Download Dilated Right Pulmonary Veins in Mitral Insufficiency

Dilated Right Pulmonary
Veins in Mitral Insufficiency*
David Bryk, M.D.#{176}#{176}
A review of 50 proved cases of mitral insufficiency from the standpoint of the
right pulmonary veins uncovered seven cases with localized dilatation of the
central right pulmonary veins. In three cases this involved all the central
right pulmonary
veins; while In four It was confined to the right superior
veins. In all seven cases there was 4+ mItral regurgitation with contrast substance refluxmg Into the dilated right pulmonary veins. This reflux Is suggested
as a possible cause of this venous dilatation.
Multiple
studies have been published describing
changes in the caliber of the pulmonary veins
which expanded during systole on cineangiocardio.
graphic study.
in mitral stenosis and left heart failure. These have
Regurgitation of contrast substance during angi
emphasized the dilatation of the superior pulmonary
ography into the pulmonary veins has been reveins and the decrease in caliber of the inferior
ported. Ross and Criley’3 and Arvidsson’4 both
pulmonary veins as correlated with pulmonary
indicate that in the presence of normal and stenotic
venous and arterial pressures.5
valves roentgen opaque material refluxes into the
Multiple reports of localized dilatations or vanpulmonary veins with atrial systole, but with mitral
cosities of pulmonary veins have been published.#{176}’t regurgitation systolic pulmonary reflux is also
These vanicosities have usually involved either the
present.
right inferior pulmonary vein or the left superior
The author recently studied two cases of mitral
pulmonary vein. In a few of these cases there was
insufficiency with apparent masses in the right hilum
caused by dilated pulmonary veins. These cases
associated mitral stenosis or left heart failure thus
suggesting that some varicosilies may represent an
stimulated a review of a series of cases of mitral
insufficiency from the standpoint of the appearance
accentuated localized venous dilatation in cases of
chronic pulmonary venous hypertension.61’
of the right pulmonary veins. This consisted of the
Also, of interest is a report by Hipona and Janroentgenographic
evaluation of this pulmonary
shidi7 of a case of varicosity of the right inferior
venous dilatation and its possible relationship to
pulmonary veins in a patient with mitral insuffithe mitral insufficiency.
ciency. The vancosity enlarged over a period of
MArEIu.i.
seven years with progression of the mitral insufficiency,
but disappeared
following
prosthetic
Fifty cases of mitral insufficiency due to rheumatic
valvulitis were studied. The diagnosis of mitral insufficiency
was proven either by left ventricular angiocardiography
or
surgical exploration,or both. The degree of mitral insufficiency was graded on left ventricular angiocardiography
by
the criteria of Sellers and ca-workers.’5 The severity of
mitral insufficiency at surgery was graded on the basis
of the surgicaloperative report.
Roentgen evaluation of the right pulmonary veins was
made on the plain films, both erect and supine and on the
frontal angiocardiograms. In a few cases tomograms were
also available.
re-
placement of the mitral valve. Similarly, Khalaf,
Chapman, and Ernst12 illustrate a case of mitral
insufficiency with giant left atrium from which
radiated enormously dilated right pulmonary veins
From the Department of Radiology,The Jewish Hospital
Medical Center of Brooklyn, Brooklyn, New York.
Direotor of Radiolo1y. Jewish Hospital and Medical
Center of Brooklyn; Clinical Associate Professorof Radiology, State University of New York-Downstate Medical
and
Center.
‘A
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DILATED RIGHT PULMONARYVEINS
25
Ro-rc
F1rnNcS
Seven of the 50 cases studied demonstrated
venous dilatation apparently confined to the central
right pulmonary veins. In two cases both the central superior and inferior pulmonary veins were
dilated; in three cases only the superior veins were
dilated and in one case there appeared to be superior, middle and inferior veins of which the superior
and middle veins were dilated.
The dilated veins were demonstrable in the supine
roentgenogram
(Fig 2A) but in two cases were also
seen in the erect postenioanterior view (Fig 1). At
times they suggested a hilar mass which was due
not only to the venous dilatation, but also to associated tortuositv with superimposed multiple venous
segments some of which were visualized end on.
Tomography was thus useful in evaluating the nature of these hilar densities.
When dilated, the right inferior pulmonary veins
were occasionally superimposed on the left atrium
as a small double density. The dilated right superior
pulmonary veins usually were seen extending laterally from the superior lateral contour of the left
atrium into the right hilum.
Left ventricular angiocardiography in these seven
cases demonstrated 4+ mitral regurgitation with
opacification of the dilated right pulmonary veins
(Case 2). Mitral insuUiciency with dilated right
and middle pulmonary veins. (A, upper): Supine
roentgenogram of the right Mum. Note the prominence of
the right hilum due to the dilated superior and middle
F,oum
superior
pulmonary
veins. (B, lower): Left ventricular
angioeardio-
gram. The dilated central right pulmonary veins are opacified
by the contrast substance regurgitating into the left atrium.
There is no pulmonaryvenous opaciflcation.
FIGuRE 1 (Case 1). Mitral irn.lficiency with dilated superior
right pulmonary veins. Erect posteroanterior roentgenogram.
Note the prominence of the right hilar area (arrows) produced by the dilated right superior pulmonary veins. The
opaCity inferior to the hilum is due to the dilated left
atrium projecting beyond the right atrial border. The left
Mum is normal except for the prominence of the main and
left pulmonary arteries. The peripheral pulmonary venous
and arterial pattern is normal.
by the regurgitating contrast substance (Fig 2B,
3B). In none of these cases was there any detectable regurgitation into the left pulmonary veins.
In one patient in whom venous angiocardiography
was also performed the discrepancy in size between
the central right and left pulmonary veins was
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DAVID
BRYK
inferior pulmonary veins. The venous dilatation
was as prominent in some of these cases as in those
with moderate venous dilatation due to mitral insufficiency. In the remaining 33 cases studied, no
detectable abnormality of the pulmonary veins
was noted.
Left ventricular angiocardiography showed regurgitation into the central right pulmonary veins,
especially the right superior veins in all cases with
3+ or 4+ mitral insufficiency. Regurgitation into
the veins was questionable or not detected in those
with lesser degrees of mitral insufficiency. Of the
43 cases mentioned above, 20 were classified as
3+ or 4+ mitral insufficiency.
Regurgitation into the left pulmonary veins was
not seen except for two cases in which it was questionably present.
DIscussioN
FIGURE3 (Case 4). Mitral insulfieiency with dilated #{149}ght
superior and inferior pulmonary veins. (A, upper): Left
heart phase of the pulmonary angiogrum. Note the dilated
central right superior and inferior pulmonary veins. Peripherally the right pulmonary veins are normal as are
the left pulmonary
veins. (B, lower): Left ventricular
angiocardiogram. Note the opacificatron of the central dilated right pulmonary veins and the dilated left atrium.
The dilated right inferior pulmonary vein is partially superimposed on the opacifledleft atrium (arrow).
readily apparent (Fig 3A).
Minimal mitral stenosis was present in only one
of the seven cases. The other six cases showed no
evidence of mitral stenosis and can be classified
as pure mitral insufficiency.
In the remainder of the 43 cases studied, there
were ten with dilatation of the superior pulmonary
veins related to associated mitral stenosis or left
heart failure. The dilatation was bilateral and symmetrical involving both superior pulmonary veins
and was associated with a decrease in caliber of the
This study indicates that in a small percentage of
cases of mitral insufficiency, especially those with
severe regurgitation, the central right pulmonary
veins may become selectively dilated. Based on this
retrospective analysis of cases of mitral insufficiency, it would appear that this dilatation is probably due to chronic regurgitation into the central
right pulmonary veins. This finding was demonstrated by angiocardiography in all of the seven
cases studied.
Although the opacified left atrial appendage to
some extent obscures the left pulmonary veins in the
frontal angiocardiogram,
comparison of the angiocardiograms with the overexposed plain roentgenograms indicated that opacification of the left pulmonary veins was not present. The localization of
the abnormality to the right pulmonary veins can
be explained by the direction of the regurgitant
flow. Since the plane of the mitral valve faces posteriorly, superiorly and to the right the regurgitant
stream is directed toward the right pulmonary
veins, especially the superior right pulmonary veins.
All seven cases showed dilatation of the superior
veins while in three the inferior veins were also
dilated but not as prominently as the superior veins.
The findings described must be distinguished from
the superior pulmonary venous dilatation noted in
mitral stenosis and left heart failure. This pattern
of venous dilatation can be distinguished from that
reported in this study by the fact that it is seen in
both upper lung zones, is not confined to the central
portions and is associated with a decrease in the
size of the vessels in the lower zones. It is postulated that shunting of blood to the uppper lobes
accounts f.or the increased venous size.3 It must be
CHEST, VOL. 58, NO. 1, JULY 1970
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DILATED RIGHT PULMONARYVEINS
admitted that three of the cases with right pulmonary venous dilatation apparently due to mitral regurgitation did have a history consistent with
episodes of left heart failure so that some of the
venous dilatation noted may have been due to this
mechanism superimposed upon that due to regurgitation.
The roentgenographic problem occasionally posed
by the dilated right pulmonary veins in mitral insufficiency is their differentiation from avascular
pulmonary hilar masses. This is similar to the problem in localized pulmonary dilatations or varicosities.
Roentgen differential diagnosis is simple, however,
because of the other manifestations of mitral heart
disease such as left atrial and left ventricular enlargement which are usually quite prominent in
these cases because of the severity of the mitral
insufficiency. In addition, tomography can be utilized to demonstrate the tributary branches of the
dilated central pulmonary veins.
REEERENCES
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hypertension with special reference to the root shadows
and lobularpattern, Brit Heart J, 23:75, 1981
Lavender JT, and Doppman J: Hihun in pulmonary
venous hypertension, Brit J Radiol, 35:303, 1962
Lavender JT, Doppmao J, Shawdon H, am! Steiner RE:
1Harley
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Pulmonary veins in left ventricular failure and mitral
ster.osis, Brit J Radial, 35:293, 1962
4 Ormond
RS, and Poznanski K: Pulmonary veins in
rheumatic heart disease,Radiology,74:542, 1960
5 Simon M: Pulmonary vessels in incipient left ventricular
decompensatiori-radiologic observations, Circulation, 4:
185, 1961
6 Bryk D, and Lesin
EJ: Pulmonary varicosity, Radiology,
1965
7 Hipona FA, and Janshidi A: Observationson the natural
history of varicosity of the pulmonary veins, Circulation,
35:471, 1967
8 Nelson WP, Hall RJ, and Garcia E: Varicositles of the
pulmonary veins simulating arteriovenous&tulas, JAMA,
195:13, 1966
9 Poller S, and Wholey MH: Pulmonary varix-evaluation
85:834,
by selective pulmonary
1966
angiography,
Radiology, 86:1078,
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and hilar disease, Amer J Roentgenol, 101:947, 1967
11 Viamonte M, and Le Page JE: Pitfalls in the radiologic
evaluations of mediastinal abnormalities, Radiol Clin
N Amer. 6:451, 1968
12 Khalaf JD, Chapman CB, and Ernst R: Cinefluorographic
approach to diagnosis of mitral regurgitation, Prog Cardiovase Dis, 5:2-30, 1962
13 Ross RS, and Criley Mj: Contrast radiography in mitral
regurgitation, Progr Cardiovasc Dis, 5:195, 1962
14 Arvidsson H: Angiocardiographicobservations in mitral
disease with special reference to volume variations in
the left atrium, Acta Radiol Scand Suppl, 158, 1, 1958
15 Sellers RD. Levy Mi, Amplatz K, and Lillehei CW:
Left retrograde cardioangiography in acquired cardiac
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Reprint requests:
New York 11238
Dr. Bryk, 555 Prospect Place, Brooklyn,
THIRD TEN DAY INTERNATIONAL ThACHING SEMINAR
ON CARDIOVASCULAR EPIDEMIOLOGY
The Council on Epidemiology and Prevention, Inter- doctoral level, with som#{128}
residency training or its
national Society of Cardiology, will present the Third
equivalent. For information, please write Jeremiah
Ten Day International Teaching Seminar on Cardio- Stamler, M.D., Secretary. Council on Epidemiology
and Prevention, Room LL 139, Chicago Civic Center,
vascular Epidemiology in the British Isles, August 23September 4, 1970. Nominees should be at the post- Chicago, Illinois 60602.
ANNUAL OTOLARYNGOLOGIC ASSEMBLY
The Airnual Otolarvngologic Assembly of 1970 will condensed postgraduate basic and clinical program for
be held September 19-25, 1970 in the Eye and Ear
practicing otolaryngologist under the direction of Dr.
Infirmary, University of Illinois Hospital, Chicago. The Emanuel M. Skolnik. Interested physicians should direct
Department of Otolarvngologv, College of Medicine,
inquiries to: Otolaryngologv, P0 Box 6998, Chicago,
University of Illinois at the Medical Center, offers a
Illinois 60680.
CHEST, VOL. 58, NO. 1, JULY 1970
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