Pulmonary vein stenosis: Etiology, diagnosis and management

Figure 1 Transesophageal echocardiography of a patient with a recent left lung transplantation and severe congestion in the graft. A: Narrowing in the common trunk of the left PVs at the level of the sutures (arrow). Color Doppler and Continuous Wave Doppler demonstrate turbulent flow (B) and high velocity (C: peak velocity 2.4 m/s; peak gradient 23 mmHg) across the vessel which is consistent with a significant stenosis. A stent was successfully implanted at the level of the stenosis (D: “en face” 3D echo image view; arrow). Laminar flow (E) and normal velocities (F: peak velocity 0.8 m/s; Peak gradient 2.5 mmHg) were seen after the procedure.

Figure 2 Computed tomography of a patient undergone radiofrequency ablation two months before and recent onset of dyspnea on exertion. A: Absent of contrast (arrow) in the left lower pulmonary vein (complete occlusion); B: Extensive infiltrate within the left lung (arrow) cause by localized edema; C and D: After stent implantation (arrows) flow was successfully restored.

Figure 3 Magnetic resonance scan of a patient with a radiofrequency ablation procedure one month before, mild hemoptysis and fever. A: Angiography shows normal caliber of the four PVs; B: Phase contrast imaging of the right lower PV. Top left: right pulmonary artery (arrow) and right lower PV (dashed arrow). Top right: Flow map. Black or white signal depends on the direction of the flow. The PV “white flow” (dashed arrow) compares with the opposite direction of flow in the pulmonary artery seen in the same image that is “black” (arrow). Bottom: the resulting velocity-time curve demonstrates normal flow morphology and velocities in the PV. Significant PVS was excluded. RUPV: Right upper pulmonary vein; RLPV: Right lower pulmonary vein; LUPV: Left upper pulmonary vein; LLPV: Left lower pulmonary vein; PV: Pulmonary vein.

Figure 4 Radionuclide lung ventilation/perfusion scan performed three months after radiofrequency ablation in a patient with shortness of breath. A and B: Normal ventilation; C and D marked hypoperfusion within the left lung consistent with significant left PV stenosis which was demonstrated on a CT scan. PV: Pulmonary vein; CT: Computed tomography.

Figure 5 Surgical techniques for pulmonary veins. A: Schematic representation of a bilateral pulmonary vein stenosis at the ostia of the vessels; B: Endarterectomy; the stenotic tissue has been excised and the PVs directly anastomosed to the LA; C: Pericardial patch venoplasty; the stenotic tissue has been resected and a pericardial patch anastomosis has been used to enlarge the tightened ostia of the vessels; D: Sutureless marsupialization: the veins ostia have been incised longitudinally, excess fibrotic tissue has been excised and in situ pericardial flaps have been sewn directly to the left atrium so direct stiches over the cut edges of the pulmonary veins are avoid. PV: Pulmonary vein; LA: Left atrium.

Figure 6 Stent implantation in a pulmonary vein stenosis. A: Angiography showing a critical stenosis in the ostium of the left lower pulmonary vein; B: Bare metal stent release; C and D: Final result. The stenosis was resolved. Normal flow can be seen in the main superior (C) and inferior (D) branches of the vein.