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(Circulation. 2006;113:e743-e744.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Compression of the Pulmonary Vein After Right-Sided Pneumonectomy

S.A. Smulders, MD; J.T. Marcus, PhD; S. Holverda, MSc; M.A. Paul, MD, PhD; P.E. Postmus, MD, PhD; A. Vonk-Noordegraaf, MD, PhD

From the Department of Pulmonology (S.A.S., S.H., P.E.P., A.V.-N.), Department of Physics and Medical Technology (J.T.M.), and Department of Surgery (M.A.P.), VU University Medical Centre/Institute for Cardiovascular Research ICaR-VU, Amsterdam, the Netherlands.

Correspondence to Dr A. Vonk-Noordegraaf, VUMC, Department of Pulmonology, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands. E-mail a.vonk{at}vumc.nl

Six years after right pneumonectomy, a 67-year-old man had progressive dyspnea during exercise. He was admitted to the hospital because of severe dyspnea after some exercise. The chest radiograph showed signs of pulmonary edema, which improved rapidly after furosemide and oxygen therapy. There were no signs of tumor recurrence or airway obstruction on computed tomography. Pulmonary function tests were not changed compared with the years before (forced expiratory volume in 1 second, 2.1 L/s; diffusion capacity for carbon monoxide, 70% of predicted). Cardiopulmonary exercise testing showed a decreased peak workload (44% of predicted), together with a low peak O₂ pulse (48% of predicted) and a normal breathing reserve of 30%. Echocardiography showed normal left ventricular function. For further analysis of the heart and pulmonary vasculature, magnetic resonance imaging (MRI) analysis was performed. This showed compression of the left upper pulmonary vein between the left atrium and descending aorta (Figure 1, left). Stroke volume was measured by flow velocity quantification and was 40 mL, with a cardiac index of 1.8 L/m². For this reason, a rethoracotomy was performed for the repositioning of the heart and placement of 2 silicone prostheses inside the pleural cavity (Figure 1, right). Flow measurement results performed using MRI orthogonal to the left upper pulmonary vein before and after the thoracotomy are presented in Figure 2. Six months after the rethoracotomy, the patient had no complaints of shortness of breath, and his exercise capacity was 88% of what was predicted. Stroke volume and cardiac index at that time were 86 mL and 4 L/m², respectively.

View larger version (84K): [in this window] [in a new window]   Figure 1. MRI images before (left) and after (right) operation. Obstruction of the pulmonary vein (arrow) is removed by repositioning of the heart. Images show the first temporal phase after the ECG R wave.

View larger version (14K): [in this window] [in a new window]   Figure 2. Flow measurement results during 1 cardiac cycle performed using MRI in the left upper pulmonary vein before (dashed line) and after (solid line) thoracotomy. Time (in milliseconds) after ECG R wave is shown on the x axis; flow through the pulmonary vein (in milliliters per second) is on the y axis. Pre-op indicates preoperative flow measurement results (dashed line); post-op, postoperative flow measurement results (black line).

This case demonstrates that compression of pulmonary veins, caused by shifting of heart and mediastinum to the operated side after pneumonectomy, might result in severe complaints and pulmonary congestion. It improves after reestablishing the normal diameter of these vessels.

	Acknowledgments

 
Disclosures

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Issue Highlights
Circulation 2006 113: 2165. [Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Smulders, S.A. Articles by Vonk-Noordegraaf, A. Search for Related Content PubMed PubMed Citation Articles by Smulders, S.A. Articles by Vonk-Noordegraaf, A. Related Collections Other heart failure CT and MRI Related Article