- Email: [email protected]
Left Anomalous Brachiocephalic Vein in a Patient With Right Lung Cancer
Ann Thorac Surg 2013;96:307–9
References 1. Nataf P, Pavie A, Jault F, Bors V, Cabrol C, Gandjbakhch I. Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus. Ann Thorac Surg 1994;58:163–7. 2. Wang A, Athan E, Pappas P, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;297:1354 – 61. 3. Gandjbakhch I, Lascar M, Pavie A, Mesnildrey P, Cabrol C. Intra-atrial implantation of the mitral valve. [Article in French] Press Med 1983;12:1723– 4. 4. David T, Feindel C, Armstrong S, Sun Z. Reconstruction of the mitral annulus. A ten year experience. J Thorac Cardiovasc Surg 1995;110:1323–32. 5. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Mitral valve replacement with a collar-reinforced prosthetic © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
307
valve for disrupted mitral annulus. Ann Thorac Surg 1995;59:187–9. 6. Karck M, Siclari F, Wahlig H, Sperling U, Schmid C, Haverich A. Pretreatment of prosthetic valve sewing-ring with the antibiotic/fibrin sealant compound as a prophylactic tool against prosthetic valve endocarditis. Eur J Cardiothorac Surg 1990;4:142– 6. 7. Edmiston C, Goheen M, Seabrook G, et al. Impact of selective antimicrobial agents on staphylococcal adherence to biomedical devices. Am J Surg 2006;192:344 –54.
Left Anomalous Brachiocephalic Vein in a Patient With Right Lung Cancer Ryota Nakamura, MD, Inage Yoshihisa, Kenichi Iwasaki, Tetsuya Yumoto, Kenji Yuzawa, and Hamaichi Ueki Department of Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan
The left anomalous brachiocephalic vein is a rare anomaly without congenital heart disease. It is important to recognize this anomalous vein especially in patients with lung cancer because misinterpretation as a superior mediastinal lymph node enlargement may cause serious complications. We report a case of a 62-year-old lung cancer patient with left anomalous brachiocephalic vein, who underwent surgical treatment safely under videoassisted thoracoscopic surgery after confirmation of this anomaly on contrast-enhanced computed tomographic scan. (Ann Thorac Surg 2013;96:307–9) © 2013 by The Society of Thoracic Surgeons
T
he brachiocephalic vein is formed by the internal jugular vein and the subclavian vein in the superior mediastinum. The left brachiocephalic vein usually locates superior and anterior to the aortic arch and passes obliquely downward, and the right brachiocephalic vein passes steeply downward behind the manubrium. They join to form the superior vena cava. The subaortic left brachiocephalic vein (SLBCV) is one of the types of congenital anomalous left brachiocephalic vein (ALBCV) [1]. The SLBCV passes lateral to the aortic arch and crosses under the aortic arch and joins to the superior vena cava (SVC) near the azygos connection. The SLBCV itself is asymptomatic and may be detected incidentally. Recognition of an anomalous left brachiocephalic vein by contrast-enhanced computed tomography (CT) is important for avoiding misinterpretation of the anomaly as an enlarged lymph node. We present, herein, a lung cancer patient with SLBCV, which was incidentally diagnosed by preoperative contrast-enhanced CT. We performed
Accepted for publication Nov 12, 2012. Address correspondence to Dr Nakamura, Department of Surgery, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibarakimachi, Higashiibarakigun, Ibaraki 311-3193, Japan; e-mail: ryo-naka@ mail.goo.ne.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.11.030
FEATURE ARTICLES
leakage and bleeding in patients with thin atrial tissues [1]. In our patient, the left atrial wall was thickened and capable of tolerating ventricular pressures, however, and did not dilate and form an aneurysm. The nondissected firm pericardial adhesion that surrounded the left atrium apparently was a secure anchor for valve sutures, reducing transmission of the shear force into the suture line. Although the original translocation was performed through a left atriotomy, a transseptal approach without dissection of the left atrial adhesion would be desirable to ensure firm fixation of the prosthesis. Furthermore, the use of a low-profile collared mechanical valve and fixation with pledgeted everting mattress sutures not only maintains a proper distance of the first-row suture line from the valve ring but also may help to disperse, and so reduce, the shear stress on the atrial suture line. Infection of the prosthesis begins at the sewing ring and extends to the interface between the prosthesis and the implantation site, forming a paravalvular abscess. Prevention of relapse is therefore dependent mainly on good isolation and antibiotic protection of the cuff from infectious foci and the bloodstream. Pretreatment of the sewing cuff with an antibioticfibrin compound, along with the pericardial sewing ring cover, appears to be effective in maintaining adequate local antibiotic levels and infection resistance through delayed antibiotic release [6]. It has been postulated in several reports that polyester samples soaked with antibiotic and fibrin sealant released the drug continuously for 3 weeks in contrast to samples pretreated with antibiotic alone [6]. Moreover, linezolid has greater affinity for tissue and greater speed in eradicating microbial adherence of methicillinresistant staphylococcal isolates [7]. The pericardial cover is also effective in preventing microembolism of the fibrin sealant and preserving topical binding of adequate quantities of linezolid for several weeks [6]. In summary, modified intraatrial translocation of the prosthetic mitral valve and shielding of the sewing ring with an antibiotic-fibrin compound appears to be a feasible surgical option to recover from severe prosthetic valve endocarditis with valvular abscess caused by methicillin-resistant gram-positive cocci in the mitral position.
CASE REPORT NAKAMURA ET AL SLBCV WITH RIGHT LUNG CANCER
308
CASE REPORT NAKAMURA ET AL SLBCV WITH RIGHT LUNG CANCER
Fig 1. Contrast-enhanced computed tomographic scan showed that subaortic left brachiocephalic vein (arrow) was crossed under the aortic arch and connected to the superior vena cava (arrow).
the operation under video-assisted thoracoscopic surgery (VATS) safely after confirmation of this anomalous vein.
FEATURE ARTICLES
The patient was a 62-year-old male who received chest screening CT that detected a 10-mm diameter nodule in the right lower lobe 2 years ago. A follow-up noncontrast-enhanced CT demonstrated that the nodule increased in size up to 20 mm in diameter and there also was a vessel-like shadow, which was connected between the SVC to aortic arch in the pretracheal space. He was introduced to our hospital as suspicious for lung cancer. The contrast-enhanced CT demonstrated a 20-mm diameter lobulated nodule in the right lower lobe without enlargement of the mediastinal lymph node. However, an anomalous SLBCV was observed clearly on contrastenhanced CT in which it crossed beneath the aortic arch, above the pulmonary artery, and anterior to the trachea (Figs 1;2). It was confluent to normal SVC nearby azygos vein connection. We performed an ultrasonic cardiogram in order to rule out congenital heart disease, and there was no abnormality. The patient underwent a right lower lobectomy with systemic lymph node dissection under VATS. We could perform lymph node dissection safely because we had preoperatively recognized an anomalous SLBCV (Fig 3). Pathologic examination showed squamous cell carcinoma and no lymph node metastasis.
Fig 2. Coronal view of the computed tomography clearly demonstrates subaortic left brachiocephalic vein (arrow) run through posterior to the aortic arch.
Ann Thorac Surg 2013;96:307–9
Fig 3. Intraoperative picture after lymph node dissection. Subaortic left brachiocephalic vein (arrow) run through beneath the aortic arch and connected to the azygos vein. They form the SVC. (Ao ⫽ ascending aorta; Az ⫽ azygos vein; SVC ⫽ superior vena cava; Tr ⫽ trachea.)
Postoperative course was uneventful and the patient was discharged on postoperative day 4.
Comment Usually, the left brachiocephalic vein is formed by the left internal jugular and the left subclavian vein in the superior mediastinum and passes superior-anterior to the aortic arch. Incidence of SLBCV, one of the most common types of ALBCV, is reported to be between 0.57% and 0.98% with congenital heart disease [2, 3]. However, the incidence is found to be 0.1% or less without congenital heart disease, as observed in our case [4]. According to Chen and colleagues [5], their theory suggested that 3 major components, which are precursors to the formation of an anomalous brachiocephalic vein during fetal development, are suggested. The first component is “a venous plexus forms between the bilateral anterior and common cardinal veins around the primitive aortic arch-pulmonary system that is ready to develop. Second, early arrest of the middle common cardinal vein forces the returned venous blood to run absolutely in a supracardiac direction. Third, the venous return finds the path of least resistance, governed by compression of the surrounding systemic and pulmonary arteries. In an anomalous brachiocephalic vein, the third component inhibits growth of the cephalic ventral portion of the venous plexus, which causes arch anomalies and preservation of the caudal dorsal portion through underdevelopment of the central pulmonary artery.” [5]. Takada and colleagues [1] classified ALBCV into 4 patterns. Pattern (A) is a type that crosses midline above the aortic arch and behind its major cephalic branch. Pattern (B) is a type that crosses midline beneath the aortic arch, above the pulmonary artery, and in front of the patent ductal arteriosus. Pattern (A⫹B) is defined as a hybrid of
patterns (A) and (B). Pattern (C) is that crossing the midline beneath the aortic arch, above the pulmonary artery, and behind the patent ductal arteriosus. Pattern (B), so-called subaortic type, SLBCV, is the most frequent type of ALBCV [1, 5], as observed in our case. Usually, SLBCV has no clinical symptoms if it may not be accompanied by any congenital heart disease. Therefore, it is difficult to find this anomalous vein in an adult case and most of them were incidentally detected on CT [4, 6]. To the best of our knowledge, we could not find any lung cancer patient with SLBCV. In our case, non-contrast-enhanced CT revealed a mass shadow under the retroaortic space. This shadow seemed to be connected into the SVC, but another side was considered to be connected to the aortic arch. At first we interpreted this shadow as a shunt vessel or enlarged lymph node. Performing a contrast-enhanced CT scan and careful evaluation of it made us understand that this was not an enlarged lymph node but SLBCV. Recently, non-contrast steady-state free precession magnetic resonance angiography provides high image quality for confident assessment of thoracic vascular diseases, including thoracic central veins, instead of contrast-enhanced CT [7]. It will be considered to use this technique to distinguish from vessels or not in patients with unsuitable contrast-enhanced CTs. In the operation, right side systemic lymph node dissection was defined that the superior mediastinal compartment, contained between the trachea, superior vena cava from the level of the azygos vein to the right subclavian artery, and the right recurrent laryngeal nerve, was dissected and the trachea, azygos vein, superior vena cava, and ascending aorta were completely freed from all tissue [8]. It was important to identify SLBCV preoperatively due to preventing any complication at the pretracheal space. Actually, we could undergo VATS lobectomy and systemic lymph node dissection safety. In conclusion, SLBCV is a rare condition in a lung cancer patient. Careful tracing chest CT is most important to distinguish SLBCV from enlargement lymph nodes and so on. The surgeon has to keep in mind this anomaly in patients with lung cancer when planning surgical treatment.
References 1. Takada Y, Narimatsu A, Kohno A, et al. Anomalous left brachiocephalic vein: CT findings. J Comput Assist Tomogr 1992;16:893– 6. 2. Choi JY, Jung MJ, Kim YH, Noh CI, Yun YS. Anomalous subaortic position of the brachiocephalic vein (innominate vein): an echocardiographic study. Br Heart J 1990;64:385–7. 3. Nagashima M, Shikata F, Okamura T, et al. Anomalous subaortic left brachiocephalic vein in surgical cases and literature review. Clin Anat 2010;23:950 –5. 4. Berko NS, Jain VR, Godelman A, Stein EG, Ghosh S, Haramati LB. Variants and anomalies of thoracic vasculature on computed tomographic angiography in adults. J Comput Assist Tomogr 2009;33:523– 8. © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT SHIINA ET AL TRICUSPID VALVE PLACEMENT AFTER BJORK PROCEDURE
309
5. Chen SJ, Liu KL, Chen HY, et al. Anomalous brachiocephalic vein: CT, embryology, and clinical implications. AJR Am J Roentgenol 2005;184:1235– 40. 6. Gülsün M, Gökog˘lu A, Ariyürek M, Demirkazik FB, Hazirolan T. Subaortic left brachiocephalic vein: computed tomography and magnetic resonance angiography findings. Surg Radiol Anat 2003;25:335– 8. 7. Tomasian A, Lohan DG, Laub G, Singhal A, Finn JP, Krishnam MS. Noncontrast 3D steady state free precession magnetic resonance angiography of the thoracic central veins using nonselective radiofrequency excitation over a large field of view: initial experience. Invest Radiol 2008;43:306 –13. 8. Naruke T, Suemasu K, Ishikawa S. Surgical treatment for lung cancer with metastasis to mediastinal lymph nodes. J Thorac Cardiovasc Surg 1976;71:279 – 85.
Tricuspid Valve Implantation After Bjork Procedure to Establish Biventricular Physiology Yumi Shiina, MD, PhD, Philip J. Kilner, MD, PhD, Anselm Uebing, MD, PhD, and Hideki Uemura, MD, FRCS Adult Congenital Heart Disease and Pulmonary Hypertension Unit, Cardiovascular Magnetic Resonance Unit, and Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
A 29-year-old male, who had undergone a Bjork procedure for tricuspid atresia with a ventricular septal defect, had redo surgery for relief of stenosis and systolic regurgitation of the right atrioventricular pathway. After revision using a valved bioprosthesis, effective biventricular physiology was established and the patient’s functional status improved. (Ann Thorac Surg 2013;96:309 –11) © 2013 by The Society of Thoracic Surgeons
T
he Bjork procedure [1] is known as an alternative to the Fontan type procedure in patients with tricuspid atresia (TA) with a ventricular septal defect (VSD). When the right ventricle (RV) has enough size and function, biventricular repair is desirable rather than univentricular repair. As its initial indication is limited, only a small number of reports have been published for surgical revision after this procedure. Here we describe a successful case that biventricular physiology was established by reconstruction of the right atrium (RA)-RV pathway and implantation of a bioprosthetic valve. A 29-year-old male (body surface area 1.9 m2) with TA with VSD was referred to our hospital because of his exercise intolerance [New York Heart Association class 2, maximum oxygen consumption of cardiopulmonary exercise test (CPET): 41% of the predicted value)]. He previously underwent a so-called Bjork procedure (conAccepted for publication Nov 12, 2012. Address correspondence to Dr Shiina, Adult Congenital Heart Disease and Pulmonary Hypertension Unit, Royal Brompton Hospital, Sydney St, London SW3 6NP, UK; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.11.032
FEATURE ARTICLES
Ann Thorac Surg 2013;96:309 –11
References 1. Nataf P, Pavie A, Jault F, Bors V, Cabrol C, Gandjbakhch I. Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus. Ann Thorac Surg 1994;58:163–7. 2. Wang A, Athan E, Pappas P, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;297:1354 – 61. 3. Gandjbakhch I, Lascar M, Pavie A, Mesnildrey P, Cabrol C. Intra-atrial implantation of the mitral valve. [Article in French] Press Med 1983;12:1723– 4. 4. David T, Feindel C, Armstrong S, Sun Z. Reconstruction of the mitral annulus. A ten year experience. J Thorac Cardiovasc Surg 1995;110:1323–32. 5. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Mitral valve replacement with a collar-reinforced prosthetic © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
307
valve for disrupted mitral annulus. Ann Thorac Surg 1995;59:187–9. 6. Karck M, Siclari F, Wahlig H, Sperling U, Schmid C, Haverich A. Pretreatment of prosthetic valve sewing-ring with the antibiotic/fibrin sealant compound as a prophylactic tool against prosthetic valve endocarditis. Eur J Cardiothorac Surg 1990;4:142– 6. 7. Edmiston C, Goheen M, Seabrook G, et al. Impact of selective antimicrobial agents on staphylococcal adherence to biomedical devices. Am J Surg 2006;192:344 –54.
Left Anomalous Brachiocephalic Vein in a Patient With Right Lung Cancer Ryota Nakamura, MD, Inage Yoshihisa, Kenichi Iwasaki, Tetsuya Yumoto, Kenji Yuzawa, and Hamaichi Ueki Department of Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan
The left anomalous brachiocephalic vein is a rare anomaly without congenital heart disease. It is important to recognize this anomalous vein especially in patients with lung cancer because misinterpretation as a superior mediastinal lymph node enlargement may cause serious complications. We report a case of a 62-year-old lung cancer patient with left anomalous brachiocephalic vein, who underwent surgical treatment safely under videoassisted thoracoscopic surgery after confirmation of this anomaly on contrast-enhanced computed tomographic scan. (Ann Thorac Surg 2013;96:307–9) © 2013 by The Society of Thoracic Surgeons
T
he brachiocephalic vein is formed by the internal jugular vein and the subclavian vein in the superior mediastinum. The left brachiocephalic vein usually locates superior and anterior to the aortic arch and passes obliquely downward, and the right brachiocephalic vein passes steeply downward behind the manubrium. They join to form the superior vena cava. The subaortic left brachiocephalic vein (SLBCV) is one of the types of congenital anomalous left brachiocephalic vein (ALBCV) [1]. The SLBCV passes lateral to the aortic arch and crosses under the aortic arch and joins to the superior vena cava (SVC) near the azygos connection. The SLBCV itself is asymptomatic and may be detected incidentally. Recognition of an anomalous left brachiocephalic vein by contrast-enhanced computed tomography (CT) is important for avoiding misinterpretation of the anomaly as an enlarged lymph node. We present, herein, a lung cancer patient with SLBCV, which was incidentally diagnosed by preoperative contrast-enhanced CT. We performed
Accepted for publication Nov 12, 2012. Address correspondence to Dr Nakamura, Department of Surgery, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibarakimachi, Higashiibarakigun, Ibaraki 311-3193, Japan; e-mail: ryo-naka@ mail.goo.ne.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.11.030
FEATURE ARTICLES
leakage and bleeding in patients with thin atrial tissues [1]. In our patient, the left atrial wall was thickened and capable of tolerating ventricular pressures, however, and did not dilate and form an aneurysm. The nondissected firm pericardial adhesion that surrounded the left atrium apparently was a secure anchor for valve sutures, reducing transmission of the shear force into the suture line. Although the original translocation was performed through a left atriotomy, a transseptal approach without dissection of the left atrial adhesion would be desirable to ensure firm fixation of the prosthesis. Furthermore, the use of a low-profile collared mechanical valve and fixation with pledgeted everting mattress sutures not only maintains a proper distance of the first-row suture line from the valve ring but also may help to disperse, and so reduce, the shear stress on the atrial suture line. Infection of the prosthesis begins at the sewing ring and extends to the interface between the prosthesis and the implantation site, forming a paravalvular abscess. Prevention of relapse is therefore dependent mainly on good isolation and antibiotic protection of the cuff from infectious foci and the bloodstream. Pretreatment of the sewing cuff with an antibioticfibrin compound, along with the pericardial sewing ring cover, appears to be effective in maintaining adequate local antibiotic levels and infection resistance through delayed antibiotic release [6]. It has been postulated in several reports that polyester samples soaked with antibiotic and fibrin sealant released the drug continuously for 3 weeks in contrast to samples pretreated with antibiotic alone [6]. Moreover, linezolid has greater affinity for tissue and greater speed in eradicating microbial adherence of methicillinresistant staphylococcal isolates [7]. The pericardial cover is also effective in preventing microembolism of the fibrin sealant and preserving topical binding of adequate quantities of linezolid for several weeks [6]. In summary, modified intraatrial translocation of the prosthetic mitral valve and shielding of the sewing ring with an antibiotic-fibrin compound appears to be a feasible surgical option to recover from severe prosthetic valve endocarditis with valvular abscess caused by methicillin-resistant gram-positive cocci in the mitral position.
CASE REPORT NAKAMURA ET AL SLBCV WITH RIGHT LUNG CANCER
308
CASE REPORT NAKAMURA ET AL SLBCV WITH RIGHT LUNG CANCER
Fig 1. Contrast-enhanced computed tomographic scan showed that subaortic left brachiocephalic vein (arrow) was crossed under the aortic arch and connected to the superior vena cava (arrow).
the operation under video-assisted thoracoscopic surgery (VATS) safely after confirmation of this anomalous vein.
FEATURE ARTICLES
The patient was a 62-year-old male who received chest screening CT that detected a 10-mm diameter nodule in the right lower lobe 2 years ago. A follow-up noncontrast-enhanced CT demonstrated that the nodule increased in size up to 20 mm in diameter and there also was a vessel-like shadow, which was connected between the SVC to aortic arch in the pretracheal space. He was introduced to our hospital as suspicious for lung cancer. The contrast-enhanced CT demonstrated a 20-mm diameter lobulated nodule in the right lower lobe without enlargement of the mediastinal lymph node. However, an anomalous SLBCV was observed clearly on contrastenhanced CT in which it crossed beneath the aortic arch, above the pulmonary artery, and anterior to the trachea (Figs 1;2). It was confluent to normal SVC nearby azygos vein connection. We performed an ultrasonic cardiogram in order to rule out congenital heart disease, and there was no abnormality. The patient underwent a right lower lobectomy with systemic lymph node dissection under VATS. We could perform lymph node dissection safely because we had preoperatively recognized an anomalous SLBCV (Fig 3). Pathologic examination showed squamous cell carcinoma and no lymph node metastasis.
Fig 2. Coronal view of the computed tomography clearly demonstrates subaortic left brachiocephalic vein (arrow) run through posterior to the aortic arch.
Ann Thorac Surg 2013;96:307–9
Fig 3. Intraoperative picture after lymph node dissection. Subaortic left brachiocephalic vein (arrow) run through beneath the aortic arch and connected to the azygos vein. They form the SVC. (Ao ⫽ ascending aorta; Az ⫽ azygos vein; SVC ⫽ superior vena cava; Tr ⫽ trachea.)
Postoperative course was uneventful and the patient was discharged on postoperative day 4.
Comment Usually, the left brachiocephalic vein is formed by the left internal jugular and the left subclavian vein in the superior mediastinum and passes superior-anterior to the aortic arch. Incidence of SLBCV, one of the most common types of ALBCV, is reported to be between 0.57% and 0.98% with congenital heart disease [2, 3]. However, the incidence is found to be 0.1% or less without congenital heart disease, as observed in our case [4]. According to Chen and colleagues [5], their theory suggested that 3 major components, which are precursors to the formation of an anomalous brachiocephalic vein during fetal development, are suggested. The first component is “a venous plexus forms between the bilateral anterior and common cardinal veins around the primitive aortic arch-pulmonary system that is ready to develop. Second, early arrest of the middle common cardinal vein forces the returned venous blood to run absolutely in a supracardiac direction. Third, the venous return finds the path of least resistance, governed by compression of the surrounding systemic and pulmonary arteries. In an anomalous brachiocephalic vein, the third component inhibits growth of the cephalic ventral portion of the venous plexus, which causes arch anomalies and preservation of the caudal dorsal portion through underdevelopment of the central pulmonary artery.” [5]. Takada and colleagues [1] classified ALBCV into 4 patterns. Pattern (A) is a type that crosses midline above the aortic arch and behind its major cephalic branch. Pattern (B) is a type that crosses midline beneath the aortic arch, above the pulmonary artery, and in front of the patent ductal arteriosus. Pattern (A⫹B) is defined as a hybrid of
patterns (A) and (B). Pattern (C) is that crossing the midline beneath the aortic arch, above the pulmonary artery, and behind the patent ductal arteriosus. Pattern (B), so-called subaortic type, SLBCV, is the most frequent type of ALBCV [1, 5], as observed in our case. Usually, SLBCV has no clinical symptoms if it may not be accompanied by any congenital heart disease. Therefore, it is difficult to find this anomalous vein in an adult case and most of them were incidentally detected on CT [4, 6]. To the best of our knowledge, we could not find any lung cancer patient with SLBCV. In our case, non-contrast-enhanced CT revealed a mass shadow under the retroaortic space. This shadow seemed to be connected into the SVC, but another side was considered to be connected to the aortic arch. At first we interpreted this shadow as a shunt vessel or enlarged lymph node. Performing a contrast-enhanced CT scan and careful evaluation of it made us understand that this was not an enlarged lymph node but SLBCV. Recently, non-contrast steady-state free precession magnetic resonance angiography provides high image quality for confident assessment of thoracic vascular diseases, including thoracic central veins, instead of contrast-enhanced CT [7]. It will be considered to use this technique to distinguish from vessels or not in patients with unsuitable contrast-enhanced CTs. In the operation, right side systemic lymph node dissection was defined that the superior mediastinal compartment, contained between the trachea, superior vena cava from the level of the azygos vein to the right subclavian artery, and the right recurrent laryngeal nerve, was dissected and the trachea, azygos vein, superior vena cava, and ascending aorta were completely freed from all tissue [8]. It was important to identify SLBCV preoperatively due to preventing any complication at the pretracheal space. Actually, we could undergo VATS lobectomy and systemic lymph node dissection safety. In conclusion, SLBCV is a rare condition in a lung cancer patient. Careful tracing chest CT is most important to distinguish SLBCV from enlargement lymph nodes and so on. The surgeon has to keep in mind this anomaly in patients with lung cancer when planning surgical treatment.
References 1. Takada Y, Narimatsu A, Kohno A, et al. Anomalous left brachiocephalic vein: CT findings. J Comput Assist Tomogr 1992;16:893– 6. 2. Choi JY, Jung MJ, Kim YH, Noh CI, Yun YS. Anomalous subaortic position of the brachiocephalic vein (innominate vein): an echocardiographic study. Br Heart J 1990;64:385–7. 3. Nagashima M, Shikata F, Okamura T, et al. Anomalous subaortic left brachiocephalic vein in surgical cases and literature review. Clin Anat 2010;23:950 –5. 4. Berko NS, Jain VR, Godelman A, Stein EG, Ghosh S, Haramati LB. Variants and anomalies of thoracic vasculature on computed tomographic angiography in adults. J Comput Assist Tomogr 2009;33:523– 8. © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT SHIINA ET AL TRICUSPID VALVE PLACEMENT AFTER BJORK PROCEDURE
309
5. Chen SJ, Liu KL, Chen HY, et al. Anomalous brachiocephalic vein: CT, embryology, and clinical implications. AJR Am J Roentgenol 2005;184:1235– 40. 6. Gülsün M, Gökog˘lu A, Ariyürek M, Demirkazik FB, Hazirolan T. Subaortic left brachiocephalic vein: computed tomography and magnetic resonance angiography findings. Surg Radiol Anat 2003;25:335– 8. 7. Tomasian A, Lohan DG, Laub G, Singhal A, Finn JP, Krishnam MS. Noncontrast 3D steady state free precession magnetic resonance angiography of the thoracic central veins using nonselective radiofrequency excitation over a large field of view: initial experience. Invest Radiol 2008;43:306 –13. 8. Naruke T, Suemasu K, Ishikawa S. Surgical treatment for lung cancer with metastasis to mediastinal lymph nodes. J Thorac Cardiovasc Surg 1976;71:279 – 85.
Tricuspid Valve Implantation After Bjork Procedure to Establish Biventricular Physiology Yumi Shiina, MD, PhD, Philip J. Kilner, MD, PhD, Anselm Uebing, MD, PhD, and Hideki Uemura, MD, FRCS Adult Congenital Heart Disease and Pulmonary Hypertension Unit, Cardiovascular Magnetic Resonance Unit, and Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
A 29-year-old male, who had undergone a Bjork procedure for tricuspid atresia with a ventricular septal defect, had redo surgery for relief of stenosis and systolic regurgitation of the right atrioventricular pathway. After revision using a valved bioprosthesis, effective biventricular physiology was established and the patient’s functional status improved. (Ann Thorac Surg 2013;96:309 –11) © 2013 by The Society of Thoracic Surgeons
T
he Bjork procedure [1] is known as an alternative to the Fontan type procedure in patients with tricuspid atresia (TA) with a ventricular septal defect (VSD). When the right ventricle (RV) has enough size and function, biventricular repair is desirable rather than univentricular repair. As its initial indication is limited, only a small number of reports have been published for surgical revision after this procedure. Here we describe a successful case that biventricular physiology was established by reconstruction of the right atrium (RA)-RV pathway and implantation of a bioprosthetic valve. A 29-year-old male (body surface area 1.9 m2) with TA with VSD was referred to our hospital because of his exercise intolerance [New York Heart Association class 2, maximum oxygen consumption of cardiopulmonary exercise test (CPET): 41% of the predicted value)]. He previously underwent a so-called Bjork procedure (conAccepted for publication Nov 12, 2012. Address correspondence to Dr Shiina, Adult Congenital Heart Disease and Pulmonary Hypertension Unit, Royal Brompton Hospital, Sydney St, London SW3 6NP, UK; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.11.032
FEATURE ARTICLES
Ann Thorac Surg 2013;96:309 –11