Left Lower Pulmonary Vein Research Articles

A preliminary investigation of the left atrial suspended cord and its significance as revealed by coronary CT angiography: an observational study with a systematic literature review

BackgroundThe occurrence of suspended cords of the left atrium (SCLA) is rare and has seldom been described. The purpose of this study was to summarize the cases of SCLA accidentally detected by coronary CT angiography (CCTA), describe their imaging features, conduct a preliminary analysis of their clinical significance, and review relevant literature.MethodsA total of 10,796 patients who underwent CCTA examinations from July 2020 to November 2021 were consecutively selected. The original and three-dimensional reconstruction images were reviewed to identify patients with SCLA. A control group was selected in a 1:2 ratio based on age, BMI, sex, and education level. The imaging characteristics and clinical data of the two groups were collected and compared. The case group was divided into two subgroups based on the starting and ending positions of the SCLA: Group 1 with the SCLA between the free wall and free wall, and Group 2 with the SCLA between the septum wall and free wall. The clinical features of these subgroups were compared. Furthermore, a review of literature on SCLA published in the past fifteen years that includes its clinical and imaging features was conducted.ResultsIn this study, a total of 35 patients were found to have SCLA, resulting in an incidence rate of approximately 0.32%. After excluding 1 patient for whom clinical features could not be obtained, the case group included a total of 18 males and 16 females, with a male-to-female ratio of 1:1 and a median age of 57.00 (52.00–64.00) years. It was found that 19 (55.88%) cases of SCLA were located near the right superior pulmonary vein ostia, while no SCLA was found near the left lower pulmonary vein orifice. A significant difference in the incidence of atrial arrhythmia between the two groups was observed (p = 0.009). Additionally, 3 patients (8.82%) in the SCLA group had a history of transient cerebral ischemic attack (TIA), which was significantly different from that in the control group (p = 0.035). The anteroposterior and transverse diameters of the left atrium were longer in the case group than in the control group (p < 0.05), but there was no significant change in left atrial volume. Subgroup analyses found no significant difference in the incidence of cerebral infarction, atrial arrhythmia, or other intracardiac structural malformations, although there was a significant difference in cord length (p = 0.013), with the length of SCLA in Group 1 and Group 2 being 2.64 ± 0.99 cm and 3.39 ± 0.68 cm, respectively. Notably, only 1 of these 34 patients was diagnosed based on echocardiography, whereas all cases were perfectly visualized using CCTA.ConclusionSCLA is rare. CCTA can accurately detect and depict this abnormal structure as compared to echocardiography. SCLA may be linked to a higher incidence of atrial arrhythmias or transient ischemic attacks. It is important for radiologists and cardiovascular experts to recognize this structure, and further investigation is necessary to determine its clinical significance.

Pulmonary Vein Occlusion Requiring Lobectomy after Radiofrequency Catheter Ablation for Atrial Fibrillation: A Case Report and Review of the Literature

Pulmonary vein stenosis is a potential complication after radiofrequency ablation for atrial fibrillation. We present an unusual case of this complication that progressed to vein occlusion and required lobectomy and review the literature. A 54-year-old man presented with persistent chest pain, dry cough, and hemoptysis. Seven months before he underwent radiofrequency catheter ablation for atrial fibrillation. Chest computed tomography showed a narrowing of the left lower pulmonary vein after the procedure. The patient was treated conservatively. On the presentation, a chest computed tomography scan showed total pulmonary vein occlusion. A quantitative ventilation/perfusion scan revealed no perfusion to the left lower lobe. A balloon angioplasty was performed, however unsuccessfully. The left lower lobectomy was performed. Six years after the lobectomy the patient has neither cardiac nor pulmonary symptoms. Pulmonary vein occlusion after radiofrequency ablation for atrial fibrillation leading to lung resection is still a possible severe complication.

Abstract 17386: Pulmonary Vein Stenosis After Pediatric Heart Transplant

Introduction: Pulmonary vein stenosis (PVS) is a rare condition in which neointimal proliferation of the pulmonary veins leads to venous and arterial hypertension. Little is known about the development of PVS after heart transplant (HTx) in children, which is a rare but known complication of HTx. Research Question: To describe the clinical characteristics, progression of disease, and outcomes of children who develop PVS after HTx. Methods: We performed a retrospective review of patients ≤18 years old who underwent HTx at two pediatric centers, Children’s Healthcare of Atlanta and Lurie Children’s Hospital, between April 2012-April 2022. Patients with a diagnosis of PVS were identified through queries of PVS databases at each center. Details related to the underlying cardiac diagnosis, location and extent of PVS, and post-HTx outcomes were recorded. Results: During the study period, 374 patients underwent HTx across both centers. Seventeen PVS patients (9 male) were identified, 15 of whom had de novo PVS. Fifteen had underlying congenital heart disease (CHD) and 2 had cardiomyopathy. Among CHD patients, 2 had a history of anomalous pulmonary venous return and 14 had prior cardiac surgery. Two patients had undergone catheter based PVS intervention prior to Tx. PVS was diagnosed at a median of 2 months (range 2 weeks-14 years) after HTx. At initial diagnosis, 12 patients had one-vessel PVS, most commonly the left upper pulmonary vein (n=8). At final follow-up, 2 patients had 2-vessel PVS and 7 had 3-4 vessels involved. Surgical intervention was required in 8 unique patients, most commonly for the left veins. Stent or balloon angioplasty were used in all left-sided veins, most commonly in the left lower pulmonary vein (n=8). Two patients were medically treated for pulmonary hypertension following PVS diagnosis. There were 3 deaths in the cohort, 2 of which were thought to be caused by right heart failure secondary to PVS. Conclusions: This is the first study to describe the characteristics of post-HTx PVS in children. PVS occurs in 4.5% of HTx and history of CHD is a strong risk factor. Multiple vessels can be involved and may require catheter-based or surgical intervention. Clinicians must be vigilant in monitoring for the development of PVS in this population.

Abstract 16284: Atypical Cause of Embolic Stroke; Intracardiac Metastasis of Mixed Germ Cell Tumor

Testicular neoplasm constitutes the most common solid organ malignancy in males between the ages of 15 and 35. Metastatic disease to the heart is a rare entity. In most cardiac cases, metastasis is by direct hematogenous spread via the inferior vena cava to the right heart. Metastatic disease to the left heart is even more infrequent. We present the case of intracardiac metastasis of mixed germ cell tumor presenting with an embolic stroke. A 47-year-old Latinx male with a history of stage IV testicular cancer s/p left radical orchiectomy with multiple bilateral pulmonary masses (largest 6x9 cm), atrial fibrillation s/p ablation, left lower extremity iliac thrombus s/p thrombectomy, HTN, and diabetes who presented with sudden onset expressive aphasia and dysarthria. CT head showed a 3x5 cm left occipital intraparenchymal hemorrhage suspected to be an embolic stroke with hemorrhagic conversion. Further evaluation with TTE and TEE revealed a highly mobile and friable multi-lobar mass attached to the anterior mitral leaflet occupying most of the left atrial cavity (4.2x4.9 cm), a small mass attached to the right ventricular aspect of the tricuspid valve, an echo-dense mass in the left lower pulmonary vein at the left atrial junction, and a large mass abutting the rim of the superior vena cava. Definitive surgical management was considered; however, patient was deemed a high-risk candidate given high burden of cardiac metastases. After multidisciplinary discussion, it was decided to pursue systemic chemotherapy. This case illustrates an exceptionally rare presentation of advanced stage testicular cancer metastasizing to the heart with large intracardiac tumor burden resulting in embolic stroke. Early cardiac screening may be beneficial in individuals with history of cancer who present with stroke symptoms. Embolization of cardiac metastasis to other organs poses a great clinical challenge and multidisciplinary decision-making is crucial to clinical management.

Bilateral video-assisted thoracic surgery for esophageal cancer with left inferior pulmonary vein invasion following chemoradiation therapy

BackgroundThe surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response.Case presentationA 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up.ConclusionsCurative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response.

Left sided Scimitar syndrome.

The images depict a rare case of Scimitar syndrome involving the left lower pulmonary vein.

Dynamic electrophysiological mechanism in patients with long-standing persistent atrial fibrillation.

BackgroundImproved understanding of the mechanisms that sustain persistent and long-standing persistent atrial fibrillation (LSpAF) is essential for providing better ablation solutions. The findings of traditional catheter-based electrophysiological studies can be impacted by the sedation required for these procedures. This is not required in non-invasive body-surface mapping (ECGI). ECGI allows for multiple mappings in the same patient at different times. This would expose potential electrophysiological changes over time, such as the location and stability of extra-pulmonary vein drivers and activation patterns in sustained AF.Materials and methodsIn this electrophysiological study, 10 open-heart surgery candidates with LSpAF, without previous ablation procedures (6 male, median age 73 years), were mapped on two occasions with a median interval of 11 days (IQR: 8–19) between mappings. Bi-atrial epicardial activation sequences were acquired using ECGI (CardioInsight™, Minneapolis, MN, United States).ResultsBi-atrial electrophysiological abnormalities were documented in all 20 mappings. Interestingly, the anatomic location of focal and rotor activities changed between the mappings in all patients [100% showed changes, 95%CI (69.2–100%), p < 0.001]. Neither AF driver type nor their number varied significantly between the mappings in any patient (median total number of focal activities 8 (IQR: 1–16) versus 6 (IQR: 2–12), p = 0.68; median total number of rotor activities 48 (IQR: 44–67) versus 55 (IQR: 44–61), p = 0.30). However, individual zones showed a high number of quantitative changes (increase/decrease) of driver activity. Most changes of focal activity were found in the left atrial appendage, the region of the left lower pulmonary vein and the right atrial appendage. Most changes in rotor activity were found also at the left lower pulmonary vein region, the upper half of the right atrium and the right atrial appendage.ConclusionThis clinical study documented that driver location and activation patterns in patients with LSpAF changes constantly. Furthermore, bi-atrial pathophysiology was demonstrated, which underscores the importance of treating both atria in LSpAF and the significant role that arrhythmogenic drivers outside the pulmonary veins seem to have in maintaining this complex arrhythmia.

Tales of the Unexpected: Donor Lung with CTEPH, a Unique Case Report

<h3>Introduction</h3> Whilst chronic thromboembolic pulmonary hypertension (CTEPH) is a recognised indication for lung transplantation, it is an undesirable finding in a lung donor. We present the case of an individual who underwent a single lung transplant with an allograft that was subsequently identified as having CTEPH. <h3>Case Report</h3> This 65 year old, 167cm, blood group A RhD+ female with fibrotic organising pneumonia was listed for a left single lung transplant on the basis of a hypokinetic right hemi-diaphragm. She received an organ from a 55year old, 159cm, blood group A RhD+, non-smoking female DBD donor, who died from a subarachnoid haemorrhage. The donor had possible asthma (not formally diagnosed) and an unenhanced CT chest demonstrated non-specific mosaic attenuation. A donor echocardiogram showed mild tricuspid regurgitation with normal right ventricular (RV) size but impaired radial systolic function. Donor blood gases on FiO₂ 1.0 demonstrated PaO₂ 35kPA in the left upper lobe and 64kPa in the left lower lobe pulmonary veins. The recipient surgery was uneventful, although she developed primary graft dysfunction with RV impairment. She was stabilised and extubated after 24 hours onto 2L/min supplemental oxygen. Day 10 post-transplant she developed increasing oxygen requirements. CT pulmonary angiography demonstrated patent vascular anastomoses, left lower lobe pulmonary artery occlusion and features of CTEPH, but no lung necrosis. A right heart catheter study confirmed mild pulmonary hypertension with a mean pulmonary artery pressure 25mmHg and pulmonary vascular resistance 6 Wood Units. She underwent pulmonary endarterectomy (PEA) with good clearance of the donor vasculature. She weaned easily from cardiopulmonary bypass and her supplemental oxygen was down-titrated. She was discharged home 6 weeks post-transplant to complete 12 weeks of anticoagulation. 5 months post-transplant she developed fever and hypoxia with imaging features of left lower lobe consolidation, but no new thrombus. In the context of poor physiological reserve, the patient and family requested palliation. <h3>Summary</h3> CTEPH is rare in the general population, with a prevalence 3-30 per million. In this case, the diagnosis of CTEPH only came to light after transplantation and this is the first report of PEA performed in a lung recipient. Transplant teams should be alert for CTEPH in potential lung donors.

Pulmonary vessels and bronchus anatomy of the left upper lobe.

The bronchopulmonary vascular bifurcation patterns in the upper lobe of the left lung are diverse. Therefore, it is important for general thoracic surgeons to understand the detailed anatomy of the pulmonary segments when performing thoracoscopic anatomical pulmonary resection. This study aimed to analyze the bronchovascular patterns of the left upper lobe and summarize the anatomical information associated with pulmonary anatomical pulmonary resection. We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus of 539 patients using computed tomography imaging data including those obtained using three-dimensional computed tomography. We herein report the anatomic structure in the left upper lobe. Regarding the superior division bronchi, a pattern of trifurcation into B1+2, B3, lingular division bronchus was observed in nine patients (1.7%). A pattern of proximal bifurcation of B4 was found in eight patients (1.5%). Regarding the lingular veins (LV), patterns of LV drainage into the left lower pulmonary vein were observed in 22 patients (4.1%). Regarding the pulmonary artery, mediastinal lingular arteries (MLA) were found in 161 patients (29.9%). The bifurcation patterns of the bronchovascular region in the upper lobe of the left lung were clarified. These results should be carefully noted when performing anatomical pulmonary resection.

Pulmonary veins reconnection pattern differences after failed radiofrequency ablation and cryoballoon ablation for atrial fibrillation

Abstract Point-by-point radiofrequency ablation (RF) and one-shot cryoballoon ablation (CRYO) electrically isolate pulmonary veins (PVs) in atrial fibrillation (AF) using different techniques and energies. This study aimed to examine differences in PVs reconnection pattern and ablation lesions required to re-isolate PVs after failed RF and failed CRYO. Methods Twenty-four patients who had their repeat ablation between January 2017-December 2020 were studied with six months of learning curve for CRYO. Fourteen patients had paroxysmal atrial fibrillation (PAF). Failed first ablations were defined by electrocardiogram (ECG) documented AF within twelve months following three months blanking period. Repeat ablations were performed using CARTO3® mapping system, which was utilized to locate ablation lesions and impedance drop details. Results 2,260 lesions were collected from 63 reconnected PVs (31 isolated after RF vs 32 isolated veins after CRYO). 849 lesions were targeted towards triggers. Repeat ablation procedure time was similar between both cohorts. However, repeat ablation after failed CRYO had longer fluoroscopy time (19.8±2 vs 12.4±2.1 minutes, P=0.019). The right lower pulmonary vein (RLPV) was reconnected after failed CRYO for AF in 92% of patients and 100% in PAF patients. Although PV reconnection pattern was similar between both cohorts, RLPV and left upper pulmonary vein (LUPV) required more ablation lesions after failed CRYO. Left lower pulmonary vein (LLPV) and right upper pulmonary vein (RUPV) required more ablation lesions after failed RF. Impedance drop was similar in both cohorts. Conclusion After failed CRYO for PAF, RLPV was reconnected in all patients. RUPV and LLPV required more ablation lesions after failed RF, while RLPV and LLPV required more ablation lesions after failed CRYO. Funding Acknowledgement Type of funding sources: None. PVs reconnection patternLesions number and percentage comparison

Abstract P120: Heparin-warfarin Therapy Could Be An Alternative Treatment For Diabetes Mellitus In Addition To Being A Standard Therapy For Pulmonary Vein Thrombi.

Background: Our previous study showed that warfarin or direct oral anticoagulants (DOACs) dissolved pulmonary vein thrombi (PVTs). However, in some instances, warfarin or DOACs could not dissolve PVT. It is unclear whether heparin-warfarin therapy affects PVT and diabetes mellitus (DM). Methods and Results: Our patient was a 74 year-old male. The patient had cerebral infarction one year prior; at that time, he was not treated with any medications. The patient was examined, and it was found that he had diabetes mellitus, hypertension and dyslipidemia. His HbA1c was 9.5%. The patient was treated with medications including ipraglifilozin L-proline (50 mg), sitagliptin (50 mg), repaglinide (0.25 mg) and clopidogrel (75 mg). One year after discharge, we detected PVTs in the patient’s left lower pulmonary vein (LLPV) via cardiac CT and transesophageal echocardiography (TEE). He was treated with standard doses of heparin and warfarin after stopping clopidogrel. The patient’s HbA1c was 6.2% at admission. After one month of treatment with heparin-warfarin, the PVTs were almost dissolved. The patient showed a tendency of hypoglycemia the day after admission, so the three glucose-lowering medications were discontinued within nine days. One month later, HbA1c was 6.1% without DM medications. After discharge, warfarin was continued, and blood glucose levels gradually increased. Three months later, HbA1c was 7.3%, and 4 months later, HbA1c was 7.8%, so DM medications were restarted. PVTs can release microclots, which can occlude the microvessels of all organs, leading to cell dysfunction. Heparin-warfarin can decrease microclots and reopen microvessels. Thus, blood glucose could be taken into cells, decreasing blood glucose levels. There is a possibility that DM could be prevented if we treat PVTs in their early stage. Compared to other similar cases, this patient showed hypoglycemia rather early, which might be caused by the interaction between repaglinide and clopidogrel. Conclusion: One month of heparin-warfarin therapy almost completely dissolved PVTs. During that course, DM medications were stopped in order to prevent hypoglycemia. During the next four months of warfarin therapy, the blood glucose levels gradually increased without DM medications.

Measurement accuracy of prototype non-contrast, compressed sensing-based, respiratory motion-resolved whole heart cardiovascular magnetic resonance angiography for the assessment of thoracic aortic dilatation: comparison with computed tomography angiography

BackgroundPatients with thoracic aortic dilatation who undergo annual computed tomography angiography (CTA) are subject to repeated radiation and contrast exposure. The purpose of this study was to evaluate the feasibility of a non-contrast, respiratory motion-resolved whole-heart cardiovascular magnetic resonance angiography (CMRA) technique against reference standard CTA, for the quantitative assessment of cardiovascular anatomy and monitoring of disease progression in patients with thoracic aortic dilatation. MethodsTwenty-four patients (68.6 ± 9.8 years) with thoracic aortic dilatation prospectively underwent clinical CTA and research 1.5T CMRA between July 2017 and November 2018. Scans were repeated in 15 patients 1 year later. A prototype free-breathing 3D radial balanced steady-state free-precession whole-heart CMRA sequence was used in combination with compressed sensing-based reconstruction. Area, circumference, and diameter measurements were obtained at seven aortic levels by two experienced and two inexperienced readers. In addition, area and diameter measurements of the cardiac chambers, pulmonary arteries and pulmonary veins were also obtained. Agreement between the two modalities was assessed with intraclass correlation coefficient (ICC) analysis, Bland–Altman plots and scatter plots.ResultsArea, circumference and diameter measurements on a per-level analysis showed good or excellent agreement between CTA and CMRA (ICCs > 0.84). Means of differences on Bland–Altman plots were: area 0.0 cm2 [− 1.7; 1.6]; circumference 1.0 mm [− 10.0; 12.0], and diameter 0.6 mm [− 2.6; 3.6]. Area and diameter measurements of the left cardiac chambers showed good agreement (ICCs > 0.80), while moderate to good agreement was observed for the right chambers (all ICCs > 0.56). Similar good to excellent inter-modality agreement was shown for the pulmonary arteries and veins (ICC range 0.79–0.93), with the exception of the left lower pulmonary vein (ICC < 0.51). Inter-reader assessment demonstrated mostly good or excellent agreement for both CTA and CMRA measurements on a per-level analysis (ICCs > 0.64). Difference in maximum aortic diameter measurements at baseline vs follow up showed excellent agreement between CMRA and CTA (ICC = 0.91).ConclusionsThe radial whole-heart CMRA technique combined with respiratory motion-resolved reconstruction provides comparable anatomical measurements of the thoracic aorta and cardiac structures as the reference standard CTA. It could potentially be used to diagnose and monitor patients with thoracic aortic dilatation without exposing them to radiation or contrast media.

Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter.

The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites. Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common. Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules. Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05mV. The mean width of scar-related isthmuses was 8.9 ± 3.5mm with a conduction speed of 31.8 ± 5.5cm/s compared to that of normal left atrium of 71.2 ± 21.5cm/s (p<0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p=0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1min; p=0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus. Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highlyeffective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.

A CASE OF PULMONARY VEIN THROMBOSIS WITH EXTENSION INTO THE LEFT ATRIUM

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary vein thrombosis (PVT) is a rare and often misdiagnosed condition due to nonspecific symptoms at presentation. PVT is most commonly associated with lung malignancy, recent major pulmonary surgery, or atrial fibrillation. Symptoms generally include cough, dyspnea, nonspecific chest pain, and hemoptysis, similar to pulmonary embolism. Delay in diagnosis can be lethal. CASE PRESENTATION: A 76-year-old female with hyperthyroidism, history of DVT in 2018 previously on rivaroxaban, venous insufficiency and hypertension presented with cough, congestion, and progressive fatigue for 3 days. She was increasingly dyspneic at rest and with activity the day prior to admission. She required supplemental oxygenation with 2 L/minute via nasal cannula on evaluation at our emergency center. She additionally tested positive for influenza A and B. She denied chest pain, palpitations, or orthopnea, but did have associated worsening right lower extremity edema. Bilateral lower extremity venous duplex showed evidence of an acute thrombus in the right common femoral, superficial femoral, deep femoral, and popliteal veins; the left leg had no thromboses. Given evidence of acute DVT and acute hypoxemic respiratory failure on presentation, a CT PE protocol was done, noting a thrombus in the left lower pulmonary vein that extended into the left atrium (figures 1-3), with chronic occlusion of the left lower lobe pulmonary arteries as well as enlarged pulmonary arteries. She was initially treated with a heparin drip from 1/23/2020 to 1/27/2020, then she was transitioned to oral anticoagulation with rivaroxaban 20 mg PO daily. She maintained resting oxygen saturations on room air for three days prior to discharge on 1/28/2020 and her respiratory symptoms improved significantly. She had no evidence of underlying malignancy at the time. She has followed up twice with her primary care physician, remains on oral anticoagulation, and has had no respiratory complaints since discharge. Pending outpatient hypercoagulable workup and repeat chest imaging, which was recommended in 6 months. DISCUSSION: PVT is a rare yet life threatening condition if undiagnosed. It can lead to pulmonary hypertension, cor pulmonale, TIA or stroke, and even pulmonary infarction or gangrene. Though there is no present gold standard for diagnosis of PVT, CT pulmonary angiography led to the diagnosis in this case. CONCLUSIONS: Chronic anticoagulation is the mainstay of therapy for PVT. Though some cases may be idiopathic, it is prudent to investigate further for hypercoagulable states, including malignancy. Reference #1: Chaaya, G., & Vishnubhotla, P. (2017). Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus, 9(1), e993. https://doi.org/10.7759/cureus.993 Reference #2: Rana, M. A., Tilbury, N., & Kumar, Y. (2016). Idiopathic pulmonary vein thrombus extending into left atrium: a case report and review of the literature. Hindawi Publishing Corporation: Case Reports in Medicine, 2016, (article ID 3528393), 1-3. https://www.hindawi.com/journals/crim/2016/3528393/ Reference #3: Sahay, S., & Lodato, R. (2013). Pulmonary vein thrombosis: a rare entity. CHEST Journal, 144 (4_MeetingAbstracts). https://journal.chestnet.org/article/S0012-3692(16)42762-5/fulltext DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

P1345 Tumors metastatic to the heart :Echo, CT, CMR Imaging

Abstract Background The frequency of secondary metastatic tumors has increased over years attributable to increased life expectancy in oncologic patients. Imaging with different methods: echo, CMR, CT and PET can provide noninvasive characterization of cardiac masses. We present 3 cases of cardiac metastasis, different for localization in the heart, pathways of dissemination and relation with neighboring structures. Case 1: a 62-years-old male was admitted to Cardiology department for chest pain and epistaxis. Patient’s medical history was negative for cardiovascular disease. The routine TTE detected a rounded,immobile,intra-myocardial mass (Panel A, fig.1) a the level of the interventricular septum protruding in the LV cavity. The mass was characterized by several anecogenic cavities and echo-contrast showed slight late hyperenhancement of the mass confirming vascularity (fig. 2).CMR gadolinium imaging confirmed late enhancement at the level of the edges of the cavities and in the external border (fig.4). In the suspicion of neuroendocrine tumor, a Gallium-68 dotatate PET/CT was performed with detection of pathological uptake at the abdominal and cardiac level (fig.3). Case 2: a 64-years-old woman presented with shortness of breath, fatigue and weight loss in the past three months. History of smoke was present and diagnosis of non-small cell lung cancer was made. PET-CT demonstrated pathological uptake at pulmonary, limph-nodes, adrenal, hepatic, bone, muscular and pericardial level (Panel B, fig.1).CMR clearly revealed a massive lesion (7x3x3.5 cm) at the level of the LV antero-lateral wall (fig.2) and TTE SAX view (fig.3) confirmed the presence of a large infiltrative immobile mass in the antero-lateral wall. In the same region the pericardium was irregular and thickened suggestive of pericardial tumor involvement. Some degree of pericardial effusion was also present. The ECG was consistent with ST-T elevation in D1 and aVL in absence of ischemic symptoms (fig.4).Case 3: a 78-years-old man known for non-small cell lung cancer underwent transthoracic echo for monitoring cardiotoxicity.Two–chamber TTE showed a intra-myocardial mass in the inferior wall of LV and another rounded mass at the left atrial level (Panel C, fig.1). Chest CT showed the pulmonary mass with irregular borders, intravascular invasion of left lower pulmonary vein (LLPV) and extension into the left atrium (fig.2).2D/3D TEE well demonstrated the atrial invasion by the mass composed by one more echogenic part inside the llpv and outside in the left atrium a rounded head with several region of cystic colliquation (fig.3). Attached to the rounded head irregular protuberances was noted (thrombus?, fig.4). Conclusion: metastasis to the heart and pericardium are much more common than primary cardiac tumors and occur late in the course of malignant disease. Echo is the initial diagnostic test to evaluate for the presence of cardiac metastases. Abstract P1345 Figure. Different cases of cardiac metastasis

Intrathoracic hemorrhage by deep pericardial sutures as detected by transesophageal echocardiography: report of two cases

BackgroundThe use of deep pericardial suture (DPS) is a widely used technique to lift the heart and expose the targeted vessels during off-pump coronary artery bypass grafting (OPCAB). Several reports alert massive bleeding due to DPS, especially for the patients with perioperative administration of tissue plasminogen activator, low molecular weight heparin, and administration of double antiplatelet agents.Case presentationWe report two cases of bleeding followed by huge hematoma formation in the left thoracic cavity caused by DPS during OPCAB. In one, bleeding was caused by damage to the left lower pulmonary vein and damage to the diaphragmatic artery in the other. Transesophageal echocardiography (TEE) is a potent tool for detecting complications and identifying the location of bleeding.ConclusionsTEE is useful for finding hemorrhagic complications and for determining the points of bleeding based on the location of the hematoma.

Aggressive Aortopathy in neonatal Marfan syndrome

BackgroundNeonatal Marfan syndrome is a rare, severe form of Marfan syndrome with a poor prognosis. Surgical intervention to address massive aortic root dilatation is uncommon as dissection rarely occurs, and death invariably results from congestive heart failure and recurrent respiratory infections.Case presentationAn 11 month old female with a prenatal diagnosis of aortic root dilatation was aggressively treated both medically and surgically. Genetic testing revealed a partial deletion in FBN1 exons 46–50 and an addition 17q11 microdeletion. Valve-sparing aortic root remodeling was successful at eliminating her risk of a type A aortic dissection. Prior to surgery, however, her root caused significant left atrial and left lower pulmonary vein compression, which has not completely resolved.ConclusionsAortic dilatation occurs rapidly despite aggressive medical management. Root remodeling and atrioventricular valve repair are possible, but the durability of the latter is uncertain. It is possible that our patient’s combined gene mutations are exacerbating her disease.

Atypical Mixed Total Anomalous Pulmonary Venous Connection: A Case Report

A 2 years old boy presented to us with a history of repeated respiratory tract infections and bluish discoloration of tongue, lips and figure tips for last 18 months. Echocardiography and Computed tomography (CT) angiogram revealed total anomalous pulmonary venous connection (TAPVC) mixed type (supracardiac and cardiac);all pulmonary veins drain into a common chamber behind left atrium (LA) and left lower pulmonary vein (LUPV) drains to vertical vein and common chamber both.The patient underwent rerouting of pulmonary veins and vertical vein ligation above the drainage of LUPV.&#x0D; Bangladesh Heart Journal 2018; 33(2) : 138-140

P2.17-26 Quantifying the Interfractional Motion of the Esophagus During Radiation Therapy for Locally Advanced Non Small Cell Lung Cancer

To quantify the interfractional motion of the esophagus during radiation therapy for locally advanced non small cell lung cancer using daily cone beam CT. The analysis of interfractional esophagus motion was performed on treatment planning 4DCT scans and daily CBCT acquired from 35 patients with stage IIIA/B NSCLC. The simulation CT and CBCT were fused using bone registries and adjusted to the carina. Interfractional motion of the esophagus in the right-left (RL) and anterior-posterior (AP) directions at levels of sternal notch (A), carina (B), 2.5 cm below the carina (C) and the left lower pulmonary vein (D) was recorded and analyzed respectively. A total of 612 CBCT image sets were obtained. The mean interfractional RL motion at level A, B, C and D was 0.5±2.9mm, -0.2±3.7mm, -0.5±3.9mm and -1.3±4.8mm, with the mean absolute value of 2.1±2.0mm, 2.7±2.6mm, 2.9±2.6mm and 3.4±3.6mm, respectively. The mean AP motion at level A, B, C and D was -0.3±2.0mm, 1.0±2.0mm, 1.3±2.2mm and 2.2±2.4mm, with the mean absolute value of 1.6±1.3mm, 1.7±1.6mm, 2.6±1.9mm and 3.4±3.6mm, respectively. Coverage of 95% of esophageal mobility requires 4.9 mm left, 4.4mm right, 3.1mm posterior and 3.7mm anterior margins at level A; 5.3 mm left, 6.5mm right, 4.5mm posterior and 1.9mm anterior margins at level B; 5.5 mm left, 7.2mm right, 4.8mm posterior, and 2.0mm anterior margins at level C; and 4.9 mm left, 7.9mm right, 6.3mm posterior, and 1.6mm anterior margins at level D. In RL and AP directions, the average of the absolute interfractional motion of the esophagus was 3.4mm or less at all the four levels. The interfractional motion was greatest at the level of left lower pulmonary vein. The absolute RL motion was greater than AP motion. These data helps to set margin for ITV for future IMRT trials to account for esophageal motion.