Hemodialysis Catheter Discovers Anomalous Pulmonary Vein

Abstract

SESSION TITLE: Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Partial anomalous pulmonary venous return (PAPVR) is a rare congenital anomaly that is often found incidentally in adults and can lead to multi-organ dysfunction. CASE PRESENTATION: A 75-year-old male with heart failure, pulmonary hypertension, and chronic kidney disease was admitted for decompensated heart failure. On day 6, patient developed sepsis and oliguric kidney injury. He was transferred to the intensive care unit. A temporary dialysis catheter was placed and the post-procedural roentgenogram was noted to be abnormal (fig 1). Suspicious for an anomalous vein, an arterial blood gas was drawn from the catheter and revealed a partial pressure of oxygen of 140mmHg. A non-contrast CT confirmed an anomalous venous return of the right upper lobe pulmonary vein to the superior vena cava (SVC). The tip of the catheter was within the anomalous vein (fig 2). A transesophageal echocardiogram revealed left ventricular hypertrophy, left atrial enlargement, normal right-sided chambers, and a patent foramen ovale. Right heart catherization revealed a mean pulmonary artery pressure of 35 mmHg. Saturations of the inferior vena cava, low right atrium, high right atrium, and SVC were 70%, 58%, 84%, and 86% respectively. The Qp/Qs was approximately 3.0. Being a poor candidate, the patient did not receive surgical intervention. He was stabilized and discharged. His conditions continue to be treated medically. DISCUSSION: PAPVR occurs when at least one, but not all, pulmonary vein connects to either a systemic vein or the right atrium. PAPVR has an estimated prevalence of <0.8% [1]. The variant seen most in adults consists of the right-upper lobe pulmonary vein draining into the right atrium or SVC with atrial septal defects noted in 60-80% of these patients [2] [3]. PAPVR may remain asymptomatic for decades. When symptomatic, presentations can range from mild exercise intolerance to severe pulmonary and cardiac dysfunction [3]. Some patients are also plagued with arrhythmias [1]. In pediatrics, a Qp/Qs greater than 1.5 is an indication for surgery. No such guidelines exist in adults. Due to comorbidities, patients are often limited to supportive therapy [1] [2]. CONCLUSIONS: PAPVR is a rare congenital anomaly. Unfortunately, due to its insidious nature, adults are often limited to conservative therapies. Reference #1: E. H. Sears, J. M. Aliotta and J. R. Klinger, “Partial anomalous pulmonary venous return presenting with adult-onset pulmonary hypertension,” Pulmonary circulation, vol. 2, no. 2, pp. 250-55, 2012. Reference #2: R. K. Sharma, B. A. Houston, J. A. C. Lima, D. E. Cameron and R. J. Tedford, “Never too old for congenital heart disease: sinus venosus atrial septal defect with anomalous pulmonary venous return in an octogenarian,” Pulmonary Circulation, vol. 5, no. 3, pp. 587-9, 2015. Reference #3: F. Senocak, S. Ozme, A. Bilgic, S. Ozkutlu, S. Ozer and M. Saraclar, “Partial Anomalous Pulmonary Venous Return: Evaluation of 51 Cases,” Jpn Heart Journal, vol. 35, no. 1, pp. 43-50, 1994. DISCLOSURE: The following authors have nothing to disclose: Jason Thomas, Sergei Robinson, Rajnish Dhingra No Product/Research Disclosure Information