Ann Thorac Surg 2009;88:1687-1689. doi:10.1016/j.athoracsur.2009.03.098
© 2009 The Society of Thoracic Surgeons
Case Reports
Percutaneous Atrioseptostomy for Right Heart Failure After Left Pneumonectomy
Thomas D'Annoville, MDa,*,
Ludovic Canaud, MDa,
Charles Marty-Ané, MD, PhDa,
Pierre Alric, MD, PhDa,
Catherine Sportouch, MDb,
Jean-Marc Frapier, MD, PhDc,
Jean-Philippe Berthet, MDa
a Department of Vascular and Thoracic Surgery, Hôpital Arnaud de Villeneuve, Montpellier, France
b Department of Cardiology, Hôpital Arnaud de Villeneuve, Montpellier, France
c Department of Cardiac Surgery, Hôpital Arnaud de Villeneuve, Montpellier, France
Accepted for publication March 25, 2009.
* Address correspondence to Dr D'Annoville, Department of Vascular and Thoracic Surgery, Hôpital Arnaud de Villeneuve, 191 Ave Doyen Gaston Giraud, Montpellier, 34090, France (Email: tomadano1{at}hotmail.fr).
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Abstract
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We present a case of right heart failure after left pneumonectomy as a result of an isolated, contralateral partial anomalous pulmonary venous return. We successfully treated this with percutaneous atrioseptostomy. For unstable patients with postoperative acute heart failure from an undetected partial anomalous pulmonary venous return, this minimally invasive procedure represents a useful primary option while allowing secondary conventional surgery if required.
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Introduction
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Right pulmonary vein drainage into the superior vena cava is a common variation of partial anomalous pulmonary venous return (PAPVR), which is almost always associated with an atrial septal defect described as the sinus venosus syndrome [1]. Anomalous pulmonary venous drainage leads to an extracardiac left-to-right shunt, as blood flows directly from the pulmonary veins into the right heart chambers. This vascular shunt can increase after contralateral pulmonary resection and become life threatening. We report a case of a right heart failure after left pneumonectomy caused by an isolated contralateral PAPVR involving the right superior pulmonary vein draining into the superior vena cava. Percutaneous atrioseptostomy successfully treated this case.
A 56-year-old woman presented with a 2-month history of worsening dyspnea, cough, and weight loss. She had no previous medical history, but she was an active smoker. First a chest roentgenogram, then a computed tomographic scan demonstrated a superior left hilar mass involving the left main pulmonary artery. Flexible bronchoscopy and biopsy of this highly suspicious lesion revealed a nonsmall cell lung carcinoma, classified as type IIIB and requiring both neoadjuvant chemotherapy and pulmonary resection.
The patient underwent a left pneumonectomy with systematic mediastinal lymph node sampling and was admitted to the intensive care unit for routine postoperative management.
Three hours later, she became hemodynamically unstable, with hypotension (systolic blood pressure of 80 mm Hg), tachycardia (140 bpm), oliguria, and metabolic acidosis. There was no sign of bleeding. Transthoracic echocardiography revealed right ventricular and auricular volume overload (38 mm3), and inadequate left atrial filling, but no left-to-right shunt. Swan-Ganz catheterization showed systolic pulmonary artery pressure at 55 mm Hg, with 2.6L/min pulmonary blood flow (Qp) and 89% venous oxygen saturation in the left ventricle. The patient required noradrenaline, diuretics, and nitric oxide gas to maintain a functional systemic blood pressure, with no possibility of weaning. A computed tomographic scan demonstrated an isolated PAPVR connecting the right upper pulmonary vein to the superior vena cava, superior to the azygos vein (Fig 1); the preoperative computed tomographic scan had not detected it. Cardiac catheterization with a PiCCO monitor (Pulsion Medical Systems AG, Munich, Germany) compared systemic (Qs) and pulmonary blood flow, measuring 1.6 L/min and 3 L/min, respectively (Qp/Qs > 1.8). Despite intensive medical care, hemodynamic measurements did not improve.
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Fig 1. Postoperative computed tomographic scan demonstrating an enlarged right pulmonary artery and anomalous right upper pulmonary vein drainage into the superior vena cava (arrow).
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As the patient was too unstable to undergo immediate conventional cardiac surgery, we considered a less invasive technique of increasing global cardiac output by creating an intracardiac right-to-left shunt using atrioseptostomy.
Under general anesthesia, with transesophageal echocardiographic monitoring and a right femoral vein approach, we created a 12-mm atrioseptostomy by balloon catheter, centered on the fossa ovalis (Meditech XXL 40 x 12; Boston Scientific, Fremont, CA). Centering the atrioseptostomy on the fossa ovalis proved technically difficult due to the very small volume of the left atrium. However, systemic blood pressure and global cardiac output increased quickly after the procedure (110 mm Hg and 2.5 L/min, respectively), allowing complete weaning from drugs the next day. The patient was discharged from the intensive care unit on postoperative day 8.
Postoperative pathologic examination confirmed a stage IIIB nonsmall cell lung carcinoma of the left lung with an R0 resection. An echocardiogram performed on postoperative day 8 and at 3 months (Fig 2) showed a moderately distended right atrium (29 mm3) and a 15-mm atrial defect, with massive right-to-left shunting of the contrast during systole, but no pulmonary artery hypertension (33 mm Hg). So far, the absence of clinical and echocardiographic signs of right heart failure has precluded conventional surgery.
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Fig 2. Transthoracic echocardiogram (two-dimensional apical, four-cavity view) 3 months after the percutaneous atrioseptostomy. Note the massive intracardiac right-to-left shunt of the contrast product through the iatrogenic atrial septal defect (arrow).
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Comment
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Partial anomalous pulmonary venous return is a rare congenital abnormality, discovered more often in children than adults. Usually right-sided (90%), the most common type is a right PAPVR into the superior vena cava, associated with an atrial septal defect [1]. Isolated PAPVR in adults is frequently asymptomatic. Patients require surgery only in cases of right ventricular volume overload, a pulmonary-systemic blood-flow ratio (Qp/Qs) greater than 1.8, or if an entire lung is affected, as pathology in the remaining lung could cause fatal anoxia.
Studies have previously reported how PAPVR relates to pulmonary resection. Conventional surgical management uses cardiopulmonary bypass and a right atriotomy to create an atrial septal defect and reroute the pulmonary venous blood with an autologous pericardial patch. In our case, we predicted that the limited right-to-left shunt through the atrioseptostomy, combined with the high oxygen saturation of mixed blood in the right atrium (89%), would not lead to massive arterial desaturation, and would probably correct the left and right cardiac outputs.
Previous reports have focused on preoperative PAPVR correction; Sakurai and colleagues [2] first corrected a right PAPVR, as described, and then performed a left pneumonectomy 3 weeks later. Similarly, Smith and colleagues [3] published a case of an obstructing left lower lobe carcinoid tumor combined with a PAPVR, connecting the left upper pulmonary vein to the left brachiocephalic vein. They successfully performed a left lower lobe sleeve resection and simultaneous repair by ligating the left upper pulmonary vein and constructing an anastomosis with the left atrial appendage.
Unexpected discoveries at the time of surgery also occurred. During a bilateral lung transplant, when removing a clamp to perfuse the left lung, Khasati and colleagues [4] identified a small bleeding vein draining the left upper lobe. They performed an end-to-end anastomosis to the left atrial appendage to repair the defect. Miwa and colleagues [5] discovered a left upper PAPVR during a left upper segmentectomy for primary lung cancer; they performed a left upper lobectomy with ligation of the anomalous connecting vein.
Postoperative discovery of isolated contralateral anomalous venous drainage after pneumonectomy may be lethal, as experienced by Black and colleagues [6]. We believe that this is the first report demonstrating that atrioseptostomy represents an alternative to surgical correction for PAPVR discovered after a major contralateral pulmonary resection. Watson and Rashkind [7] first described balloon catheter atrioseptostomy in children with transposition of the great arteries in 1967. This minimally invasive procedure may offer a useful option for unstable patients with postoperative acute heart failure from an undetected PAPVR. Conventional surgery, if required, can be performed later, provided that the clinical status of the patient is compatible.
These case reports should remind thoracic surgeons of the possibility of PAPVR when considering pulmonary resection. Both hilar structures must be reviewed carefully for issues that may impact the postoperative period.
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Acknowledgments
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The authors thank Angloscrib and Theresa Sawyers for their translation assistance.
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References
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- Alpert JS, Dexter L, Vieweg WV, Haynes FW, Dalen JE. Anomalous pulmonary venous return with intact atrial septum: diagnosis and pathophysiology Circulation 1977;56:870-875.[Abstract/Free Full Text]
- Sakurai H, Kondo H, Sekiguchi A, et al. Left pneumonectomy for lung cancer after correction of contralateral partial anomalous pulmonary venous return Ann Thorac Surg 2005;79:1778-1780.[Abstract/Free Full Text]
- Smith 2nd RL, Zorn 3rd GL, Peeler BB, Jones DR. Combined bronchial sleeve resection and repair of partial anomalous pulmonary venous return J Thorac Cardiovasc Surg 2006;132:982-983.[Free Full Text]
- Khasati NH, MacHaal A, Thekkudan S, Kumar S, Yonan N. An aberrant donor pulmonary vein during lung transplant: a surgical challenge Ann Thorac Surg 2005;79:330-331.[Abstract/Free Full Text]
- Miwa K, Takamori S, Hayashi A, Fukunaga M, Ikeda K, Shirouzu K. Incidental partial anomalous pulmonary venous connection in left lung cancer Jpn J Thorac Cardiovasc Surg 2004;52:189-190.[Medline]
- Black MD, Shamji FM, Goldstein W, Sachs H. Pulmonary resection and contralateral anomalous venous drainage: a lethal combination J. Ann Thorac Surg 1992;53:689-691.
- Watson H, Rashkind WJ. Creation of atrial septal defects by balloon catheter in babies with transposition of the great arteries Lancet 1967;25:403-4051.
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Abstract
Introduction
