Pulmonary Venous Infarction Secondary to Pulmonary Venous Stenosis

Abstract

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: The etiology for hemoptysis and new pulmonary opacities in an immunocompromised host can be difficult to ascertain and may require an exhaustive workup. Pulmonary venous stenosis is an uncommon cause of hemoptysis due to pulmonary infarction. CASE PRESENTATION: A 51-year-old male with Crohn's disease and radiofrequency ablation (RFA) for atrial fibrillation five months prior presented with fever and hemoptysis while on Vedolizumab and Clopidogrel. Chest CT angiography (CTPA) showed multifocal left upper lobe (LUL) opacities and ipsilateral pleural effusion with no evidence of pulmonary embolism (Image 1). Bronchoscopy and thoracentesis were non-diagnostic for infection, malignancy, and other inflammatory lung diseases. Video assisted thoracoscopic biopsy of the LUL revealed venous infarcts associated with edema and fibrosis of interlobular septa (Image 2). Expert reassessment of initial CTPA found thrombosis of the left upper lobe pulmonary vein and a filling defect of the left lower lobe pulmonary vein, which were confirmed with subsequent dedicated CT coronary angiography which showed complete occlusion of superior left pulmonary vein and significant stenosis of the left inferior pulmonary vein. DISCUSSION: The differential for pulmonary venous stenosis includes congenital stenosis, neoplasm, mediastinal mass, granulomatous disease, and less commonly RFA for atrial fibrillation secondary to thermal injury at the veno-atrial junction. The incidence of pulmonary venous stenosis with RFA is 30-40%, most often without clinical manifestations [1]. Only 0.29% of cases require intervention such as angioplasty with or without stenting [2]. When pulmonary venous stenosis is suspected, diagnostic imaging modalities including ventilation-perfusion scintigraphy, and venography (CT or MR) can be useful for confirmation. CONCLUSIONS: Symptomatic pulmonary venous stenosis secondary to RFA is uncommon, and can be difficult to identify as the cause of hemoptysis and pulmonary infarction in immunocompromised patients where other common entities are more strongly considered. Reference #1: Braun S, Platzek I, Zopheel K, Weise M, Kolditz M, Halank M, Hoeffken G. Haemoptysis due to pulmonary venous stenosis. European Respiratory Journal 2014; 170-179. Reference #2: Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ. Arrhythm. Electrophysiol. 2010 Feb;3(1):32-8. DISCLOSURE: The following authors have nothing to disclose: Tyson Sjulin, Michael Morris, Teri Franks, David Ferraro No Product/Research Disclosure Information