Pulmonary Vein Stenosis—Evolving Surgical Management of a Challenging Disease

Figure 1. Sutureless repair. (A) Right pulmonary vein repair. Veins are opened widely and diseased tissue is resected. Pericardial flap is folded down and sewn to left atrium leaving cut edge of veins without sutures; (B) Left pulmonary vein repair. Heart is retracted rightward. Left pulmonary veins are widely opened and left atrial appendage is sewn to pericardium outside/around veins. (RPV = right pulmonary veins; LA = left atrium; LPV = left pulmonary veins; LPA = left pulmonary artery; Dashed lines = planned suture line for left atrial-pericardial anastomosis). Adapted from Viola, N.; Calderone, C.A. Surgical repair of post-repair pulmonary vein stenosis using “sutureless” techniques. Op Tech Thorac Cardiovasc Surg 2011, 15, 112–121.

Figure 2. Left pulmonary veins (CT images). (A) Left upper pulmonary vein takes long, angulated course as it passes from lung parenchyma over left mainstem bronchus, across pericardial reflection into left atrium medially; (B) Left lower pulmonary vein courses anteriorly over the descending thoracic aorta taking an angulated course; (C) Left lower pulmonary vein crossing the pericardial reflection and entering far medially into left atrium. (LA = left atrium; LUPV = left upper pulmonary vein; LMSB = left mainstem bronchus; LLPV = left lower pulmonary vein; Asterisk = descending thoracic aorta).

Figure 3. Right pulmonary veins (CT images). (A) Right upper pulmonary vein crosses over right pulmonary artery causing angulation as it passes across pericardial reflection into left atrium; (B) Right lower pulmonary vein stenosis involves more posteriorly directed pulmonary vein that angulates when crossing pericardial reflection; (C) Right lower pulmonary vein without stenosis has straight, less angulated course into left atrium. (RUPV = right upper pulmonary vein; RPA = right pulmonary artery; RLPV = right lower pulmonary vein; LA = left atrium).

Figure 4. Right pulmonary vein repair. (A) Right-sided pulmonary veins crossing pericardial reflection before entering left atrium more medially; (B) Complete mobilization of pericardial reflection and right pulmonary veins with stenotic region denoted (yellow arrow); (C) Right pulmonary veins widely opened up and diseased tissue resected creating patulous pulmonary vein-left atrial pathway (white outline); (D) Patch augmentation moves pulmonary vein-left atrial connection out laterally to shorten/straighten pulmonary vein course. (RUPV = right upper pulmonary vein; RPA = right pulmonary artery; PV-LA = pulmonary vein-left atrium).

Figure 5. Left pulmonary vein repair. (A) Pre-repair—Left pulmonary veins cross pericardial reflection and enter back of left atrium more medially; (B) Post-repair—Pericardial reflection has been taken down and PV-LA confluence is straighter/lateralized. (PV-LA = pulmonary vein-left atrium).

Figure 6. Intraoperative stent placement. (A) Hypoplastic left upper and lower pulmonary veins; (B) Patch enlargement and lateralization of vein-atrial connection; (C) Stent trimmed to ~3 mm and predilated over balloon; (D) Placement of left lower pulmonary vein stent; (E) Placement of left upper pulmonary vein stent; (F) Final position of stents in left veins to maintain luminal caliber and prevent compression. (LUPV = left upper pulmonary vein; LLPV = left lower pulmonary vein).

Figure 7. Pre- and post-repair pulmonary vein CT imaging. (A) Pre-operative left upper pulmonary vein taking long course over left bronchus before entering medially into left atrium; (B) Post-repair left upper vein course is shorter and more lateral—minimizing angulation; (C) Pre-operative left lower vein entering left atrium very medially after coursing over descending aorta; (D) Post-repair left lower vein takes shorter/straighter course as it enters atrium more laterally. (LUPV-LA = left upper pulmonary vein-left atrium; LMSB = left mainstem bronchus; LLPV-LA = left lower pulmonary vein-left atrium; Asterisk = descending thoracic aorta).