A rare case of pulmonary vein sarcoma.
Pulmonary vein tumours are rare. They can cause significant morbidity and mortality. The present report discusses a rare case of pulmonary vein sarcoma in an elderly male patient.
Aged↗
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Pulmonary vein thrombosis.
Pulmonary vein thrombosis is difficult to diagnose clinically and requires a combination of conventional diagnostic modalities. Transesophageal echocardiography was used in the present case to readily diagnose this entity and follow thrombus regression on anticoagulant therapy. This limited experience suggests that transesophageal echocardiography may be the initial diagnostic study of choice for pulmonary vein thrombosis.
Aged↗
Pulsed wave and color Doppler echocardiography and cardiac catheterization findings in bilateral pulmonary vein stenosis.
Pulmonary vein stenosis is a rare condition that usually is congenital in origin; it is almost invariably fatal in its bilateral and severe forms. It is often overlooked, however, during clinical examination, routine echocardiography, and even at cardiac catheterization. This report describes the pulsed Doppler, color flow echocardiography, and hemodynamic findings of bilateral pulmonary vein stenosis that accompany ventricular septal defect and atrial septal defect corrected by surgery.
Adult↗
Intracardiac Doppler echocardiographic quantification of pulmonary vein flow velocity: an effective technique for monitoring pulmonary vein ostia narrowing during focal atrial fibrillation ablation.
INTRODUCTION: Ablation at the pulmonary vein (PV) ostium to isolate triggers for atrial fibrillation (AF) may induce PV narrowing. The AcuNav ultrasound catheter can image PV flow and quantify peak velocity and may be useful in assessing the degree of narrowing of PV ostia. METHODS AND RESULTS: In 93 patients with AF undergoing PV ostial ablation (up to 40 W, 52 degrees C, 90 sec), the ultrasound catheter was placed in the right atrium and PV peak flow velocities were measured during systole and diastole before and after ablation. Ostial PV electrical isolation was achieved in 216 of the 219 targeted PVs. The ultrasound catheter provided flow imaging of all PVs. The ostial peak flow velocities measured 56 +/- 12 cm/sec before ablation and increased to 101 +/- 22 cm/sec after ablation (P < 0.001). Peak velocity >100 cm/sec was detected in 103 (47%) of 219 and > or = 158 cm/sec (estimated pressure gradient 10 mmHg) with turbulent flow features, in 7 (3.2%) of 219 PVs. The highest velocity detected in one PV was 211 cm/sec (17.7 mmHg). Follow-up ultrasound catheter measurements were obtained in 13 patients (30 previously ablated PVs) during repeat ablations. The ostial peak velocity had decreased by 22 +/- 14 cm/sec and in 25 (83%) of 30 PVs was within the baseline range (<100 cm/sec) at a mean follow-up of 4.9 +/- 2.2 months. Follow-up magnetic resonance imaging (MRI) or contrast-enhanced CT was obtained at 7.0 +/- 3.8 months in seven patients with PV velocity > 158 cm/sec after initial ablation. No significant stenosis (<30%) was identified, and no patient suffered clinical symptoms (follow-up 6-18 months) related to the described acute changes in PV flow after an initial ablation procedure. Of 13 patients with repeat ablation, two had PV velocities >100 cm/sec before repeat ablation, and three PVs in two patients had flow velocity >158 cm/sec after repeat ablation. One of these patients developed symptoms of exertional dyspnea; MRI at 4 months showed 50% to 60% ostial narrowing. CONCLUSION: Ostial ablation for PV isolation may induce a mild-to-moderate increase in PV flow velocity, which can be identified using an ultrasound catheter with Doppler color flow imaging. Increases in PV flow velocity (<158 cm/sec) after a primary ablation procedure appear to be well tolerated, and a return toward baseline flow characteristics should be anticipated by 3 months. A more cautious approach may be required for patients undergoing repeat PV isolation.
Atrial Fibrillation↗
Active response of pulmonary veins to distention of a single pulmonary vein in intact dogs.
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Animals↗
Common pulmonary vein atresia without anomalous pulmonary venous connection.
Common pulmonary vein atresia without pulmonary venous connection is a rare form of congenital heart disease. No communication exists between the confluence of the pulmonary veins and the heart or a major systemic vessel. A case diagnosed antemortem is presented. Correct early diagnosis is imperative as surgery may be corrective.
Heart Defects, Congenital↗
Morphofunctional study of the junction between the left atrium and the pulmonary veins in patient with pulmonary hypertension.
OBJECTIVE: To study the arrangement of the myocardial fiber bundles at the pulmonary venous left atrial junction in patients with pulmonary hypertension, and to discuss the pathophysiological importance of this element in the etiology of acute pulmonary edema. METHODS: We obtained 12 hearts and their pulmonary vein extremities from postmortem examinations of patients with the anatomicopathological diagnosis of acute pulmonary edema. The specimens, which had no grossly visible morphological cardiac alterations, were fixed in 10% formalin, and the muscular arrangement of the pulmonary venous left atrial junctions was analyzed. This material was then isolated, embedded in paraffin, underwent serial cutting (50 micrometer of thickness), and was stained with Azam's trichrome. RESULTS: We observed in our specimens that: a) the myocardial fiber bundles that originate in the atrial wall and involve the openings of the pulmonary veins were fewer than those observed in healthy material; b) the myocardial fiber bundles that extend into the pulmonary veins were shorter than those found in material originating from individuals with no pulmonary hypertension. CONCLUSION: Anatomical changes that result in a reduction in the amount of myocardial fiber bundles in the pulmonary venous left atrial junction, isolated or associated with other factors, may be the cause of disorders in pulmonary circulation, leading to an increase in pulmonary venous pressure, and, consequently, to acute pulmonary edema.
Acute Disease↗
Relation between pulmonary vein firing and extent of left atrial-pulmonary vein connection in patients with atrial fibrillation.
BACKGROUND: The purpose of this study was to measure the extent of left atrial-pulmonary vein (LA-PV) connections and determine the relation to PV firing in patients with atrial fibrillation (AF). METHODS AND RESULTS: Ten close-bipolar (1 mm-spacing) Lasso electrograms were recorded circumferentially around 210 PVs (excluding 2 right middle PVs and 4 left common trunks) in 62 patients with AF. PV firing was provoked by isoproterenol (4 microg/min) and cardioversion of pacing-induced AF. The width of each LA-PV connection was measured in tenths of PV circumference, based on number of continuous close-bipolar Lasso electrode sites required for ablation (10% for each close-bipolar electrode site). One, 2, or 3 to 4 discrete LA-PV connections (discrete connection defined by ablation along 10% to 30% of PV circumference) were present in 18 (9%), 31 (14%), and 32 (15%) of 210 PVs, respectively: 1 broad connection (ablation along continuous 40% to 80% circumference) in 46 (22%) PVs; 1 broad plus other broad or discrete connections in 54 (26%) PVs; and a circumferential connection (ablation along 90% to 100%) in 29 (14%) PVs. Circumferential LA-PV connections were more common in superior than in inferior PVs (20% versus 7%, P<0.01). There was no major difference in distribution of the other types of LA-PV connections between the four PVs. PV firing occurred in 27%, 47%, and 72% of PVs with discrete only, broad and circumferential connections, respectively (P<0.01). Dissociated PV potentials after isolation were more common in arrhythmogenic (firing) PVs (32% versus 8%, P<0.01). CONCLUSIONS: The extent of LA-PV connections corresponds with arrhythmognesis. The incidence of PV firing increases with progressively wider LA-PV connections (discrete versus broad versus circumferential).
Action Potentials↗
Tree-shaped pulmonary veins in infracardiac total anomalous pulmonary venous drainage.
Three consecutive patients undergoing corrective operation for the infracardiac type of total anomalous pulmonary venous drainage (TAPVD) were found to have tree-shaped pulmonary veins. Preoperative angiocardiography revealed that in 2 patients the superior and inferior pulmonary veins drained separately, bilaterally, into the vertical vein. In the third patient the right pulmonary veins united to connect with the vertical vein, while the left superior and inferior pulmonary veins drained separately into the vertical vein. At operation inferior pulmonary veins connecting separately with the vertical vein were found to be located posterior to the pericardium. In the previous literature dealing with successful repair of infracardiac TAPVD, there is no mention of the tree-shaped pulmonary veins described in this report. As this particular type of pulmonary vein does not seem to be uncommon, its possible presence should be kept in mind during operation, as it may dictate the selection of surgical procedures.
Angiocardiography↗
Incidence of pulmonary vein stenosis in patients submitted to atrial fibrillation ablation: a comparison of the Selective Segmental Ostial Ablation vs the Circumferential Pulmonary Veins Ablation.
INTRODUCTION: Pulmonary vein (PV) stenosis is an important complication of the AF ablation and could be underestimated if their assessment is not systematically done. Selective Segmental Ostial Ablation (SSOA) and Circunferential Pulmonary Veins Ablation (CPVA) have demonstrated efficacy in atrial fibrillation (AF) treatment. In this study the real incidence of PV stenosis in patients (pts) submitted to both SSOA and CPVA was compared. METHODS: Those pts with focal activity and normal left atrial size were submitted to SSOA, remaining pts were submitted to CPVA to treat refractory, symptomatic AF. Contrast enhanced magnetic resonance angiography (MRA) was routinely performed in all patients 4 months after the procedure. RESULTS: A series of 73 consecutive patients (mean age of 51 +/- 11 years; 75% male) were included. SSOA was performed in 32 patients, and the remaining 41 patients underwent to CPVA, obtaining similar efficacy rates (72% vs 76% arrythmia free probability at 12 months; log rank test p = NS). Six patients had a significant PV stenosis, all in SSOA group none in CPVA group (18.8% vs 0%; p = 0.005). All patients were asymptomatic and the stenosis was detected in routine MRA. No predictors of stenosis has been identified analysing patient procedure characteristics. CONCLUSION: PV stenosis is a potential complication of SSOA not seen in CPVA. The study confirms than MRA is useful for identifying patients with asymptomatic PV stenosis.
Atrial Fibrillation↗
Partial pressure of oxygen is lower in the left upper pulmonary vein than in the right in adults with atrial septal defect: difference in P(O2) between the right and left pulmonary veins.
BACKGROUND: The right-to-left shunt at the atrial level is responsible for arterial hypoxemia in patients with atrial septal defect. OBJECTIVES: This study investigated the mechanism of arterial hypoxemia in patients with atrial septal defect by measuring the P(O2) in both the right and left upper pulmonary veins. SUBJECTS AND METHOD: We prospectively measured the P(O2) in the femoral artery and the right and left upper pulmonary veins during cardiac catheterization in 13 adults (median age, 53 years) and 7 children (median age, 7 years) with secundum atrial septal defect. The adults and children were studied consecutively. Contrast echocardiography was performed to evaluate right-to-left shunt in all adults. RESULTS: Among the children, there were no patients showing arterial hypoxemia, and there was no difference in the P(O2) (+/-SD) between the right and left upper pulmonary veins (right, 100+/-3.8 mm Hg vs left, 100+/-7.8 mm Hg; p = 0.92). However, arterial hypoxemia was present in 11 of the 13 adult patients, although contrast echocardiography showed more than a moderate degree of right-to-left shunt in only four adults. The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in all adult patients (right, 91.6+/-13.8 mm Hg vs left, 73.0+/-11.5 mm Hg; p < 0.0001). CONCLUSION: The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in adults with atrial septal defect. Care must be taken in measuring pulmonary blood flow if the P(O2) in the left upper pulmonary vein is low enough to influence oxygen content. The decreased P(O2) in the left upper pulmonary vein may contribute to arterial hypoxemia in addition to right-to-left shunt at the atrial level in adults with atrial septal defect.
Adult↗
Errors in pulmonary vein identification and ostia location in the absence of pulmonary vein imaging.
BACKGROUND: A key point in atrial fibrillation (AF) ablation is the ability to identify the pulmonary vein (PVs) and locate their ostia. OBJECTIVES: The purpose of this study was to assess the error margin of PV identification and ostia location in the absence of previous PV imaging. METHODS: This study was performed in patients referred for catheter ablation of AF. PVs were reconstructed before ablation using the CARTO system. The operator tagged the superior and inferior edges of the PV ostia before and after examining the corresponding PV angiograms. The distances between the tagged PV ostia were measured using CARTO software. RESULTS: A total of 105 location estimations of 54 PVs were analyzed. The location of PV ostia without angiography deviated from the angiographic PV ostia by a median of 13 mm (95% confidence interval = 11-14 mm; P < .0001). In 84 of the 105 estimations (80%), wrong tagging was performed inside the PV. A multiple logistic regression revealed that, at sites displaying PV potentials, the left atrial potential amplitude was an independent predictor of location at the angiographic PV ostium (odds ratio 24 [95% confidence interval = 3.7-227] per 1-mV increase). Receiver operator characteristic analysis set the optimal cutoff level at 0.7 mV. Use of this criterion improved the accuracy of PV ostium location by 4 mm (95% confidence interval = 1-6 mm; P = .005). CONCLUSION: Attempts at PV identification and ostia location in the absence of previous PV imaging are subject to a broad error margin.
Adult↗
Pulmonary vein varix in association with bilateral pulmonary vein stenosis.
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Adult↗
Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction.
BACKGROUND: The role of pulmonary vein (PV) isolation in ablative treatment of atrial fibrillation (AF) has been debated in conflicting reports. We sought to compare PV conduction in patients who had no AF recurrence (group I), patients who could maintain sinus rhythm on antiarrhythmic medication (group II), and patients who had recurrent AF despite antiarrhythmic medication (group III) after PV antrum isolation (PVAI). METHODS AND RESULTS: PV conduction was examined in consecutive patients undergoing second PVAI for AF recurrence. We also recruited some patients cured of AF to undergo a repeat, limited electrophysiological study at >3 months after PVAI. All patients underwent PVAI with an intracardiac echocardiography (ICE)-guided approach with complete isolation of all 4 PV antra (PVA). The number of PVs with recurrent conduction and the shortest atrial to PV (A-PV) conduction delay was measured with the use of consistent Lasso positions defined by ICE. Late AF recurrence was defined as AF >2 months after PVAI with the patient off medications. Patients in groups I (n=26), II (n=37), and III (n=44) did not differ at baseline (38% permanent AF; ejection fraction 53+/-6%). Recurrence of PV-left atrial (LA) conduction was seen in 1.7+/-0.8 and 2.2+/-0.8 PVAs for groups II and III but only in 0.2+/-0.4 for group I (P=0.02). In patients with recurrent PV-LA conduction, the A-PV delay increased from the first to second procedure by 69+/-47% for group III, 267+/-110% for group II, and 473+/-71% for group I (P<0.001). When pacing was at a faster rate, A-PV block developed in all 5 of the group I patients with recurrent PV-LA conduction. CONCLUSIONS: The majority of patients with drug-free cure show no PV-LA conduction recurrence. Substantial A-PV delay is seen in patients able to maintain sinus rhythm on antiarrhythmic medication or cured of AF compared with patients who fail PVAI.
Anticoagulants↗
Usefulness of Doppler assessment of pulmonary vein and left atrial appendage flow following pulmonary vein isolation of chronic atrial fibrillation in predicting recovery of left atrial function.
Atrial fibrillation (AF) is a widespread condition that causes significant morbidity and mortality. Recently, pulmonary venous (PV) isolation using radiofrequency ablation has been used successfully to exclude the pulmonary venous ostia, resulting in correction of AF. Further, miniaturized high-frequency ultrasound phased-array transducers currently provide Doppler and 2-dimensional imaging during the ablation procedure. We examined atrial function and its determinants using intracardiac echocardiography before and after PV isolation in 45 patients who had chronic AF (56 +/- 11 years old). PV, left atrial (LA) appendage, and mitral and tricuspid flows were recorded. Recovery of booster pump function (defined by the presence of mitral inflow A wave, LA appendage a-wave, and PV A-reversal wave velocities >10 cm/s) was observed in 39 of 45 patients (86.6%). PV flow systolic wave before and after ablation correlated with the degree of LA booster pump function after PV isolation. An early systolic PV flow peak velocity >57.47 cm/s predicted "good" LA booster pump function recovery with 96% specificity. Diastolic LA appendage emptying in AF correlated (p <0.001) and predicted good LA booster pump function with 92% specificity for velocities >46.4 cm/s. Thus, monitoring LA function during PV isolation for chronic AF is feasible. Most patients recovered LA booster pump function immediately after PV isolation, and the degree of recovery correlated with LA reservoir function. Preserved reservoir function during AF is predictive of satisfactory recovery of booster pump function after PV isolation.
Aged↗
Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired magnetic resonance imaging.
INTRODUCTION: There are currently no studies systematically evaluating pulmonary vein (PV) stenosis following catheter ablation of atrial fibrillation (AF) using the anatomic PV ablation approach. METHODS AND RESULTS: Forty-one patients with AF underwent anatomic PV ablation under the guidance of a three-dimensional electroanatomic mapping system. Gadolinium-enhanced magnetic resonance (MR) imaging was performed in all patients prior to and 8-10 weeks after ablation procedures for screening of PV stenosis. A PV stenosis was defined as a detectable (> or =3 mm) narrowing in PV diameter. The severity of stenosis was categorized as mild (<50% stenosis), moderate (50-70%), or severe (>70%). A total 157 PVs were analyzed. A detectable PV narrowing was observed in 60 of 157 PVs (38%). The severity of stenosis was mild in 54 PVs (34%), moderate in five PVs (3.2%), and severe in one PV (0.6%). All mild PV stenoses displayed a concentric pattern. Moderate or severe PV stenosis was only observed in patients with an individual encircling lesion set. Multivariable analysis identified individual encircling lesion set and larger PV size as the independent predictors of detectable PV narrowing. All patients with PV stenosis were asymptomatic and none required treatment. CONCLUSIONS: The results of this study demonstrate that detectable PV narrowing occurs in 38% of PVs following anatomic PV ablation. Moderate or severe PV stenosis occurs in 3.8% of PVs. The high incidence of mild stenosis likely reflects reverse remodeling rather than pathological PV stenosis. The probability of moderate or severe PV stenosis appears to be related to creation of individual encircling rather than encircling in pairs lesion.
Adult↗
Characterization of a new pulmonary vein variant using magnetic resonance angiography: incidence, imaging, and interventional implications of the "right top pulmonary vein".
INTRODUCTION: Catheter ablation of the pulmonary veins (PVs) for prevention of recurrent atrial fibrillation requires precise anatomic information. We describe the characteristics of a new anatomic variant of PV anatomy using magnetic resonance angiography. METHODS AND RESULTS: A 1.5-T magnetic resonance imaging system with a body coil or a torso phased-array coil was used before and after gadolinium injection. Magnetic resonance angiograms were acquired with a breath-hold three-dimensional fast spoiled gradient-echo imaging sequence in the coronal plane. Three-dimensional reconstruction with maximum intensity projections and multiplanar reformations was performed. A newly described variant PV ascending from the roof of the left atrium was found in 3 of 91 subjects. The mean ostial diameter of the roof PV was 7 +/- 2 mm, the mean distance from the ostium to the first branching point was 22 +/- 8.5 mm, and the mean distance to the right superior PV was 3.3 +/- 0.6 mm. CONCLUSION: We refer to the newly described variant of PV anatomy as the "right top pulmonary vein." It is important to be aware of this anatomic pattern to avoid inadvertent catheter intubation, which can result in misleading mapping results and PV stenosis.
Adult↗
Pulsed Doppler echocardiographic assessment of extraparenchymal pulmonary vein flow.
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.
Adolescent↗