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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 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21497/ on 05/10/2017 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 CHEST, VOL. 58, NO. 1, JULY 1970 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21497/ on 05/10/2017 26 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 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21497/ on 05/10/2017 27 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 changes in pulmonary venous 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 2 3 HRS: Radiological 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, 10 Steinberg I: Pulmonary varices mistaken for pulmonary 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 disease, technic, indications and interpretations in 700 cases,AmerJ Cardiol, 14:437, 1964 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 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21497/ on 05/10/2017