Ismael A Salas de Armas1, Manish K Patel1, Bindu Akkanti2, Jorge Salazar3, Biswajit Kar1, Igor D Gregoric4. 1. Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center at Houston/Memorial Hermann Hospital - Texas Medical Center, 6400 Fannin St., Suite 2350, Houston, TX, 77030, USA. 2. Department of Internal Medicine, Divisions of Critical Care, Pulmonary and Sleep, The University of Texas Health Science Center at Houston/Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA. 3. Pediatric Cardiothoracic Surgery, The University of Texas Health Science Center at Houston/Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA. 4. Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center at Houston/Memorial Hermann Hospital - Texas Medical Center, 6400 Fannin St., Suite 2350, Houston, TX, 77030, USA. Igor.D.Gregoric@uth.tmc.edu.
Abstract
BACKGROUND: Partial anomalous pulmonary venous return (PAPVR) is a congenital heart defect. Reports of repair and treatment in pediatric cases have been published, but incidence of PAPVR in adults is not common. To our knowledge, there has not been a diagnosis of left-sided PAPVR after a heart transplant an in adult patient. CASE PRESENTATION: A 62-year-old patient with ischemic cardiomyopathy and systolic heart failure underwent orthotopic heart transplantation. The immediate post-operative course was remarkable for an elevated cardiac index and pulmonary artery pressures as well as decreased systemic vascular resistance. The post-operative echocardiogram did not reveal an intra-cardiac shunt. However, computed tomographic angiography (CTA) showed a left superior pulmonary vein draining into the innominate vein. Operative repair of the left superior pulmonary venous connection to the left atrial appendage was completed under cardiopulmonary bypass with beating heart. Her hemodynamics improved immediately, and she had an unremarkable postoperative course. CONCLUSIONS: While uncommon, any patient with a high cardiac output and abnormal hemodynamics after heart transplant should be evaluated for the existence of a shunt. While not a part of all traditional preoperative imaging protocols, a chest CTA should be considered if PAPVR is suspected as it can both diagnose the condition and enable a plot of the corrective course of surgical action.
BACKGROUND: Partial anomalous pulmonary venous return (PAPVR) is a congenital heart defect. Reports of repair and treatment in pediatric cases have been published, but incidence of PAPVR in adults is not common. To our knowledge, there has not been a diagnosis of left-sided PAPVR after a heart transplant an in adult patient. CASE PRESENTATION: A 62-year-old patient with ischemic cardiomyopathy and systolic heart failure underwent orthotopic heart transplantation. The immediate post-operative course was remarkable for an elevated cardiac index and pulmonary artery pressures as well as decreased systemic vascular resistance. The post-operative echocardiogram did not reveal an intra-cardiac shunt. However, computed tomographic angiography (CTA) showed a left superior pulmonary vein draining into the innominate vein. Operative repair of the left superior pulmonary venous connection to the left atrial appendage was completed under cardiopulmonary bypass with beating heart. Her hemodynamics improved immediately, and she had an unremarkable postoperative course. CONCLUSIONS: While uncommon, any patient with a high cardiac output and abnormal hemodynamics after heart transplant should be evaluated for the existence of a shunt. While not a part of all traditional preoperative imaging protocols, a chest CTA should be considered if PAPVR is suspected as it can both diagnose the condition and enable a plot of the corrective course of surgical action.
Entities:
Keywords:
Case report; Heart transplant; Partial anomalous pulmonary venous return
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