Ann Thorac Surg 2005;79:1778-1780
© 2005 The Society of Thoracic Surgeons
Case report
Left Pneumonectomy for Lung Cancer After Correction of Contralateral Partial Anomalous Pulmonary Venous Return
Hiroyuki Sakurai, MD*,a,b,
Haruhiko Kondo, MDa,c,
Akihiko Sekiguchi, MDd,
Yoshihiro Naruse, MDe,
Haruo Makuuchi, MDe,
Kenji Suzuki, MDa,
Hisao Asamura, MDa,
Ryosuke Tsuchiya, MDa
a Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
b Second Department of Surgery, University of Yamanashi, Yamanashi, Japan
c Division of Thoracic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
d Division of Cardiovascular Surgery, National Center for Child Health and Development, Tokyo, Japan
e Division of Cardiovascular Surgery, Toranomon Hospital, Tokyo, Japan
Accepted for publication October 28, 2003.
* Address reprint requests to Dr Sakurai, Second Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Tamaho-cho, Nakakoma-gun, Yamanashi 409-3898, Japan
sakuraihm{at}ybb.ne.jp
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Abstract
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We report the successful treatment of a 48-year-old man with left lung cancer and contralateral partial anomalous pulmonary venous return (PAPVR). He was found to have an abnormal shadow on a regular checkup. Sputum cytology revealed squamous cell carcinoma. Chest computed tomography showed not only a left hilar mass but also showed that his right superior pulmonary vein was draining into the high portion of the superior vena cava. In the presence of the right partial anomalous pulmonary venous return, it was believed that left pneumonectomy would cause serious postoperative heart failure due to an increase in the left-to-right shunt. Therefore his partial anomalous pulmonary venous return was corrected first under cardiopulmonary bypass, and 3 weeks later he underwent successful radical left pneumonectomy.
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Introduction
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If possible, surgical treatment should be selected for primary non-small cell lung cancer. On the other hand, minor congenital anomalous conditions such as pulmonary arterial, venous, or bronchial variations are sometimes found during an operation. Most of these conditions do not cause any serious problems during or after lung resection. However, when a vascular shunt is present in another lobe of the lung, major lung resection may cause a fatal problem (ie, acute right heart failure with large left-to-right shunt) [1, 2]. We report a case of contralateral pneumonectomy after the surgical treatment of partial anomalous pulmonary venous return (PAPVR) of the right lung.
A 48-year-old man was found to have an abnormal shadow on a regular checkup in July 2000. He was asymptomatic and his past history was unremarkable. Sputum cytologic examination was positive for squamous cell carcinoma, and he was referred to the National Cancer Center Hospital. The chest roentgenogram showed a hilar mass shadow in the left lung. A chest computed tomography revealed a hilar mass in the left upper lobe with no mediastinal lymph node swelling and an anomalous vessel on the right hilar site (Figs 1, 2). Based on the results of a digital subtraction pulmonary angiogram, we diagnosed the abnormality as a PAPVR of the superior pulmonary vein draining into the high portion of the superior vena cava (Fig 3). Fiberoptic bronchoscopy revealed occlusion of the B1+2 bronchus by an endobronchial lesion. Transbronchial biopsy revealed squamous cell carcinoma. Clinical examination did not reveal any remarkable abnormalities. The echocardiogram and electrocardiogram showed normal cardiovascular activity without atrial septal defect. Based on the findings in cardiac catheterization, the patient had a pulmonary to systemic flow ratio (Qp/Qs) of 1.5 and his pulmonary artery pressure was 25/14 mm Hg. Blood gas analysis revealed a partial pressure of oxygen (PaO2) of 82.1 mm Hg, whereas his carbon dioxide (PaCO2) was 39.1 mm Hg; these measurements were both normal for his age. His lung cancer was considered to be a resectable lesion of clinical T2 N1 M0 stage IIB. The planned operation for his lung cancer was a left pneumonectomy, which may have caused fatal right-side heart failure postoperatively unless the right PAPVR was corrected.
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Fig 1. Chest computed tomographic scans show tumor involving hilar lymph nodes adjacent to the left pulmonary artery of the lung. (PA = pulmonary artery.)
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Fig 2. Chest computed tomographic scans show a right anomalous vein draining into the superior vena cava. (SVC = superior vena cava; AV = anomalous vein.)
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Fig 3. Digital subtraction pulmonary angiogram shows the superior pulmonary vein anomalously draining into the superior vena cava. (SVC = superior vena cava; SPV = superior pulmonary vein.)
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Thus, we decided to first repair the PAPVR at Toranomon Hospital. After establishing total cardiopulmonary bypass and cardioplegic arrest, the superior vena cava was divided above the anomalous pulmonary vein and oversewn proximally. An atrial septal defect creation and a baffle rerouting of the pulmonary venous blood with autologous pericardium was performed through a right atriotomy. The repair was completed by anastomosing the distal end of the superior vena cava to the right atrial appendage with ringed polytetrafluoroethylene graft (14 mm in diameter). The patient was rewarmed and weaned from cardiopulmonary bypass in the usual fashion. He made favorable progress after his cardiotomy. Three weeks after the correction of the PAPVR, he was referred to the National Cancer Center Hospital at which he underwent radical left pneumonectomy for his lung cancer. His postoperative course was uneventful without any cardiac or respiratory failure. In the resected specimen, the tumor measured 5.0 cm and histopathologically it showed poorly differentiated squamous cell carcinoma growing adjacent to the left main pulmonary artery. Pathologic stage was IB (T2 N0 M0) for lung cancer. The patient has been in good health without recurrence or cardiovascular events for 34 months after his operation. We administered warfarin as an anticoagulant therapy because of the correction of the PAPVR.
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Comment
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Partial anomalous pulmonary venous return is a rare congenital anomaly that is found in 0.4% to 0.7% of the general population at autopsy, and it is often associated with other congenital heart defects, especially atrial septal defect [3–6]. Most cases of PAPVR involve the right lung [4]. Some reports have suggested that PAPVR occurs approximately 10 times more frequently in the right pulmonary vein than in the left pulmonary vein [4]. Most cases of right PAPVR are likely to connect the superior vena cava or right atrium.
The surgical treatment of PAPVR has been recommended for patients with a Qp/Qs greater than 2.0, regardless of associated cardiac defects [4, 7]. Our patient had a Qp/Qs of 1.5 in preoperative cardiac catheterization. His pulmonary artery systolic pressure was 25 mm Hg. Based solely on cardiac considerations, surgical correction of the PAPVR may have not been necessary for our patient because he had no cardiopulmonary symptoms before his lung disease was detected. It is possible that the PAPVR of a single anomalous pulmonary vein with an intact atrial septum may not be clinically important. However, in patients with this anomaly in combination with lung cancer, this may present some serious problems. Black and associates [1] reported a patient with fatal right heart failure after right pneumonectomy for lung cancer with a missed contralateral PAPVR. When PAPVR is present in the other lobe, major lung resection (especially pneumonectomy) for lung cancer can result in acute right heart failure due to increased shunting through the PAPVR.
Therefore, the preoperative discovery of asymptomatic PAPVR may be very important for patients with planned lung resection. We must carefully interpret the findings of the existing architectural structure, including pulmonary artery, vein, or bronchus, as well as a lung tumor on the chest computed tomographic scan. Most of the findings of PAPVR can be identified by enhanced chest computed tomography [8]. Conversely, if the findings of right heart overload are preoperatively detected by an electrocardiogram or echocardiogram, we should consider heart defects such as atrial septal defect or PAPVR. If patients with an asymptomatic PAPVR require major lung resection, the PAPVR should be corrected before lung resection to prevent fatal postoperative heart failure.
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References
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- Gaynor JW, Burch M, Dollery C, Sullivan ID, Deanfield JE, Elliott MJ. Repair of anomalous pulmonary venous connection to the superior vena cava. Ann Thorac Surg. 1995;59:1471–1475[Abstract/Free Full Text]
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Abstract
Introduction
