Tree-shaped pulmonary veins in infracardiac total anomalous pulmonary venous drainage

Three consecutive patients undergoing corrective operation for the infracardiac type of total anomalous pulmonary venous drainage (TAPVD) were found to have tree-shaped pulmonary veins. Preoperative angiocardiography revealed that in 2 patients the superior and inferior pulmonary veins drained separately, bilaterally, into the vertical vein. In the third patient the right pulmonary veins united to connect with the vertical vein, while the left superior and inferior pulmonary veins drained separately into the vertical vein. At operation inferior pulmonary veins connecting separately with the vertical vein were found to be located posterior to the pericardium. In the previous literature dealing with successful repair of infracardiac TAPVD, there is no mention of the tree-shaped pulmonary veins described in this report. As this particular type of pulmonary vein does not seem to be uncommon, its possible presence should be kept in mind during operation, as it may dictate the selection of surgical procedures.     

Veins of Retzius at CT during arterial portography: anatomy and clinical importance

PURPOSE: To classify the veins of Retzius demonstrated at computed tomography (CT) during arterial portography (CTAP) on the basis of anatomic location and to evaluate the relationship between the frequency of CT visualization and associated disease. MATERIALS AND METHODS: The authors reviewed axial CTAP scans from 130 patients. Patients were classified into one of two groups: patients with liver cirrhosis (group 1 [n = 81]) and patients without liver cirrhosis (group 2 [n = 49]). RESULTS: The pathways of the veins of Retzius were classified as follows: (a) The ileocolic vein drained into the inferior vena cava (IVC) or the right renal vein through the right gonadal vein (n = 61); (b) the pancreaticoduodenal vein drained into the IVC (n = 8); (c) the proximal branches of the superior mesenteric vein drained into the left gonadal vein (n = 6); and (d) the ileocolic vein drained directly into the IVC (n = 5). The veins of Retzius were demonstrated in 41 (51%) of the 81 patients in group 1 and 26 (53%) of the 49 patients in group 2. There was no statistically significant difference between the two groups. CONCLUSION: The veins of Retzius were demonstrated at CTAP in approximately 50% of patients with and 50% of patients without liver cirrhosis.     

Kinetic and spectroscopic characterization of an intermediate peroxynitrite complex in the nitrogen monoxide induced oxidation of oxyhemoglobin

A rare case of absence of the azygos vein associated with double superior vena cava is presented. Imaging findings on plain chest film and on contrast-enhanced computed tomography are described, and the embryology of azygos and hemiazygos veins is reviewed.     

The inferior thyroid veins--the ultimate guardians of the trachea

The inferior thyroid veins and their multiple tributaries are the ultimate guardians of the cervical trachea. Deeply embedded in the pretracheal fat pad, this plexus of veins is consistently encountered during low tracheostomy that accompanies conservation laryngral procedures as well as in tracheal reconstruction. In a high tracheotomy, the handling of the thyroid isthmus is simplified by an appreciation of these veins. Even cricothyrotomy is potentially complicated by hemorrhage sebsequent to a tear in a tributary of the inferior thyroid venous system. A cadaver study, employing 10 embalmed head and neck specimens, was performed to elucidate the tributary patterns of these veins. In every dissection there was at least one and as many as five veins overlying the trachea just below the thyroid isthmus. In 7 of 10 dissections a confluence of right and left inferior thyroid veins formed a large thyroid ima vein draining into the left innominate vein, and in 1 of 10 cases the thyroid ima vein drained into the right innominate. This confluence was present at a level which would be encountered in low tracheostomy or tracheal repair procedures. Six of 10 dissections presented large tributaries of the inferior thyroid veins overlying the cricothyroid membrane. An awareness of such anatomical considerations should result in safer surgical procedure performed in a dry operative field.     

Modified repair of mixed anomalous pulmonary venous connection

A modified repair technique is reported for mixed total or partial anomalous pulmonary venous connection with the right superior pulmonary vein connecting to the superior vena cava, the right inferior pulmonary vein to the right atrium or left atrium, and the left pulmonary veins to the coronary sinus. The superior vena cava is transected above the highest right superior pulmonary vein, its cephalad end is anastomosed to the right atrial appendage, and a pericardial baffle is constructed between the cardiac ostium of the superior vena cava, the ostium of the right inferior pulmonary vein, and the left atrium, including the coronary sinus, which is unroofed. The reported technique may be valuable to avoid pulmonary venous obstruction in complex mixed forms of total or partial anomalous pulmonary venous connection.     

Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed

OBJECTIVE: We evaluated findings on contrast-enhanced abdominal CT scans that suggest obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein. SUBJECTS AND METHODS: We conducted a retrospective review of 22 patients with superior vena caval, brachiocephalic vein, or subclavian vein obstruction and analyzed the upper abdominal images on a chest CT scan or an abdominal CT scan. We assessed collateral vessels in the upper abdomen to answer the following question: Did enhancement approach undiluted IV contrast or were there other findings? In the second part of our study, we conducted a prospective review of abdominal CT scans of 200 patients without known mediastinal disease or known upper extremity venous occlusion to determine the frequency of abnormal enhancement of these vessels in a healthy population. RESULTS: The groups of collateral vessels revealed on abdominal CT scans were azygos or hemiazygos veins, internal mammary veins, lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus veins, and small mediastinal collateral veins. In the retrospective series, one patient had focal enhancement of the liver and early inferior vena caval enhancement due to collateral vessels. In the prospective series, abdominal CT scans of two patients (1%) revealed dense undiluted enhancement of one or more groups of collateral vessels: One patient had an ipsilateral pacemaker, and the other patient had an anterior neck phlegmon to the upper mediastinum. Both conditions may have been factors in the revealing of the collateral vessels. Two other patients (1%) in the prospective series had mild to moderate vessel enhancement that was less than that from undiluted contrast material. In one of these patients, the enhancement was related to abdominal wall hyperemia after surgery. In the other patient, enhancement may have been the result of ipsilateral axillary nodes. CONCLUSION: On upper abdominal CT scans, dense undiluted contrast material in the collateral vessel groups that we studied suggests possible obstruction of the superior vena cava, brachiocephalic vein, or subclavian vein.     

Thrombosis of the superior vena cava and lateral-cervical lymphadenopathy (probably of metastatic origin). Report of a case

The authors describe a case of superior vena cava thrombosis with laterocervical lymphoadenopathy (probably of metastatic origin). Vascular tumors are a large neoplasm family with a wide clinical and histological spectrum. They may localize on the skin, soft tissues, liver, spleen and parotid gland. The case describes a 65 year-old male, affected by COLD and chronic hepatitis. He came to the hospital for strong gastric pain, which did not vary with meal assumption and objectivity of inflated superficial veins of arms, jugular veins, chest superficial veins and venous capillars and of the epigastric zone, accompanied with right laterocervical lymphoadenomegaly. Endoscopic ultrasonic and X-ray examinations showed a superior vena cava thrombosis determining superficial collateral, azygos and emiazygos vein inflation. The histologic examination of pathologic lymph nodes resulted as hemangioendotelioma/angiosarcoma, a rare case of lymphonodal vascular tumor with a very poor prognosis.     

Atrial septal displacement for repair of anomalous pulmonary venous return into the right atrium

BACKGROUND: In the repair of anomalous connection of the pulmonary veins to the right atrium, the use of a baffle of pericardium to divert the pulmonary venous blood into the left atrium could cause pulmonary venous obstruction as a result of thickening of the pericardial patch. Anomalous pulmonary venous drainage to the right atrium caused by malposition of the atrial septum primum can be repaired by displacing the shifted septum primum to the normal position. METHODS: In 5 patients with total (n=2) or partial (n=3) anomalous pulmonary venous drainage into the right atrium, the septum primum was shifted toward the left atrium and the pulmonary veins drained into the anatomic right atrium despite their normal connection with the posterior wall of the left atrium. This method consisted of incision of the posterior edge of the atrial septum primum and displacement of the incised atrial septum between the anomalous pulmonary veins and both venae cavae. No patch was used. RESULTS: Postoperative echocardiography showed a wide pathway from the pulmonary veins to the left atrium with no stenotic portions. No atrial arrhythmias occurred after the operation. CONCLUSIONS: This technique may be advantageous because it allows for future growth of the route of the pulmonary venous pathway and avoids postoperative supraventricular arrhythmias.     

Infrahepatic interruption of the inferior vena cava with azygos continuation: a potential mimicker of aortic pathology

Infrahepatic interruption of the inferior vena cava (IVC) with azygos or hemiazygos continuation is a rare finding. In this anatomic entity, the intrahepatic segment of the IVC is absent, and the hepatic veins empty directly into the right atrium. Venous blood flow from the lower body is directed from the IVC into the azygos system at the level of the renal veins, with resultant dilation of the azygos and/or hemiazygos veins. Because these enlarged vessels lie parallel to the descending thoracic aorta, they may be mistaken for aortic pathology (dissection, aneurysm, or rupture) during transesophageal echocardiography (TEE). We describe a case of azygos continuation of the IVC initially misdiagnosed by TEE as partial aortic rupture. Repeat TEE with intravenous agitated saline injection correctly identified the condition, and the echocardiographic features are described.     

Dilatation of the azygos vein: an unusual cause of pulmonary mass

Infrahepatic interruption of the inferior cava vein, is a rare congenital anomaly, usually associated with congenital heart and abdominal diseases. The systemic venous flow is accommodated by the dilated azygos. This dilated azygos arch accounts for the right paratracheal or mediastinal mass, and may be misinterpreted as a neoplasm. We report a case with this congenital vascular anomaly, associated with another of tracheobronchial tree.     

Experiences of the approaches to heart for a patient with a tracheostoma

The performance of open heart surgery in a patient with a tracheostoma can present difficult problems, including postoperative mediastinitis and inadequate operative exposure. Recently, we experienced two cases in which tracheostomy had been done preoperatively due to heart failure and reported the satisfactory results in this paper. Case 1; A 59-year-old woman who had mitral stenosis and massive regurgitation received mitral valve replacement and left atrial raphy. The approach to heart was performed in according to the following. A transverse submammary skin incision was made from right anterior axillar line to left mammary line and then a bilateral thoracotomy was made at the fourth intercostal space. Case 2; A 73-year-old man who had old myocardial infarction and postinfarction angina received coronary artery bypassgrafting to right coronary artery and left anterior descending branch, using saphenous vein grafts. A skin incision was placed at the second intercostal space in the fashion of "collar skin incision" and then made from the center of collar skin incision to the xiphoid process. The sternum was transected at the second intercostal space and divided longitudinally to the xiphoid process. These two approaches provided the adequate operative field. The cannulation of the ascending aorta, the superior vena cava and the inferior vena cava presented no difficulty and the operative procedure could be performed easily in a routine manner. We think that in a case of open heart surgery of a patient with a tracheostoma the approach in which the skin incision is distant from the area of a tracheostoma and no dissection near a tracheostoma is necessary have to be selected in order to decrease the risk of postoperative wound infection and mediastinitis.     

Portal decompression using the inferior mesenteric vein

We report five patients with variceal hemorrhage, in three cases secondary to diffuse thrombosis of the portal, superior mesenteric and splenic veins. Mesenteric angiography demonstrated patency of the inferior mesenteric vein (IMV) in each, and successful portal decompression by anastomosis of the IMV to the left renal vein (n = 4) or the inferior vena cava (n = 1) was accomplished. Bleeding was permanently controlled: four patients have survived from one to eight years post-operatively. Because shunt procedures utilizing the IMV are technically straightforward, subtotally decompress the portal system and avoid the right upper quadrant, they may be advantageous in certain clinical settings.     

Anatomic arrangement of the hepatic veins in the goat

In gross anatomic and angiographic examinations of the hepatic veins of 15 goats, the following were seen: (i) The middle hepatic vein was formed by the contribution of two main branches, one branch coming from the quadrate lobe and the other branch from the right lobe. (ii) There were two right hepatic veins, one of them running along the caudate process and the other formed by branches coming from the dorsal part of the right lobe. (iii) The entrance of the middle hepatic vein, as well as the entrance of the left hepatic vein into the caudal vena cava were partly covered by valvelike membranous flaps.     

Rare malposition of a subclavian vein catheter

Deviation of a left subclavian vein catheter into the azygos vein occurred in a patient with cancer of the colon. On the p.a.-projection, the catheter seemed to be kinked in the vena cava. In the lateral view, the malposition in the azygos vein could be detected and was visualised by giving a bolus of contrast medium. By retracting the catheter under fluoroscopic control the proper position could be achieved. The importance of the lateral-view chest x-ray is discussed.     

Pulsatile total cavopulmonary shunt for hypoplastic right heart syndrome with abnormal systemic venous return--a case report

A pulsatile total cavopulmonary shunt was successfully performed on a 5-year-old girl with hypoplastic right heart syndrome associated with abnormal systemic venous return; at the same time, modified mitral valve replacement was performed for mitral regurgitation. The right atrium, tricuspid valve and right ventricle were all extremely dimunitive. The diameter of the tricuspid valve was 50% of normal and the volume of the right ventricle was 8.6% of normal. In addition, there were severe subpumonary stenosis, a restrictive ventricular septal defect (VSD) and an atrial septal defect (ASD). The bilateral superior venae cavae (SVCs) and the hepatic vein drained to the left atrium, and the inferior vena cava was infrahepatically interrupted with a hemiazygos connection to the left superior vena cava. At the operation, each SVC was anastomosed end-to-side to each branch of the pulmonary artery (PA). The restrictive ventricular septal defect and stenotic subpulmonary lesion were left. The diameter of the ASD was reduced from 12 mm to 7 mm. The main PA was neither divided nor banded. The pulsatile blood flow from the left heart to the PA was regurated by a native restrictive VSD and stenotic subpulmonary lesion, and that from the right heart via the ASD was limited by reducing the size of the ASD. These described anatomic arrangements produced adequate antegrade pulsatile flow in the PA, which might prevent the development of pulmonary arteriovenous fistulae and, besides permit transfer of drainage of the hepatic vein from the left to the right atrium via the ASD in future.     

Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins

BACKGROUND: Atrial fibrillation, the most common sustained cardiac arrhythmia and a major cause of stroke, results from simultaneous reentrant wavelets. Its spontaneous initiation has not been studied. METHODS: We studied 45 patients with frequent episodes of atrial fibrillation (mean [+/-SD] duration, 344+/-326 minutes per 24 hours) refractory to drug therapy. The spontaneous initiation of atrial fibrillation was mapped with the use of multielectrode catheters designed to record the earliest electrical activity preceding the onset of atrial fibrillation and associated atrial ectopic beats. The accuracy of the mapping was confirmed by the abrupt disappearance of triggering atrial ectopic beats after ablation with local radio-frequency energy. RESULTS: A single point of origin of atrial ectopic beats was identified in 29 patients, two points of origin were identified in 9 patients, and three or four points of origin were identified in 7 patients, for a total of 69 ectopic foci. Three foci were in the right atrium, 1 in the posterior left atrium, and 65 (94 percent) in the pulmonary veins (31 in the left superior, 17 in the right superior, 11 in the left inferior, and 6 in the right inferior pulmonary vein). The earliest activation was found to have occurred 2 to 4 cm inside the veins, marked by a local depolarization preceding the atrial ectopic beats on the surface electrocardiogram by 106+/-24 msec. Atrial fibrillation was initiated by a sudden burst of rapid depolarizations (340 per minute). A local depolarization could also be recognized during sinus rhythm and abolished by radiofrequency ablation. During a follow-up period of 8+/-6 months after ablation, 28 patients (62 percent) had no recurrence of atrial fibrillation. CONCLUSIONS: The pulmonary veins are an important source of ectopic beats, initiating frequent paroxysms of atrial fibrillation. These foci respond to treatment with radio-frequency ablation.     

Gross anatomy of the cardiac blood vessels in the North American beaver (Castor canadensis)

The cardiac arteries and veins are described in the North American beaver (Castor canadensis) following the injection of the vessels of 15 hearts with either latex, vinyl plastic or barium sulfate. The left coronary artery gives off the typical circumflex and paraconal interventricular branches which supply the left atrium and ventricle and part of the right ventricle and interventricular septum. The right coronary artery vascularizes the right atrium and ventricule and by means of its subsinuosal interventricular branch, part of the left ventricle and interventricular septum. The paraconal interventricular branch of the left coronary artery lies within the myocardium and is not visible on the surface of the heart. There are no intercoronary anastomoses between the right and left vessels. The major cardiac veins open into the terminal end of the left cranial vena cava. Unlike the arteries, there are venous anastomoses interconnecting the great cardiac vein and the middle cardiac vein. It is concluded that the cardiac blood vessels in Castor canadensis are typically mammalian and resemble those of both land and aquatic mammals.     

Aneurysmal bulb dilation of the azygos vein: radiological and clinical significance

An aneurysm of the azygos vein is usually detected in the course of routine chest X-rays. It presents as a sharply circumscribed tumor shadow in the area of the right tracheobonchial angle or as an enlargement of the upper right mediastinum. A tentative diagnosis is supplemented both by further X-rays in a supine position in combination with the Valsalva and Müller tests and by tomography. The most frequent cause of an azygos aneurysm found in our material is aplasia of the inferior vena cava. Infrahepatic interruption of the inferior vena cava with azygos continuation can also be an associated malformation. Therefore, bilateral pelvic phlebography with visualization of the retroperitoneal venous and azygos systems is mandatory for establishing the correct, complete diagnosis. We have found no concomitant hemodynamic derangements. It is important to note that under these circumstances no therapy is indicated.     

Lung abscess caused by Paecilomyces lilacinus

AIM: To present characteristics of heart and great vessel injuries in patients wounded during the 1992-1994 war in Bosnia and Herzegovina and their management in conditions of lack of complex diagnostic and therapeutic procedures. METHODS: Retrospective analysis was performed on the medical records of 31 patients treated for cardiac and great vessel injuries at the Department of Surgery, Tuzla University Hospital, between January 1992 and December 1994. RESULTS: The most frequent localization of the injuries was the right and left ventricles (each 10 cases), left atrium in 5, superior caval vein in 5, and inferior caval vein in 5 cases. Isolated pericardial injury was found in 5 cases. Immediately after injury, 22 injured suffered from shock, 7 from pericardial tamponade, and 2 were in a stable state. The mortality rate was 58%. Eight patients died during the operation as a consequence of bleeding. The highest mortality rate was recorded in the injuries of the left ventricle followed by the injuries of the in right ventricle and of superior caval vein. All 4 patients with multiple heart and great vessel injuries died. Mortality rate was significantly higher in patients who suffered from shock than in those who suffered from tamponade. CONCLUSIONS: Penetrating war injuries of heart and great vessels are among the most serious injuries in war. These injuries require prompt treatment to save life, but this is hardly manageable in hospitals without cardiopulmonary bypass facilities.     

Asymmetries in the effect of side of seizure onset on recognition memory following intracarotid amobarbital injection

OBJECTIVE: To report gross anatomic examination of the canine myocardial bridge (MB), a muscular band found above the coronary artery (CA), with respect to its occurrence, location, vascularization, and innervation. SAMPLE POPULATION: 629 canine hearts obtained within 1 to 3 hours after euthanasia. PROCEDURE: After an incision was made at the left fifth intercostal space, the pericardial sac was cut open, and if an MB was present, the heart, lungs, and annexed structures were removed together and subsequently subjected to macroscopic examination of MB musculature and innervation after formalin fixation. Vascular casting was performed by use of methyl methacrylate perfusion. RESULTS: Of the 629 canine hearts examined, 189 (30%) had MB, occurrence of which was independent of sex, age, and breed. Among 13 MB-containing specimens examined in detail, there was great variation in thickness (0.11 to 2.24 mm; mean, 0.45 mm) of MB and distance (24 to 236 microns; mean, 103 microns) between the MB and the paraconal interventricular branch of the left CA (PIBL). One pair or 2 pairs of blood vessels from the PIBL supplied the MB muscle. Venous blood returned to the coronary circulation via the branches of the great coronary vein coursing on both sides of the PIBL, in close contact with the PIBL and the groove wall. The 2 veins rejoined at the upper portion of the PIBL and passed obliquely to the coronary groove under the left auricle, and finally drained the blood through the coronary sinus into the right ventricle. Innervation to the MB muscle was derived from nerve branches of the middle cervical ganglion and left vagus nerve. CONCLUSION: Prevalence and localization of MB in dogs and human beings are similar. Vascularization of the MB muscle originates from the PIBL. The cervical ganglion and vagus nerve control the MB muscle.