Compression of the Pulmonary Vein After Right-Sided Pneumonectomy
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.
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.