- Email: [email protected]
Decompressing extrinsic pulmonary vein obstruction
Accepted Manuscript Decompressing extrinsic pulmonary vein obstruction Rachel D. Vanderlaan, Christopher A. Caldarone PII:
S0022-5223(17)32188-8
DOI:
10.1016/j.jtcvs.2017.09.128
Reference:
YMTC 12085
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 28 September 2017 Accepted Date: 29 September 2017
Please cite this article as: Vanderlaan RD, Caldarone CA, Decompressing extrinsic pulmonary vein obstruction, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/ j.jtcvs.2017.09.128. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Decompressing extrinsic pulmonary vein obstruction
SC
Rachel D Vanderlaan 1 and Christopher A Caldarone 2
RI PT
ACCEPTED MANUSCRIPT
University of Toronto, Division of Cardiac Surgery, Toronto Canada
2
Hospital for Sick Children, Division of Cardiovascular Surgery, Toronto Canada
TE D
Funding: no funding source
EP
Correspondence: Rachel D Vanderlaan
AC C
[email protected] Hospital for Sick Children 555 University Ave
Rm 1518b Hill Wing
Toronto ON Canada M5G 1X8
M AN U
1
Rachel D Vanderlaan 1 and Christopher A Caldarone 2
SC
Decompressing extrinsic pulmonary vein obstruction
RI PT
ACCEPTED MANUSCRIPT
University of Toronto, Division of Cardiac Surgery, Toronto Canada
2
Hospital for Sick Children, Division of Cardiovascular Surgery, Toronto Canada
Correspondence:
EP
TE D
Funding: no funding source
M AN U
1
AC C
Rachel D Vanderlaan
[email protected] Hospital for Sick Children 555 University Ave
Rm 1518b Hill Wing
Toronto ON Canada M5G 1X8
ACCEPTED MANUSCRIPT
Title: Decompressing extrinsic pulmonary vein obstruction
Central Message:
RI PT
Pulmonary venous obstruction/stenosis (PVS) can result from extrinsic compression by intrathoracic structures. Relief of PVS using aortopexy is a novel surgical approach to add to the armamentarium.
A.
B.
LA
LPV Ao
M AN U
LA
SC
Central Figure:
Ao
LPV
Key words:
EP
TE D
Figure 1. Relief of external compression of the left pulmonary vein (1A) following heart transplantation (1B). 1A. External compression of the left lower pulmonary vein in a child with single ventricle physiology. Anterior location of the descending aorta and cardiomegaly are risk factors for developing pulmonary venous obstruction. 1B. Heart transplantation relieved external compression of the pulmonary vein and follow up demonstrated no residual pulmonary venous obstruction. Ao, aorta; LA, left atrium; LPV left pulmonary vein
AC C
Pulmonary vein obstruction, pulmonary vein stenosis, external compression, aortopexy
ACCEPTED MANUSCRIPT
RI PT
The more frequent use of computed tomography (CT) and magnetic resonance imaging (MRI) in the work up of pulmonary vein pathology has led to an increased awareness of the role of external compression from intrathoracic structures in pulmonary venous obstruction/stenosis (PVS). Early identification of external compression as a primary contributor to PVS requires consideration of alternative repair approaches to the commonly used sutureless repair, which best addresses intraluminal PVS near the veno-atrial junction.
M AN U
SC
In contrast to the well described intracardiac repair for intraluminal PVS, description and surgical approaches to external compression of the pulmonary veins is limited. In single ventricle patients, the left lower pulmonary vein can traverse anterior to the descending aorta as it enters posteriorly into the atrium (1-3) and in the context of cardiomegaly and anterolateral positioning of the descending aorta, this can be a risk factor for left sided pulmonary vein obstruction (4). In addition, compression of the left lower pulmonary vein between the descending aorta and dilated coronary sinus has also been described, with decompression occurring with coronary sinus plasty (5). While not formally investigated, the presence of a persistent left superior vena cava (SVC) has been hypothesized to impact on the left atrial and pulmonary vein development and potentially increasing the risk for subsequent left pulmonary vein obstruction (5).
EP
TE D
In this issue of the Journal, Kotani et al. describe a case of pulmonary venous obstruction resulting from abnormal anatomical relationships of the left pulmonary vein, descending aorta and left atrium after reimplantation of a persistent left SVC. Using a left thoracotomy approach, they used an aortopexy technique to relocate the aorta more posterior, and plicated the redundant left atrial tissue to relieve pulmonary vein obstruction. In left main stem bronchial compression, posterior descending aortopexy has proven useful (6), and thus extrapolation of this technique to an isolated compressed left lower pulmonary vein prior to progression of neointimal lesions into the intraparenchymal pulmonary veins is advantageous, as the extracardiac repair avoids direct manipulation of the pulmonary veins.
AC C
The use of isolated extracardiac repair for PVS requires an individualized approach to the patient, and factors such as associated cardiomegaly may limit the effectiveness of an isolated aortopexy. As an example, left PVS in a child with left pulmonary vein compression due to cardiomegaly and an anterior descending aorta, transplantation provided sufficient decompression without additional repair to the pulmonary veins or aorta (Figure 1A,1B). Neointimal formation in intraparenchymal veins can occur with long standing compression (7) and therefore timing and extent of intraluminal PVS are important considerations when undertaking an isolated extracardiac repair. Just as close surveillance with echocardiography and CT/MRI is required in primary or post repair PVS, vigilant surveillance following extracardiac repair is required to ensure adequate decompression and no further progression of PVS. When presented with a child with suspected PVS, CT/MR imaging should be used to define anatomical relationships of intrathoracic structures and their contribution to PVS. Aortopexy of
ACCEPTED MANUSCRIPT
an antero-lateral descending aorta is an innovative extracardiac approach that can be added to the current techniques to surgically treat PVS.
RI PT
References:
1. O'Donnell CP, Lock JE, Powell AJ, Perry SB. Compression of pulmonary veins between the left atrium and the descending aorta. Am J Cardiol.
SC
91(2003), pp. 248-51.
M AN U
2. Ho I, Heist EK, Aryana A, Mela T, d'Avila A, Ruskin J, Mansour M. Compression of the left atrium by the thoracic aorta in patients undergoing pulmonary vein isolation procedure for atrial fibrillation. J Interv Card Electrophysiol. 19(2007), pp. 29-36.
TE D
3. Kawahira Y, Kadoba K, Matsuda H. Compression of the pulmonary veins by the descending aorta in patients corrected surgically by the Fontan procedure. Cardiol Young. 8 (1998), pp. 86-9.
EP
4. Kotani Y, Zhu J, Grosse-Wortmann L, Honjo O, Coles JG, Van Arsdell GS, Caldarone CA. Anatomical risk factors, surgical treatment, and clinical outcomes
AC C
of left-sided pulmonary vein obstruction in single-ventricle patients. J Thorac Cardiovasc Surg. 149 (2015), pp. 1332-8.
5. Kalfa D, Lai W, Ferris A, Krishnan U, Bacha E. Technique of coronary sinus plasty for left pulmonary vein stenosis. Ann Thorac Surg. 98 (2014), e27-9.
6. Weber TR, Keller MS, Fiore A. Aortic suspension (aortopexy) for severe
ACCEPTED MANUSCRIPT
tracheomalacia in infants and children. Am J Surg. 184 (2002), pp. 573-7.
7. Kato H, Fu YY, Zhu J, Wang L, Aafaqi S, Rahkonen O, Slorach C, Traister A,
RI PT
Leung CH, Chiasson D, Mertens L, Benson L, Weisel RD, Hinz B, Maynes JT, Coles JG, Caldarone CA. Pulmonary vein stenosis and the pathophysiology of "upstream"
AC C
EP
TE D
M AN U
SC
pulmonary veins. J Thorac Cardiovasc Surg. 148 (2014), pp. 245-53.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0022-5223(17)32188-8
DOI:
10.1016/j.jtcvs.2017.09.128
Reference:
YMTC 12085
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 28 September 2017 Accepted Date: 29 September 2017
Please cite this article as: Vanderlaan RD, Caldarone CA, Decompressing extrinsic pulmonary vein obstruction, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/ j.jtcvs.2017.09.128. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Decompressing extrinsic pulmonary vein obstruction
SC
Rachel D Vanderlaan 1 and Christopher A Caldarone 2
RI PT
ACCEPTED MANUSCRIPT
University of Toronto, Division of Cardiac Surgery, Toronto Canada
2
Hospital for Sick Children, Division of Cardiovascular Surgery, Toronto Canada
TE D
Funding: no funding source
EP
Correspondence: Rachel D Vanderlaan
AC C
[email protected] Hospital for Sick Children 555 University Ave
Rm 1518b Hill Wing
Toronto ON Canada M5G 1X8
M AN U
1
Rachel D Vanderlaan 1 and Christopher A Caldarone 2
SC
Decompressing extrinsic pulmonary vein obstruction
RI PT
ACCEPTED MANUSCRIPT
University of Toronto, Division of Cardiac Surgery, Toronto Canada
2
Hospital for Sick Children, Division of Cardiovascular Surgery, Toronto Canada
Correspondence:
EP
TE D
Funding: no funding source
M AN U
1
AC C
Rachel D Vanderlaan
[email protected] Hospital for Sick Children 555 University Ave
Rm 1518b Hill Wing
Toronto ON Canada M5G 1X8
ACCEPTED MANUSCRIPT
Title: Decompressing extrinsic pulmonary vein obstruction
Central Message:
RI PT
Pulmonary venous obstruction/stenosis (PVS) can result from extrinsic compression by intrathoracic structures. Relief of PVS using aortopexy is a novel surgical approach to add to the armamentarium.
A.
B.
LA
LPV Ao
M AN U
LA
SC
Central Figure:
Ao
LPV
Key words:
EP
TE D
Figure 1. Relief of external compression of the left pulmonary vein (1A) following heart transplantation (1B). 1A. External compression of the left lower pulmonary vein in a child with single ventricle physiology. Anterior location of the descending aorta and cardiomegaly are risk factors for developing pulmonary venous obstruction. 1B. Heart transplantation relieved external compression of the pulmonary vein and follow up demonstrated no residual pulmonary venous obstruction. Ao, aorta; LA, left atrium; LPV left pulmonary vein
AC C
Pulmonary vein obstruction, pulmonary vein stenosis, external compression, aortopexy
ACCEPTED MANUSCRIPT
RI PT
The more frequent use of computed tomography (CT) and magnetic resonance imaging (MRI) in the work up of pulmonary vein pathology has led to an increased awareness of the role of external compression from intrathoracic structures in pulmonary venous obstruction/stenosis (PVS). Early identification of external compression as a primary contributor to PVS requires consideration of alternative repair approaches to the commonly used sutureless repair, which best addresses intraluminal PVS near the veno-atrial junction.
M AN U
SC
In contrast to the well described intracardiac repair for intraluminal PVS, description and surgical approaches to external compression of the pulmonary veins is limited. In single ventricle patients, the left lower pulmonary vein can traverse anterior to the descending aorta as it enters posteriorly into the atrium (1-3) and in the context of cardiomegaly and anterolateral positioning of the descending aorta, this can be a risk factor for left sided pulmonary vein obstruction (4). In addition, compression of the left lower pulmonary vein between the descending aorta and dilated coronary sinus has also been described, with decompression occurring with coronary sinus plasty (5). While not formally investigated, the presence of a persistent left superior vena cava (SVC) has been hypothesized to impact on the left atrial and pulmonary vein development and potentially increasing the risk for subsequent left pulmonary vein obstruction (5).
EP
TE D
In this issue of the Journal, Kotani et al. describe a case of pulmonary venous obstruction resulting from abnormal anatomical relationships of the left pulmonary vein, descending aorta and left atrium after reimplantation of a persistent left SVC. Using a left thoracotomy approach, they used an aortopexy technique to relocate the aorta more posterior, and plicated the redundant left atrial tissue to relieve pulmonary vein obstruction. In left main stem bronchial compression, posterior descending aortopexy has proven useful (6), and thus extrapolation of this technique to an isolated compressed left lower pulmonary vein prior to progression of neointimal lesions into the intraparenchymal pulmonary veins is advantageous, as the extracardiac repair avoids direct manipulation of the pulmonary veins.
AC C
The use of isolated extracardiac repair for PVS requires an individualized approach to the patient, and factors such as associated cardiomegaly may limit the effectiveness of an isolated aortopexy. As an example, left PVS in a child with left pulmonary vein compression due to cardiomegaly and an anterior descending aorta, transplantation provided sufficient decompression without additional repair to the pulmonary veins or aorta (Figure 1A,1B). Neointimal formation in intraparenchymal veins can occur with long standing compression (7) and therefore timing and extent of intraluminal PVS are important considerations when undertaking an isolated extracardiac repair. Just as close surveillance with echocardiography and CT/MRI is required in primary or post repair PVS, vigilant surveillance following extracardiac repair is required to ensure adequate decompression and no further progression of PVS. When presented with a child with suspected PVS, CT/MR imaging should be used to define anatomical relationships of intrathoracic structures and their contribution to PVS. Aortopexy of
ACCEPTED MANUSCRIPT
an antero-lateral descending aorta is an innovative extracardiac approach that can be added to the current techniques to surgically treat PVS.
RI PT
References:
1. O'Donnell CP, Lock JE, Powell AJ, Perry SB. Compression of pulmonary veins between the left atrium and the descending aorta. Am J Cardiol.
SC
91(2003), pp. 248-51.
M AN U
2. Ho I, Heist EK, Aryana A, Mela T, d'Avila A, Ruskin J, Mansour M. Compression of the left atrium by the thoracic aorta in patients undergoing pulmonary vein isolation procedure for atrial fibrillation. J Interv Card Electrophysiol. 19(2007), pp. 29-36.
TE D
3. Kawahira Y, Kadoba K, Matsuda H. Compression of the pulmonary veins by the descending aorta in patients corrected surgically by the Fontan procedure. Cardiol Young. 8 (1998), pp. 86-9.
EP
4. Kotani Y, Zhu J, Grosse-Wortmann L, Honjo O, Coles JG, Van Arsdell GS, Caldarone CA. Anatomical risk factors, surgical treatment, and clinical outcomes
AC C
of left-sided pulmonary vein obstruction in single-ventricle patients. J Thorac Cardiovasc Surg. 149 (2015), pp. 1332-8.
5. Kalfa D, Lai W, Ferris A, Krishnan U, Bacha E. Technique of coronary sinus plasty for left pulmonary vein stenosis. Ann Thorac Surg. 98 (2014), e27-9.
6. Weber TR, Keller MS, Fiore A. Aortic suspension (aortopexy) for severe
ACCEPTED MANUSCRIPT
tracheomalacia in infants and children. Am J Surg. 184 (2002), pp. 573-7.
7. Kato H, Fu YY, Zhu J, Wang L, Aafaqi S, Rahkonen O, Slorach C, Traister A,
RI PT
Leung CH, Chiasson D, Mertens L, Benson L, Weisel RD, Hinz B, Maynes JT, Coles JG, Caldarone CA. Pulmonary vein stenosis and the pathophysiology of "upstream"
AC C
EP
TE D
M AN U
SC
pulmonary veins. J Thorac Cardiovasc Surg. 148 (2014), pp. 245-53.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT