Pulmonary veins in congenital heart disease in the adult.

Abstract

The roentgen signs of congenital cardiac disease have been the subject of intensive study since the advent of corrective heart surgery. For the successful operative repair of cardiac defects, accurate preoperative evaluation of the anatomy and physiology of the heart is mandatory and for this purpose cardiac catheterization and angiocardiography have proved decisive. The routine roentgenogram, however, remains the base line for appraisal of the cardiac patient and, because the usual lesion encountered in congenital heart disease in the adult is monopathic, the radiologist can be quite accurate in his prediction of the abnormality. Alterations in the configuration of the silhouette due to enlargement of individual chambers are well documented and universally used. The appearance of the pulmonary arteries in pulmonary hypertension, as well as in lesions leading to alterations in blood flow, have been described, and more recently Campbell has called attention to the appearance of the aorta in conditions leading to altered flow through that structure. The present study is directed to an analysis of the pulmonary veins in congenital heart disease in adults. Because of the great complexity of lesions encountered in infants and the instability of their physiologic state, that group has been excluded. Familiarity with the position and course of the pulmonary veins is necessary before they can be distinguished roentgenographically from other vascular shadows within the lungs. Upright laminagrams in the postero-anterior and oblique projections are of considerable aid in delineating the veins and separating them from the arteries. Magnification views are also useful. The anatomy of the veins has been thoroughly presented by Boyden and reviewed by Michelson and Salik. Figure 1 is a schematic superimposition of the major pulmonary veins upon the heart and lung fields. Four major venous channels are constant in position and can usually be identified on routine postero-anterior films of the chest. They are: the posterior division of the superior pulmonary veins, the superior and inferior divisions of the inferior pulmonary veins, and the middle pulmonary veins. These vessels can be seen crossing the arterial channels and entering the left atrium below the main pulmonary arteries. Postero-anterior roentgenograms made in the 120- to 150-kv range are optimal in delineating veins. Variation in vein size in normal patients is considerable, and in studying unselected patients one quickly appreciates that no absolute value can be ascribed to the diameter of a normal vein. With experience, the subjective impression of vein size obtained from scanning the individual film proves quite useful. In congenital heart disease the veins in the lower lung fields are better correlated with blood flow, while in acquired heart disease the upper lobe veins are better correlated with left atrial pressure.