Lower Pulmonary Vein Research Articles

Abstract 4122350: Most Diabetes Mellitus Patients Had Right Lower Pulmonary Vein Thrombi; Additionally, Many Patients Had Extended Large Rod-Like Thrombi in the Left Atrium

Background: Retrieved thrombus studies have shown that retrieved thrombi have calcifications, indicating that the thrombi are old. Left atrium diverticula (LADs) are common; however, the mechanisms of LAD formation are poorly understood. Pulmonary vein thrombi (PVTs) are common and are underestimated. In 2022, we reported that 98.6% of senior patients with age-related diseases such as hypertension, dyslipidemia and atrial fibrillation had PVTs, as estimated by cardiac computed tomography (CT) and transesophageal echocardiography (TEE). Additionally, we reported a case in which a malignant lymphoma patient had ATs in the right lower pulmonary vein, in which extended large rod-like thrombi in the left atrium (LA) were found, as determined by TEE. Patients with type 2 diabetes mellitus (T2DM) must have PVTs. The characteristics of extended LA thrombi in patients with T2DM are unclear. Methods: Thirty-one patients with T2DM (73.5 +/- 8.9 y.o., from 50 y.o. to 88 y.o.; male, 24) were examined for PVTs, as estimated via TEE and cardiac CT. Results: Thirty (97%) patients with T2DM had PVTs in the right lower pulmonary vein (RLPV) and connected LA thrombi, as estimated using TEE. Among them, 27 (87%) patients had large white rod-like LA thrombi extending from RLPV thrombi, and the diameter of the thin part of the rod-like LA thrombi was approximately 5 mm. The end of the LA thrombi was mainly attached to the left side of the anterior wall or the posterior side of left side wall of the LA. Additionally, there were left atrium diverticula (LADs) around the attachment regions. Three patients had RLPV thrombi and connected shorter LA thrombi. A 79-year-old male patient did not have detectable PVTs. The patient had taken apixaban (2.5 mg, twice daily) for six years due to atrial fibrillation and stroke. Conclusions: Most (97%) elderly T2DM patients had RLPV thrombi. Additionally, many (87%) patients had extended large rod-like thrombi in the LA. The diameter of the thin part of the large rod-like LA thrombi was approximately 5 mm. There were LADs around the attachment regions where the ends of the LA thrombi from the RLPV thrombi were attached.

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.

Left ventricular dysfunction in pulmonary arterial hypertension is attributed to underfilling rather than intrinsic myocardial disease: a CMR 2D phase contrast study

The pathophysiology underlying impaired LV function in PAH remains unclear, with some studies implicating intrinsic myocardial dysfunction and others pointing to LV underfilling. Evaluation of pulmonary vein area (PVA) and flow may offer novel, mechanistic insight by distinguishing elevated LV filling pressure common in myocardial dysfunction from LV underfilling. This study aimed to elucidate LV filling physiology in PAH by assessing PVA and flow using cardiac magnetic resonance (CMR) and compare pulmonary vein flow in PAH with HFrEF as a model representing elevated filling pressures, in addition to healthy controls. Patients with PAH or heart failure with reduced ejection fraction (HFrEF) referred for CMR were retrospectively reviewed, and healthy controls were included as reference. Pulmonary vein S, D and A-wave were compared between groups. Associations between pulmonary vein area (PVA) by CMR and echocardiographic indices of LV filling pressure were evaluated. Nineteen patients with PAH, 25 with HFrEF and 24 controls were included. Both PAH and HFrEF had lower ejection fraction and S-wave velocity than controls. PAH displayed smaller LV end-diastolic volumes than controls, while HFrEF demonstrated larger PVA and higher A-wave reversal. PVA was associated with mitral E/e′ ratio (r2 = 0.10; p = 0.03), e′ velocity (r2 = 0.23; p = 0.001) and left atrial volume (r2 = 0.07; p = 0.005). Among PAH, PVA was not associated with LV-GLS. A PVA cut-off of 2.3cm2 displayed 87% sensitivity and 72% specificity to differentiate HFrEF and PAH (AUC = 0.82). PAH displayed lower pulmonary vein S-wave velocity, smaller LV volume and reduced function compared with controls. Reduced LV function in PAH may be owing to underfilling rather than intrinsic myocardial disease. PVA demonstrates promise as a novel, non-invasive imaging marker to assess LV filling status.

Efficacy and Safety of Laser Balloon Versus Irrigated Radiofrequency Ablation as Initial Therapies for Atrial Fibrillation: A Meta-Analysis.

Catheter ablation (CA) is an effective therapy for atrial fibrillation (AF) and, although radiofrequency ablation (RFA) is the standard treatment for pulmonary vein isolation (PVI), it is complex and time-consuming. Laser balloon ablation (LBA) has been introduced to simplify the conventional RFA; however, results of studies comparing LBA and RFA remain controversial. As such, this investigation aimed to comprehensively evaluate the efficacy and safety of LBA versus RFA. The PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases were searched for relevant studies. The primary endpoints were the freedom from atrial tachyarrhythmia (ATA) and procedure-related complications. Twelve studies including 1274 subjects were included. LBA and RFA yielded similar rates of freedom from ATA (72.5% vs. 68.7%, odds ratio [OR] = 1.26, 95% confidence interval [CI] 1.0-1.7, p = 0.11) and procedure-related complications (7.7% vs. 6.5%, OR = 1.17, 95% CI 0.72-1.90, p = 0.536). LBA with the second- and third-generation laser balloons (LB2/3) yielded remarkably higher rates of freedom from ATA than RFA using contact-force technology (RFA-CF) (OR = 1.91, p = 0.013). Significantly lower pulmonary vein (PV) reconnection rates (OR = 0.51, p = 0.021), but higher phrenic nerve palsy (PNP) rates (OR = 3.42, p = 0.023) were observed in the LBA group. LBA had comparable procedure (weighted mean difference [WMD] = 8.43 min, p = 0.337) and fluoroscopy times (WMD = 3.09 min, p = 0.174), but a longer ablation time (WMD = 12.57 min, p = 0.00) than those for RFA. LBA and RFA treatments were comparable in terms of freedom from ATA and postprocedural complications in patients with AF. Compared with RFA, LBA was associated with significantly lower PV reconnection rates, but a higher incidence of PNP and longer ablation time.

Pulmonary vein isolation by cryoablation on patients with paroxysmal atrial fibrillation

Aim: Atrial fibrillation is just one of many arrhythmias that affects the cardiac rhythm and the heart as a pump which consequently increases the chance of an embolic insult. Due to the electric stimuli that originate from pulmonary vein ostia and their lumen, an isolation procedure is initiated, mostly by cryoablation. The main goals of this study were to investigate the relationship between measured nadir temperatures during cryoablation of each individual pulmonary vein and to compare the success of first-time cryoablation between left and right pulmonary veins. Participants and methods: The study involved 40 participants who underwent pulmonary vein isolation by cryoablation due to paroxysmal atrial fibrillation, irrespective of gender and age. The procedures were carried out throughout the year 2022 at the University Hospital Centre Zagreb, where the data were collected. All necessary patient data were permanently recorded and saved in a separate cryoconsole used to dictate the entire procedure. Results: Given the 40 participants in the study, a total of 160 pulmonary veins were analyzed. The t-test shows that the left upper pulmonary vein was the most advantageous vein to isolate, and the lower right pulmonary vein was the least advantageous. p-value analysis has also shown significant differences between left and right pulmonary veins, with that difference being lower in value between the left-sided pulmonary veins. Additionally, the chi-squared test confirmed a statistically significant difference between successful cryoablations of left-sided and right-sided pulmonary veins. This has shown that the left-sided pulmonary veins are easier to isolate on first cryoablation, rather than their right-sided counterparts. Conclusion: Pulmonary vein isolation by cryoablation is an excellent proof of incorporating fundamental physical principles in medicinal purposes. This study keeps the doors open for further research into optimal approaches in atrial fibrillation treatment. Therefore, comparing our study with recent publications and literature suggests higher success in isolating left pulmonary veins compared to right pulmonary veins.

Case Report: Giant bronchogenic cyst compressing the pericardium and the lung hilum

Introduction: The bronchogenic cyst is a congenital anomaly of the trachea and the bronchi resulting in a malformation that develop in the bronchial tree, most often in the middle mediastinum. It is a benign pathology, often asymptomatic, however in the case of a large bronchogenic cyst, signs of compression of the intra-thoracic organs appear and early surgery is necessary to avoid complications. Case presentation: A 49-year-old patient was referred to our department with dry cough, dyspnea and chest tightness progressing for six months. Radiological exploration concluded that a giant bronchogenic cyst, 90 mm in diameter, was very probable. Surgery was performed via a right posterolateral thoracotomy. Intraoperatively, there was a large cystic formation 100mm*80 mm of the middle mediastinum in intimate contact with the origin of the right pulmonary artery, the lower right pulmonary vein as well as the right atrium exerting a compressive effect on the bronchi. The lesion was firmly adhered to the pericardium. The cystic was ‘en bloc’ resected in totality. The postoperative course was uncomplicated. Histological examination confirmed diagnosis of a bronchogenic cyst. The patient was asymptomatic throughout the follow-up period. Clinical discussion: Apart from the possibility of malignant degeneration, a bronchogenic cyst can increase in size and become huge causing serious complications. Despite the predictive diagnostic value of imaging, definitive diagnosis of a bronchogenic cyst is confirmed by surgical excision and pathological examination. Conclusions: Surgery is almost obligatory especially if the cyst is above a certain size (about 60 mm) and in the case of giant bronchogenic cysts.

Pulmonary Artery Wedge Pressure Can Underestimate Direct Pulmonary Vein Pressure in Pediatric Pulmonary Vein Stenosis

BackgroundPulmonary artery wedge pressure (PAWP) can underestimate directly measured pulmonary vein pressure (PVP) as demonstrated in animal studies and human case reports. This concept has not been validated in a larger cohort of pediatric patients with pulmonary vein stenosis (PVS). MethodsPediatric patients who underwent cardiac catheterization for PVS at a single center from January 1, 2018, to March 31, 2023, were retrospectively reviewed. Mismatch between the PAWP and directly measured PVP or LA pressure was defined as >3 mm Hg. Preintervention angiography was reviewed and percent stenosis calculated. ResultsTwenty-six patients met inclusion criteria; 51 lower pulmonary veins (34 left, 17 right) from 42 catheterizations were evaluated. Significant PVS (≥30% stenosis) was seen in 38/51 (75%) veins, and 9/51 (18%) veins had no angiographic narrowing (0% stenosis). PAWP-PVP mismatch occurred in 37/51 (73%) veins with a median difference of 8 mm Hg (IQR, 6-12). Of these, PAWP was equal to LA pressure in 26 instances, all of which had significant PVS (median % stenosis 54 [IQR, 45-60]). Six of the cases with PAWP-PVP mismatch, PVS (range, 41%-70% stenosis), and no PAWP-LA mismatch reported both a proximal and distal segmental PAWP. In all 6 instances, there was no distal PAWP-PVP mismatch (median difference 1 mm Hg [range, 0-3]). ConclusionsIn this single-center study of pediatric patients with PVS, PAWP significantly underestimated directly measured PVP in lower pulmonary veins. Balloon wedge or end hole catheter position in a distal lobar segment may more accurately estimate the PVP.

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 18886: Rare but Fatal: Thrombus Formation and Cerebral Infarction Following Atrial Fibrillation Ablation

Introduction: Atrial fibrillation (AF) ablation has become increasingly common as a first line treatment for young, healthy patients and recurrent AF. While the procedures are effective and safe with a mortality rate of &lt;0.1%, it can be associated with fatal complications. Case Presentation: A 74-year-old male with a history of AF status post epicardial ablation, ascending and thoracic aortic aneurysm, hypertension, dilated cardiomyopathy, sick sinus syndrome and alcohol use presented with left hemiparesis and left sided facial droop. He had undergone radiofrequency ablation about 3 weeks prior. Initial evaluation for stroke with computed tomography (CT) of head and CT angiography (CTA) of head/neck was negative. He was intubated for airway protection. Upon insertion of the nasogastric tube, it had dark blood concerning for an upper gastrointestinal bleed. The hospital course was complicated by sinus bradycardia and severe hypotension requiring dopamine and norepinephrine infusions. Repeat CTA head/neck demonstrated new evolving infarcts in the left middle cerebral artery (MCA), left posterior cerebral artery and right MCA territories. During an esophagogastroduodenoscopy to rule out atrioesophageal fistula, patient had a vasovagal episode which resolved with epinephrine. Subsequent transesophageal echocardiogram (TEE) demonstrated an echogenic long protruding thrombus extending across the iatrogenic atrial septal defect from the right atrium to the posterior wall of the left atrium, attached near the ostium of the right lower pulmonary vein. Repeat CT head multiple new areas concerning for developing infarctions and pneumocephalus. Given his overall grim prognosis, the patient was transitioned to comfort care. Conclusions: As ablative procedures for management of AF become more prevalent, it is imperative to maintain a high clinical suspicion for rare but fatal complications which require prompt diagnosis and early aggressive management.

Abstract 13693: Left Atrial Sarcoma Mimicking Myxoma in Embolic Stroke

Background: Myxomas cause about 0.5% of strokes. Cardiac sarcomas are rare, may mimic myxomas, and are also associated with stroke. Imaging can provide clues to diagnosis. Case: A 53-year-old woman with diabetes, hypertension and prior strokes was admitted with new left hemiparesis. Computed tomography (CT) of the head revealed large middle cerebral artery infarct with petechial hemorrhages. Transthoracic echocardiogram (TTE; panel A) revealed large left atrial (LA) mass suspicious for myxoma protruding through the mitral valve. CT of the chest (panel B) revealed hilar adenopathy and LA mass concerning for myxoma or thrombus with stalk attachment to the right pulmonary vein (PV). Decision-making: Following heart team meeting decision was to remove the mass surgically given its embolic potential. Intraoperative transesophageal echocardiogram (TEE; panel C) revealed a large LA mass with multiple papillary protrusions and attachment via a stalk to the right lower PV. The mass was successfully removed and the patient recovered and was discharged. Follow up pathology returned as cardiac sarcoma. Conclusion: Pulmonary vein intimal sarcomas are rare tumors with poor prognosis, presenting early with chest pain, dyspnea and hemoptysis, or late with stroke. They can mimic myxomas and are therefore often diagnosed post-operatively. Preoperative diagnosis however is imperative to plan treatment and for prognostication. TEE and cardiac magnetic resonance imaging are the modalities of choice to diagnose sarcomas and evaluate extent of cardiac structure involvement.

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.

Abstract 12390: Differences in the Impact of Use of Contact Force Sensing Catheters on Subsequent Rates of Pulmonary Vein Reconnection Detected Between Men and Women During Repeat Ablation of Atrial Fibrillation

Background: Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF). Contact force (CF) sensing catheters permit tissue contact monitoring that may lead to durable pulmonary vein (PV) isolation. Objective: To assess the impact of CF-sensing catheters on PV reconnection rates at repeat AF ablation and whether there are sex-based differences. Methods: We conducted a retrospective study of patients who underwent repeat AF ablation after index PV isolation between 2010 and 2022. Patients were divided into 2 groups: Group 1 (non-CF sensing catheters) and Group 2 (CF-sensing catheters). Results: One hundred sixty-one patients were included in the study (76 in Group 1 and 85 in Group 2, 32% female, 70 ± 10 years old). Initial use of CF-sensing catheters at index ablation was associated with a lower PV reconnection rate at repeat ablation (60% for Group 2 vs 87% for Group 1; P = 0.001). There were no significant differences in locations of PV reconnection between Group 1 and Group 2. When stratified by sex, there were significantly lower rates of PV reconnection in male patients with use of CF-sensing catheters (92% for Group 1 vs 67% for Group 2; p=0.001) but not for female patients (71% for Group 1 vs 50% for Group 2; p=0.23). On multivariable logistic regression analysis, use of CF-sensing catheters at index ablation (adjusted odds ratio [aOR]: 0.28, 95% CI: 0.12 to 0.65; p=0.003) and female sex (aOR: 0.38, 95% CI: 0.17 to 0.86; p=0.02) were associated with significantly lower rates of PV reconnection found at repeat ablation. Conclusion: Use of CF sensing catheters reduced PV reconnection rate found at repeat AF ablation. Females have lower rates of PV reconnection identified at repeat ablation which suggest that non-PV triggers may be a more common cause of recurrent AF, thereby blunting the impact of CF-sensing catheters on reducing recurrent AF in females.

Achievement of pathological complete response with osimertinib for EGFR-mutated lung adenocarcinoma

BackgroundTyrosine-kinase inhibitors (TKIs) of epidermal growth factor receptor (EGFR) usually provide a potent anti-tumor efficacy with robust radiographic response for non-small cell lung cancer (NSCLC) harboring activating mutations in the EGFR gene. However, first-generation EGFR-TKIs may provide only modest pathological response in the majority of EGFR-mutated NSCLC. Here, we present a case of EGFR-mutated adenocarcinoma in which a pathological complete response was revealed in histological specimens obtained during conversion surgery following systemic treatment using a third-generation EGFR-TKI.Case presentationA 61-year-old Japanese man was admitted to our hospital for salvage surgery. Four months prior to the admission, he had been diagnosed with unresectable adenocarcinoma (clinical stage IIIA/T4N1MO) originating from the right lower lobe. Chest computed tomography had revealed a 3.4-cm tumor and enlarged hilar nodes that invaded into the left atrium through the lower pulmonary vein. An activating EGFR-mutation (L858R) had been detected in the tumor specimen. Osimertinib monotherapy had provided a dramatic radiographic response. The patient was diagnosed with potentially resectable disease after 4 months’ osimertinib treatment and was referred to our hospital. Complete resection with right lower lobectomy and combined resection of the left atrium was achieved. Pathological examination showed no viable tumor cells in the resected specimens. Postoperative course was uneventful. The patient is alive without tumor recurrence at 2 years after surgery.ConclusionsPathological complete response was achieved with systemic treatment with osimertinib prior to surgery. Conversion surgery after osimertinib treatment may be safe and effective for NSCLC harboring activating EGFR-mutations.

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.

Artificial intelligence-guided automated measurement of pulmonary vein diameter in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This research was supported by Basic Science Research Program through the National Research Foundation of Korea(NRF) funded by the Ministry of Education(2022R1I1A1A01071083). This work was also supported by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health &amp; Welfare, the Ministry of Food and Drug Safety) (Project Number: RS-2022-00141473). Background In the planning of atrial fibrillation (AF)-related procedures, predicting left atrial (LA) anatomy and pulmonary vein (PV) diameter is important for the effectiveness and safety of the procedures but requires a labor-intensive measurement process. Here, we propose an artificial intelligence (AI) based PV diameter measurement algorithm for the computed tomogram (CT)-based automated PV evaluation. Methods We implemented a mesh-based convolutional neural network for the surface segmentation of four PVs and the LA appendage (LAA) in a 3D LA surface mesh. Our algorithm includes two originative methods of surface depth feature and cohesion loss function to improve the performance. We trained the model with the LA mesh of 210 AF patients’ CT scan and validated the accuracy of surface segmentation and PV diameter with independent 158 samples. Results Using an AI-based automated LA measurement model, we achieved an average Intersection over Union (IoU) of 83.4% and a regional IoU from 78.4 to 87.2 % in 158 LA meshes. When we added the surface depth feature, the IoU was improved by 31.7% compared to the conventional 3D feature. The cohesion loss function reduced the fragmentation rate of the surface label by 3.2%. Post-processed PV diameters did not differ from manually measured left (P=0.56) and right upper PV diameters (P=0.08) but differed in both lower PVs (p&amp;lt;0.001). The eccentricity variance of the PV ostia did not differ between AI-measured and manually measured PVs (P=0.68~0.84). Conclusion We proposed an AI-guided automated algorithm for surface segmentation and PV diameter measurement and validated it at both upper PVs and the eccentricity of the PV ostia. Our algorithm can be applied to the automated sizing of LA appendage and improve labor-intensive manual segmentation.

Left common trunkus pulmonary veins have genetic background and poor rhythm outcome after atrial fibrillation catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background There is a genetic background in pulmonary vein (PV) development and atrial fibrillation (AF). However, the genetic trait of PV variations and their rhythm outcome after AF catheter ablation (AFCA) is unclear. Objective We explored the genetic and clinical characteristics and long-term rhythm outcomes of AF patients with PV variation or left common trunkus (LCT)-PV. Methods We included 2,897 AF patients (74.0% male, age 59.0 ± 10.7 years, 66.3% paroxysmal AF) with available genome-wide association study results, cardiac computed tomogram data, and protocol-based regular rhythm follow-up from the Yonsei AF ablation cohort database. We defined LCT-PV when the upper and lower PV separate at &amp;gt;10 mm distal to the left PV antrum margin. PV variations included both LCT-PV and accessory PVs. We analyzed the polygenic risk score (PRS) of 12 AF-associated genes (DSP, GJA1, HCN4, KCNQ1, NPPA, PITX2, RYR2, SCN5a, SHOX2, ATP2A2, TBX3, and TBX5) and long-term rhythm outcomes after AFCA. Results We found PV variation in 296 (10.2%) and LCT-PV in 102 (3.5%). PRS of 1,227 single nucleotid polymorphisms (SNPs) was significantly higher in PV variation patients (p=4.93e-08) and LCT-PV patients (p=1.95e-20). The patients with LCT-PV had higher CHA2DS2VASc scores (p=0.024) and lower atrial epicardial adipose tissue volume (p=0.034). During 39.7 ± 34.8 months follow-up period, LCT-PV patients had a significantly higher recurrence rate than their counter part in the paroxysmal AF sub-group (Log-rank p=0.036), but not in overall PV variations. LCT-PV with the highest 10% PRS was independently associated with AF recurrence after AFCA (HR 2.10, 95% CI 1.21-3.63, p=0.008). Conclusions Among the patients who underwent AFCA, PV variation, including LCT-PV, has a significant genetic background. The post-AFCA recurrence rate was significantly higher in patients with LCT-PV and high PRS, especially in paroxysmal AF.

Our experience with solitary fibrous tumors in the chest area.

The article reports on three patients with a solitary fibrous tumor of the chest. The first patient had a tumor in the area of the dome of the right pleural cavity which was radically resected together with the chest wall around its origin. In the second case, the tumor was attached by a vascular pedicle to the lower lobe of the right lung. This tumor was resected atypically, via thoracotomy, along with a margin of healthy lung tissue at the base of its pedicle. The last patient had a tumor of the lower lobe of the right lung, surrounding the lower pulmonary vein, which did not have a clear margin of healthy lung tissue. This finding required right lower lobectomy via posterolateral thoracotomy. The presented cases describe rare types of tumors in the chest area which at the time of detection often reach large dimensions, necessitating extensive surgical procedures. Due to the biological nature of these tumors, long-term patient follow-up is advisable.

Primary sutureless repair concomitant with the Warden procedure.

A 2-month-old girl who had supracardiac total anomalous pulmonary venous connection (Darling classification type 1b) was referred to our institution. Computed tomography showed that multiple right upper pulmonary veins drained into the vertical vein, near the entry to the superior vena cava. The common pulmonary venous chamber was located lower right than usual, and right upper pulmonary veins were far from the common chamber. We successfully performed primary sutureless repair concomitant with the Warden procedure. Postoperative computed tomography showed unobstructed pulmonary veins and superior vena cava routes, and the vertical vein between right upper and lower pulmonary veins shrank slightly.