and resolved within 48 hours. One morbidly obese patient had more serious complications related to comorbid conditions. Average postoperative follow-up is approximately 6 months (173.6 days). Twenty-three patients have been followed up for greater than 3 months, and 21 of these patients are free of atrial fibrillation (91.3%). The results of magnetic resonance angiography were normal (no pulmonary vein stenosis) in 12 of 12 patients evaluated 3 to 6 months postoperatively. CONCLUSIONS: Bilateral video-assisted thoracoscopic pulmonary vein isolation with excision of the left atrial appendage is feasible and safe and offers a promising, new, minimally invasive, beating-heart approach for curative surgical treatment of atrial fibrillation.     

Encircling isolation of pulmonary vein orifice for elimination of persistent atrial fibrillation associated with mitral valve disease

The authors treated a 70-year-old woman with persistent atrial fibrillation associated with mitral valve stenosis. Restoration of sinus rhythm was achieved with encircling isolation of pulmonary vein orifices concomitant with mitral valve replacement. A vertical incision in the right side of left atrium was extended to the margin of the upper and lower left pulmonary vein orifices. Supplemental cryo-coagulation was applied to the remnant of the circular incision, avoiding the entire encircling incision. Consequently, all pulmonary veins were electrically isolated. Encircling pulmonary vein orifice isolation is less invasive than the MAZE procedure because of reductions in surgical time and cardiopulmonary bypass time, minimization of atrial incisions, and prevention of injury to the coronary artery. It is thus an effective option for selected patients with atrial fibrillation.     

Ischemic cardiomyopathy with mitral valve regurgitation and atrial fibrillation; report of a case

A 45-year-old man suffering from severe heart failure due to mitral regurgitation and atrial fibrillation was admitted to our hospital. He underwent intracoronary thrombolysis for left anterior descending artery 10 years ago and stent insertion for right coronary artery 3 years ago. We performed mitral annuloplasty using a Carpentier-Edwards Physio ring 28mm and modified maze procedure. The modified maze procedure consists of right sided left atriotomy extended to the left margin of the left pulmonary vein orifices and cryoablation applied to the remnant of the left atrial wall between the left upper and lower pulmonary vein orifice and cryoablation applied to the right atrial isthmus. These procedures could be effective for endstage heart failure.     

Successful removal of ball thrombus in the left atrium

Two cases of left atrial ball thrombus associated with severe mitral stenosis in which echocardiography provided the clue to the diagnosis preoperatively were reported. First case was a 58 years old man who was admitted because of dyspnea and frequent syncopal attacks. An echocardiographic examination revealed a tight mitral stenosis and a floating ball thrombus in the left atrium. Under the extracorporeal circulation, the ball thrombus, 30 X 40 mm in size, weight 20 g was taken out. The other case was a 51 years old woman who had undergone surgery for closed mitral commissurotomy 14 years ago. She had a episode of syncope attack and a sudden loss of consciousness. The removed thrombus was 20 X 26 mm in size and weighed 5 g. Their cut surfaces showed an laminated structure in both cases. These mitral valves were replaced by Bj?rk-Shiley prosthetic valves.     

Free-floating left atrial ball thrombus without mitral valve disease

Reports of left atrial ball thrombus without mitral valve disease are few. We experienced a case of free-floating left atrial ball thrombus that developed in a short period in a patient with atrial fibrillation and dilated left atrium but intact mitral valve. Surgical removal of the thrombus was performed. It was presumed that atrial fibrillation and enlarged left atrium were the contributory factors to thrombus development.