Higher small pulmonary artery and vein volume on computed tomography is associated with mortality in current and former smokers.

BACKGROUND: In chronic obstructive pulmonary disease (COPD), vascular alterations have been shown to contribute to hypoxia and pulmonary hypertension, but the independent contribution of small vessel abnormalities to mortality remains unclear. METHODS: We quantified artery and vein dimensions on computed tomography (CT) down to 0.2 mm. Small vessel volumes (<1 mmᴓ) were normalized by body surface area. In 7903 current and former smokers of the COPDGene study (53.2% male) the independent contribution of small artery and small vein volume to all-cause mortality was tested in multivariable Cox models. Additionally, we calculated the 95th percentile of small arteries and veins in 374 never smokers to create two groups: normal and high small artery or vein volume. We describe clinical, physiological and imaging characteristics of subjects with a high small artery and high small vein volume. FINDINGS: Both high small artery and high small vein volumes were independently associated with mortality with an adjusted hazard ratio of 1.07 [1.01, 1.14] and 1.34 [1.21, 1.49] per mL/m2 increase, respectively. In COPDGene, 447 (5.7%) had high small artery volume and 519 (9.1%) subjects had high small vein volume and both had more emphysema, more air trapping and more severe coronary calcium. INTERPRETATION: In smokers, abnormally high volumes in small arteries and veins are both relevant for mortality, which urges investigations into the aetiology of small pulmonary vessels and cardiac function in smokers. FUNDING: Award Number U01-HL089897 and U01-HL089856 from the NHLBI. COPD Foundation with contributions from AstraZeneca, Boehringer Ingelheim, Genentech, GlaxoSmithKline, Novartis, Pfizer, Siemens, and Sunovion.

Endovascular embolization of a congenital inferior phrenic artery-to-pulmonary arteriovenous malformation: a rare case report.

BACKGROUND: Pulmonary arteriovenous malformation (PAVM) is abnormal arteriovenous shunts between pulmonary artery (PA) and pulmonary vein, and rarely has congenital direct communications with systemic arteries. CASE PRESENTATION: A 33-year-old male presented to our hospital with intermittent bloody sputum with no evidence of pulmonary infection, trauma or surgery. Chest computed tomography angiography (CTA) indicated the congenital inferior phrenic artery (IPA)-to-PAVM surrounded by diffuse alveolar hemorrhage located in the lower lobe of right lung. Both the afferent PA and IPA were successfully embolized with coils. Recurrent hemoptysis did not occur during one-year follow up. CONCLUSIONS: The congenital communication between IPA and PAVM is rare, and the abnormal direct shunt would induce hemodynamically unstable condition within PAVM. Endovascular embolization of the afferent PA and IPA is a safe and effective method for this abnormal congenital shunt in lung.

Left pulmonary vein anatomical variation in Turner syndrome. Benefits of three-dimensional visualization for surgical planning.

A 41 year-old female with a medical history of Turner syndrome underwent a chest computed tomography (CT) scan which revealed a varicose left pulmonary vein and an endobronchial tumor of the left lower lobe. As venous drainage of each lobe seemed to be respected, surgical resection was considered. During surgical exploration, the absence of fissure and a unique venous trunk was observed. Surgical resection was aborted as only pneumonectomy was possible in this context. Endobronchial resection was performed. To better understand this particular anatomy, a three-dimensional (3D) reconstruction was performed a posteriori. This technique is already commonly used in the preoperative planning of pulmonary segmentectomy. Here, we have shown its interest in a lung malformative context.

Multimodal ultrasound imaging for patent foramen ovale and pulmonary arteriovenous malformation in patients with cryptogenic stroke or migraine: A prospective diagnostic study.

Right-to-left shunt (RLS) caused by patent foramen ovale (PFO) and pulmonary arteriovenous malformations (PAVM) have been associated with a variety of diseases, and reliable techniques for detecting RLS are essential for diagnosis. This study aimed to compare the diagnostic accuracy of multimodal ultrasound imaging, including transthoracic echocardiography (TTE) plus contrast transthoracic echocardiography (CTTE) and transesophageal echocardiography (TEE) plus contrast transesophageal echocardiography (CTEE) for PFO and PAVM in patients with cryptogenic stroke or migraine. This prospective study enrolled patients with cryptogenic stroke or migraine admitted to First Hospital of Shanxi Medical University between July 2018 and April 2023. The TTE + CTTE + TEE + CTEE multimodal ultrasound imaging was defined as the gold standard. A total of 230 patients with cryptogenic stroke (108) or migraine (122) were enrolled. The TEE + CTEE generated a better area under the receiver operator characteristic (ROC) curves (AUC) than TTE + CTTE [0.995 (0.988-1.000) vs 0.975 (0.767-0.984), P < .001], indicating better identification of PFO and PAVM. The sensitivity and specificity of the TTE + CTTE were 89.4% and 85.7%, respectively, whereas the sensitivity and specificity of TEE + CTEE were 99.1% and 100%, respectively. The missed diagnosis rate of TTE + CTTE and TEE + CTEE was 65.7 % and 12.5%, respectively. The combination of TEE + CTEE may be a more reliable and sensitive tool to detect PFO and PAVM than TTE + CTTE in patients with cryptogenic stroke or migraine.

Evaluation of the associations of pulmonary vein vertical diameter, cardiothoracic ratio, and atrial fibrillation combined hiatal hernia.

Recent studies have suggested that there may be a relationship between hiatal hernia (HH) and atrial fibrillation (AF), but the specific mechanism is unclear. The aim of this study was to explore the clinical characteristics associated with HH and AF and to identify the potential relationship between the 2 diseases. The study comprised 180 patients with HH, of which 54 had AF. Every patient had chest computed tomography to quantify the cardiothoracic ratio, HH volume, thoracic cavity volume, and diameters of the pulmonary veins. The clinical data of all patients was acquired through an electronic medical record system. Patients who experienced AF had a noticeably smaller total pulmonary vein vertical diameter (TPVVD) and a higher cardiothoracic ratio compared to those who only had HH. Logistic multivariate regression study demonstrated a significant association between TPVVD, cardiothoracic ratio, and AF in individuals with HH. This study established a correlation between TPVVD, cardiothoracic ratio, and HH in conjunction with AF. Patient with HH who had a thinner TPVVD and a bigger cardiothoracic ratio were found to have a greater likelihood of suffering from AF.

Alveolar capillary dysplasia complicated by subglottic stenosis.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) is an interstitial lung disease. In ACDMPV, respiratory impairment with severe pulmonary hypertension occurs from the early hours of life. Anomalies in the cardiovascular, gastrointestinal and genitourinary systems have been reported. However, little is known about upper airway abnormalities. We encountered a genetically diagnosed ACDMPV infant who presented with subglottic and bronchial stenosis. The prenatal diagnosis was hypoplastic left heart syndrome. Her respiratory condition worsened at 16 hours of life. We found subglottic stenosis when intubating. She died on day 7. Autopsy imaging with CT scan showed bilateral main bronchial stenosis. Chromosomal microarray revealed a 531 kb deletion in chromosome 16q24.1, including FOXF1.

Pulmonary Vein in a Pinch.

The pulmonary veins normally drain into the left atrium, with the superior pulmonary veins typically situated anterior and inferior to the right pulmonary arteries. However, anomalies can happen. We encountered an exceedingly rare pulmonary vascular anomaly for a patient presenting with atypical chest pain, where the right superior pulmonary vein aberrantly ran posterior to the right pulmonary artery (RPA) and became compressed between the RPA and the right main bronchus. Coronary computed tomography angiography identified this specific pulmonary vein anomaly but revealed unremarkable coronary arteries.

Let's put the clues together and find the aetiology in this patient with dilated right heart!

A 39-year-old woman with intermittent palpitations, psoriasis, and a family history of sudden death presented with dilated right heart chambers and an enlarged coronary sinus. Despite a normal bubble study, further evaluation with transesophageal echocardiography revealed an abnormal pulmonary venous return: the left pulmonary veins drained into the coronary sinus. Cardiac computed tomography confirmed this finding, suggesting a partial abnormal pulmonary venous return as the underlying issue. Cardiac catheterization indicated increased pulmonary artery flow with normal pulmonary vascular resistance. The patient was referred for surgery. In this pathway involving the differential diagnosis of right heart dilatation, despite a confusing history and conflicting findings, echocardiographic clues led to the diagnosis.

The value of computed tomography angiography for evaluation of left atrial enlargement in patients with persistent atrial fibrillation.

BACKGROUND: The post-processing technology of CTA offers significant advantages in evaluating left atrial enlargement (LAE) in patients with persistent atrial fibrillation (PAF). This study aims to identify parameters for rapidly and accurately diagnosing LAE in patients with PAF using CT cross-sections. METHODS: Left atrial pulmonary venous (PV) CT was performed to 300 PAF patients with dual-source CT, and left atrial volume (LAV), left atrial anteroposterior diameter (LAD1), left atrial transverse diameter (LAD2), and left atrial area (LAA) were measured in the ventricular end systolic (ES) and middle diastolic (MD). LA index (LAI) = LA parameter/body surface area (BSA). Left atrial volume index (LAVIES) > 77.7 ml/m2 was used as the reference standard for the LAE diagnosis. RESULTS: 227 patients were enrolled in the group, 101 (44.5%) of whom had LAE. LAVES and LAVMD (r = 0.983), LAVIES and LAVIMD (r = 0.984), LAAES and LAVIES (r = 0.817), LAAMD and LAVIES (r = 0.814) had strong positive correlations. The area under curve (AUC) showed that all measured parameters were suitable for diagnosing LAE, and the diagnostic efficacy was compared as follows: LAA/LAAI> LAD> the relative value index of LAD, LAD2> LAD1. LAA and LAAI demonstrated comparable diagnostic efficacy, with LAA being more readily available than LAAI. CONCLUSIONS: The axial LAA measured by CTA can be served as a parameter for the rapid and accurate diagnosis of LAE in patients with PAF.

Clinical value of artificial intelligence 3D echocardiography in evaluating left atrial volume and pulmonary vein structure in patients with atrial fibrillation.

OBJECTIVE: To explore the clinical value of 3D Echocardiography (3DE) in evaluating the changes of left atrial volume and pulmonary vein structure in patients with Atrial Fibrillation (AF). METHODS: Clinical data were collected from 54 AF patients. Left Atrial Anteroposterior Diameter (LADap), Left Atrial left and right Diameter (LADml), and Left Atrial upper and lower Diameter (LADsi) were measured; the maximum Left Atrial Volume (LAVmax), minimum Left Atrial Volume (LAVmin), left atrial presystolic volume (LAVpre), and Cross-Sectional Area (CSA) of each pulmonary vein were analyzed. Passive Ejection Fraction (LAPEF) was calculated. The differences in left atrial volume and pulmonary vein structure between patients with AF and healthy people were compared, and the correlation between the indexes was analyzed. The diagnostic value of the above indicators for AF patients was analyzed. RESULTS: LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA of AF patients were significantly higher. There was a significant positive correlation between left atrial diameter and pulmonary vein structure. There was a significant positive correlation between left atrial volume and pulmonary vein structure. There was a negative correlation between LAPEF and pulmonary vein structure. LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA had a diagnostic value for AF patients. CONCLUSION: 3DE is applicable for evaluating left atrial volume and pulmonary vein structure in patients with AF.

The prognostic value of changes in pulmonary vein flow patterns after surgical repair for primary mitral regurgitation.

BACKGROUND: The pulmonary vein (PV) flow pattern is influenced by the presence of mitral regurgitation (MR). After a successful reduction in MR severity, the pattern is expected to be changed. We aimed to evaluate the prognostic value of a change in the PV flow pattern in patients with primary MR undergoing mitral valve repair (MVR). METHODS: The PV flow pattern was assessed with transthoracic echocardiography in 216 patients (age 65 [IQR 56-72] years, 70% male) with primary MR before and after surgical MVR. The population was divided according to a change in the PV flow pattern following MVR into 'improvers' and 'non-improvers'. RESULTS: Non-improvers (15%) had a higher prevalence of paroxysmal AF at baseline (46% vs. 22%, p = 0.004), left ventricular dysfunction (LVEF ≤60%) (39% vs. 21%, p = 0.020), and had lower systolic pulmonary artery pressure (28[IQR 25-38] vs. 35[IQR 26-48] mmHg, p = 0.018) compared to improvers (85%). After a median follow-up of 83[IQR 43-140] months, 26(12%) patients died. Non-improvers had higher mortality rates than improvers (p = 0.009). On multivariable Cox regression analysis, a lack of improvement in the PV flow pattern remained independently associated with all-cause mortality (HR 2.322, 95% CI 1.140 to 4.729, P = 0.020). CONCLUSION: A lack of improvement in the PV flow pattern is independently associated with worse long-term survival in patients with primary MR undergoing MVR.

An Underestimated Cause of Hemoptysis in a 41-Year-Old Man.

CASE PRESENTATION: A 41-year-old man who currently smokes with previous sporadic use of cocaine and cannabinoids was admitted at the hospital suffering from hemoptysis which had developed 4 days before. The patient was on anticoagulant therapy with rivaroxaban due to paroxysmal atrial fibrillation diagnosed in 2018, for which he had undergone pulmonary vein electrical isolation by radiofrequency and ablation of cavotricuspid isthmus in January 2019. The procedure was completed in July 2019. Treatment with flecainide was introduced due to recurrences of atrial fibrillation. In February 2021, a new attempt at ablation was performed by electrical isolation of the left atrial posterior wall. The latest cardiologic checkup documented an echocardiographic framework of mild left atrial dilatation and normal-sized right ventricle with longitudinal shortening index at the lower limits, and a recurrence of asymptomatic atrial fibrillation at Holter ECG (March 2022).

Pulmonary Vein Thrombus After Mitral Valve Transcatheter Edge-to-Edge Repair.

A 76-year-old female with a complicated medical history presented for Watchman (Boston Scientific) placement 2 months after mitral valve transcatheter edge-to-edge repair (TEER). Preoperative workup before Watchman placement confirmed the presence of a thrombus in the left superior pulmonary vein. Post-procedure mitral valve TEER transesophageal echocardiogram showed no thrombus in the left atrium appendage or pulmonary veins. We believe the thrombus in the left superior pulmonary vein occurred secondarily due to epithelium damage during the mitral valve TEER.

[Mispositioned central line with catheterization of partial anomalous pulmonary venous return]. / Voie centrale mal positionnée avec cathétérisme d'un retour veineux pulmonaire anormal partiel.

Central venous access is common practice in intensive care, anesthesia and emergency departments. It is, however, a delicate technical procedure, prone to complications. We present a case report on the placement of a left jugular central venous line in the emergency room, which was thought to be a routine procedure. However, the operator observed arterial blood during sampling, and the central line was described as poorly positioned on the control X-ray. After verification and other examinations, the existence of a vertical vein was discovered in this patient, connecting the left superior pulmonary vein to the brachiocephalic trunk. A poorly positioned central venous line can therefore lead to the discovery of asympomatic congenital vascular anomalies, unrelated to the clinical context. This case study illustrates the various tools available to ensure the correct position of a central venous line, and their clinical implications.

La mise en place d'une voie veineuse centrale est de pratique courante aux soins intensifs, en anesthésie et aux urgences. Il s'agit cependant d'un acte technique relativement invasif, délicat et potentiellement sujet à complications. Nous présentons un cas clinique relatant la mise en place d'une voie veineuse centrale jugulaire gauche en salle de déchocage, manœuvre réputée banale. Cependant, l'opérateur objective visuellement du sang d'allure artérielle lors du prélèvement sanguin sur le cathéter. En outre, l'imagerie par radiographie thoracique décrit une malposition de ce dispositif. Après vérifications et examens complémentaires, nous découvrons finalement l'existence d'une veine verticale chez ce patient, reliant la veine pulmonaire supérieure gauche au tronc brachio-céphalique. Une voie veineuse centrale, apparemment mal positionnée, peut, dès lors, conduire à la découverte d'anomalies vasculaires congénitales asymptomatiques, sans lien nécessaire avec le contexte clinique sous-jacent. Ce cas clinique nous permet d'aborder les différents outils à notre disposition actuelle afin de déterminer le positionnement adéquat d'une voie veineuse centrale et les implications cliniques qui en découlent.

Atrial thrombus after total anomalous pulmonary venous connection repair.

A 6-year-old boy had previously undergone total anomalous pulmonary venous connection repair and postoperative pulmonary vein stenosis release. Magnetic resonance imaging revealed blood stasis caused by a collision between the inflow from the pulmonary veins and the outflow from the left atrial appendage. A surgical specimen revealed evidence of advanced thrombus attachment. Infra-cardiac total anomalous pulmonary venous connection with an antler appearance may be a risk factor for thrombus formation in the left atrial appendage and for postoperative pulmonary venous stenosis due to blood flow collision in the left atrium after total anomalous pulmonary venous connection repair.

Expiratory Venous Volume and Arterial Tortuosity are Associated with Disease Severity and Mortality Risk in Patients with COPD: Results from COSYCONET.

Purpose: The aim of this study was to evaluate the association between computed tomography (CT) quantitative pulmonary vessel morphology and lung function, disease severity, and mortality risk in patients with chronic obstructive pulmonary disease (COPD). Patients and Methods: Participants of the prospective nationwide COSYCONET cohort study with paired inspiratory-expiratory CT were included. Fully automatic software, developed in-house, segmented arterial and venous pulmonary vessels and quantified volume and tortuosity on inspiratory and expiratory scans. The association between vessel volume normalised to lung volume and tortuosity versus lung function (forced expiratory volume in 1 sec [FEV1]), air trapping (residual volume to total lung capacity ratio [RV/TLC]), transfer factor for carbon monoxide (TLCO), disease severity in terms of Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D, and mortality were analysed by linear, logistic or Cox proportional hazard regression. Results: Complete data were available from 138 patients (39% female, mean age 65 years). FEV1, RV/TLC and TLCO, all as % predicted, were significantly (p < 0.05 each) associated with expiratory vessel characteristics, predominantly venous volume and arterial tortuosity. Associations with inspiratory vessel characteristics were absent or negligible. The patterns were similar for relationships between GOLD D and mortality with vessel characteristics. Expiratory venous volume was an independent predictor of mortality, in addition to FEV1. Conclusion: By using automated software in patients with COPD, clinically relevant information on pulmonary vasculature can be extracted from expiratory CT scans (although not inspiratory scans); in particular, expiratory pulmonary venous volume predicted mortality. Trial Registration: NCT01245933.

Vascular Plugs Improve Pulmonary Arteriovenous Malformation Occlusion over Coil Embolization Alone: A Proof-of-Concept Study Using Dual-Energy CT.

PURPOSE: To evaluate effectiveness of pulmonary arteriovenous malformation (PAVM) embolization using dual-energy computed tomography (CT) and spectral curve analysis by characterizing contrast enhancement and vascular perfusion as a surrogate of the degree of vascular occlusion after embolotherapy. MATERIALS AND METHODS: Nine consecutive adult patients underwent embolization for 21 PAVMs (size range, 0.4-2.0 cm; 15/21 simple angioarchitecture) and subsequent postembolization chest dual-energy CT angiography. Twelve PAVMs were treated with vascular plugs with or without coils, whereas 9 PAVMs were treated with coils alone. Virtual spectral curves were generated using dual-energy image postprocessing in order to measure embolization effectiveness. RESULTS: Complete occlusion of target PAVM was achieved in all cases on digital subtraction angiography (DSA) at the end of the embolization procedure. With a median follow-up of 12.7 months, the vascular plug group demonstrated significantly less vascular opacification compared with the coils-only group, as measured by opacification between upstream feeding artery and different downstream vasculature locations (Δslope1: median 79.1 vs 28.6; P = .003; Δslope2: 76.4 vs 28.6; P = .0197; Δslope3: 78.9 vs 28.6; P = .004). Persistence occurred in 3 PAVMs based on size criteria, which demonstrated higher vascular opacification by dual-energy CT (Δslope1: 72 vs 28.6; P = .253; Δslope2: 65.1 vs 32.7; P = .326; Δslope3: 72.9 vs 53.5; P = .733), although statistical significance was not reached. CONCLUSIONS: Similar to emerging literature, dual-energy CT showed improved occlusion in PAVMs treated with vascular plugs compared with those treated with coils alone.

Diffuse pulmonary arteriovenous malformation presenting with secondary polycythemia and headaches: a case report.

BACKGROUND: Pulmonary arteriovenous malformations are a relatively uncommon medical condition, affecting roughly 1 in every 2500 individuals. Of those suffering from pulmonary arteriovenous malformations, 80% have an underlying genetic condition: hereditary hemorrhagic telangiectasia. CASE PRESENTATION: We present the case of a 20-year-old Pakistani male with a history of persistent slower-onset frontal headaches that increased in severity within the course of the day. His hemoglobin was 18 g/dl, indicating polycythemia, for which he had undergone seven venesections in a month previously. His physical examination was unremarkable. His computed tomography scan depicted multiple dilated tortuous vessels with branching linear opacities in the right lower lobe of the lungs. The multiple feeding arteries were supplied by the right main pulmonary artery, and the large draining veins led to the right inferior pulmonary vein. This was identified as a diffuse pulmonary arteriovenous malformation. He was recommended for a right pulmonary artery angiogram. It showed multiple tortuous vessels with a nidus and large draining veins-features of a diffuse arteriovenous malformation in the right lower lobe of the lung consistent with the computed tomography scan. Embolization of two of these vessels feeding the arteriovenous malformation was conducted, using Amplatzer Vascular plug 2, whereas multiple pushable coils (five coils) were used for embolizing the third feeding vessel. This achieved 70-80% successful embolization of right pulmonary AVM; however, some residual flow was still seen in the arteriovenous malformation given the complexity of the lesion. Immediately after, his oxygen saturation improved from 78% to 96%. CONCLUSION: Diffuse pulmonary arteriovenous malformations, as seen in this patient, are rare, accounting for less than 5% of total pulmonary arteriovenous malformations diagnosed. The patient presented with a complaint of progressive frontal headaches, which can be attributed to low oxygen saturation or the presence of a cerebral arteriovenous malformation. There was no history of hereditary hemorrhagic telangiectasia in the patient's family. Furthermore, although most patients with hereditary hemorrhagic telangiectasia and hence pulmonary arteriovenous malformation have complaints of iron-deficiency anemia, our patient in contrast was suffering from polycythemia. This can be explained as a compensatory mechanism in hypoxemic conditions. Moreover, the patient had no complaint of hemoptysis or epistaxis, giving a varied presentation in comparison with a typical pulmonary arteriovenous malformation.