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• W2000664640 abstract "We report a case of a 64-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found before right lower lobectomy for lung cancer. In addition to lung cancer, there was a right superior pulmonary vein that drained into the superior vena cava (SVC). There was a concern of right ventricular heart failure resulting from increased left-to-right shunt flow after lobectomy. Therefore cardiac catheterization was performed to calculate the pulmonary-to-systemic flow rate in the presence of blocked blood flow to the lower lobe pulmonary artery. As a result, we successfully performed lobectomy without correcting the PAPVC. We report a case of a 64-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found before right lower lobectomy for lung cancer. In addition to lung cancer, there was a right superior pulmonary vein that drained into the superior vena cava (SVC). There was a concern of right ventricular heart failure resulting from increased left-to-right shunt flow after lobectomy. Therefore cardiac catheterization was performed to calculate the pulmonary-to-systemic flow rate in the presence of blocked blood flow to the lower lobe pulmonary artery. As a result, we successfully performed lobectomy without correcting the PAPVC. Pulmonary venous anatomic variants are occasionally identified during thoracic surgical procedures. A partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly that is frequently associated with an atrial level shunt. In most asymptomatic patients, PAPVCs are not clinically significant. However if patients with PAPVC require pulmonary resection, the surgical procedure could precipitate a fatal outcome without correction of the PAPVC. We present a case of right lower lobectomy in which we did not correct the PAPVC of the right superior pulmonary vein. Evaluation of the pulmonary-to-systemic flow ratio (Qp/Qs) preoperatively indicated that correction of the PAPVC was not necessary. The procedure was successfully performed by evaluating safety preoperatively and perioperatively. A 64-year-old man was found to have a lung nodule in the anterior segment of the right upper lobe by computed tomography (CT) performed at routine medical examination. After 6 months, there was no change in the nodule, but a mass in the right lower lobe was detected. He was referred to our institution for further investigation. He was asymptomatic, with no past history of significant illness. Chest CT showed a 4.8 × 3.7 cm mass in the lateral basal segment of the right lung and swelling in the subcarinal lymph node (Fig 1). By careful interpretation of the computed tomographic images, we incidentally found an anomalous vessel originating from the hilum of the right upper lobe and draining into the superior vena cava (SVC) (Fig 2). Three-dimensional contrast-enhanced CT confirmed these findings, and we diagnosed the abnormality as a PAPVC of the right superior pulmonary vein. Reticular opacities and honeycombing were detected in the bilateral lower lobes. A CT-guided transcutaneous needle biopsy was performed, and the mass in the right lower lobe was histologically diagnosed as adenocarcinoma of the lung. The patient was diagnosed with stage IIIA (T2bN2M0) lung cancer with PAPVC and idiopathic pulmonary fibrosis (IPF). Echocardiography revealed no remarkable abnormality such as an atrial septal defect. A pulmonary function study showed a forced expiratory volume in 1 second of 72% of the predicted value, a forced vital capacity of 108% of the predicted value, and a carbon monoxide diffusing capacity of 58% of the predicted value. An arterial blood gas analysis revealed a Pao2 of 86.2 mm Hg and a PaCo2 of 33.1 mm Hg in room air. Immunologic analyses indicated elevations in KL-6 to 1,400 U/mL, surfactant protein A to 106 ng/mL and surfactant protein D to 198 ng/mL.Fig 2Contrast-enhanced CT showing the right upper pulmonary vein draining into the superior vena cava (SVC) (AV = anomalous vein).View Large Image Figure ViewerDownload (PPT) Cardiac catheterization was performed to calculate the Qp/Qs and evaluate the necessity of correcting the PAPVC. The procedure showed an oxygen saturation of 74.0% in the right brachiocephalic vein and 95.9% in the SVC. The Qp/Qs was 1.2 during balloon occlusion of the truncus intermedius, a part between the origin of the branches to the upper lobe and a superior branch to the lower lobe. Therefore surgical correction of the PAPVR was not necessary. Although the lung cancer was accompanied by subcarinal lymph node metastasis, it was completely resectable by performing lobectomy with lymph node dissection. Chemotherapy and radiotherapy were difficult to manage because the IPF was comparatively active. Based on careful consideration of the surgical risk associated with the PAPVC and IPF, we decided to perform the operation after obtaining consent from the patient and approval from the ethics committee in our hospital. The operation was performed through a right posterolateral thoracotomy, with careful monitoring of pulmonary arterial pressure using a Swan-Ganz catheter. The anomalous pulmonary vein was found on the right hilum, originating from the upper right lobe and draining into the SVC. We observed no hemodynamic changes when a vascular clamp was placed across the truncus intermedius. A right lower lobectomy with lymph node dissection was completed successfully. The patient had an uneventful postoperative course. The final pathologic diagnosis was pleomorphic carcinoma of the lung (T3N2M0-IIIA). PAPVC is a comparatively rare congenital anomaly that is found in only 0.4% to 0.7% of adults at the time of autopsy [1Healey Jr, J.E. An anatomic survey of anomalous pulmonary veins: their clinical significance.J Thorac Surg. 1952; 23: 433-444PubMed Google Scholar]. These anomalies are frequently associated with atrial septal defects and have similar clinical findings. The anomalous veins are often connected to the SVC, left brachiocephalic vein, and right atrium. The surgical indication for PAPVC repair is commonly a Qp/Qs greater than 2.0 [1Healey Jr, J.E. An anatomic survey of anomalous pulmonary veins: their clinical significance.J Thorac Surg. 1952; 23: 433-444PubMed Google Scholar, 2Hijii T. Fukushige J. Hara T. Diagnosis and management of partial pulmonary venous return.Cardiology. 1998; 89: 148-151Crossref PubMed Scopus (55) Google Scholar]. PAPVC without an atrial septal defect is generally asymptomatic and may be clinically insignificant. However if a patient with a PAPVC requires major pulmonary resection, the surgical procedure could lead to fatal complications. When the PAPVC is located in the resected lobe, no hemodynamic problems should occur during the procedure. Conversely, when the anomalous vein is located in the other lobe, serious complications may occur, such as right ventricular heart failure caused by increased left-to-right shunt flow. Most of these anomalies can be identified with contrast-enhanced CT, but they can often be missed. Therefore accurate preoperative interpretation of clinical imaging is required, and the PAPVC that is not contained in the resected lobe should be corrected before lung resection. Several cases of PAPVC with lung cancer have been reported in the past. Generally, a PAPVC on the left side is corrected by a simple repair, such as end-to-side anastomosis directly to the left auricular appendage or the left atrium or end-to-end anastomosis to the stump of the resected normal pulmonary vein. Extracorporeal circulation is not required for the operative procedure [3Takei H. Suzuki K. Asamura H. et al.Successful pulmonary resection of lung cancer in a patient with partial anomalous pulmonary venous connection: report of a case.Surg Today. 2002; 32: 899-901Crossref PubMed Scopus (21) Google Scholar, 4Meter C.V. LeBlanc J.G. Culpepper W.S. Ochsner J.L. Partial anomalous pulmonary venous return.Circulation. 1990; 82: IV195-IV198PubMed Google Scholar]. When the PAPVC is located on the right side, however, cardiopulmonary bypass is required for the repair because of the shortness of the anomalous vein traveling to the SVC or the right atrium. Sakurai and associates [5Sakurai 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: 1778-1780Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] reported a case of right PAPVC repair before left pneumonectomy for lung cancer. The correction was performed using total cardiopulmonary bypass. Thus the treatment strategy depends on the location of the PAPVC. In our patient, pulmonary resection by itself carried a high surgical risk because of IPF. Chida and colleagues [6Chida M. Kobayashi M. Karube Y. et al.Incidence of acute exacerbation of interstitial pneumonia in operated lung cancer: institutional report and review.Ann Thorac Surg. 2012; 18: 314-317Crossref Scopus (26) Google Scholar] reported that the incidence of acute exacerbation after operation in patients with IPF was 15.8%, and the rate of mortality in those cases was 56.7%. Therapeutic issues for patients with IPF commonly include the incidence of acute exacerbation and low pulmonary function. Although the possibility of acute exacerbation could not be completely excluded, we concluded that respiratory function was preserved and that the patient could tolerate the surgical procedure. However we determined that the patient could not tolerate an additional surgical procedure to correct the anomalous vein under extracorporeal circulation. Therefore we carried out cardiac catheterization to evaluate the need to correct the PAPVC. Transient balloon occlusion of the truncus intermedius was performed and the Qp/Qs was calculated. This process is possibly useful for cases of concomitant PAPVC and lower lobe lung cancer. Therefore we wish to highlight the importance of cautious interpretation of clinical images and sufficient hemodynamic assessment before pulmonary resection for safe perioperative management." @default.
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• W2000664640 title "Pulmonary Resection of Lung Cancer in a Patient With Partial Anomalous Pulmonary Venous Connection" @default.
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