Cardiovascular Disease |

Anomalous Pulmonary Venous Return Resulting in Unilateral Localized Pulmonary Edema: A Case Report FREE TO VIEW

Lakshya Chandra, MD; Ahmar Malik, MD; Fatima Khan, MD; Anjum Anwar, MBBS; Wayne Davis, MD; Vishal Poddar, MD
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Howard University Hospital, Silver Spring, MD

Chest. 2015;148(4_MeetingAbstracts):74A. doi:10.1378/chest.2266587
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SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Partial anomalous pulmonary venous return (PAPVR) is a congenital cardiovascular anomaly caused by abnormal return of one or more pulmonary veins to the right side of the heart. It might occur isolated or combined with atrial septal defect. All PAPVRs are left-to-right shunts, and the shunt is usually hemodynamically insignificant. We report a unique case where localized pulmonary edema in a single lobe of lung was found to be secondary to PAPVR.

CASE PRESENTATION: A 47-year-old African American man with history of hypertension, coronary artery disease with bypass grafting and angioplasty, diastolic congestive heart failure (CHF) and end-stage-renal disease on hemodialysis was admitted for worsening dyspnea and chest pain of two-days duration with impression of decompensated heart failure and fluid overload. Chest X-ray (CXR) showed severe cardiomegaly with interstitial pulmonary infiltrates more pronounced in the LUL. Chest computerized tomography (CT) confirmed the CXR findings and further revealed PAPVR in the same lobe. The anomaly was further investigated with multislice CT angiography of the heart and vessels with three-dimensional reconstruction images demonstrating LUL anomalous pulmonary vein draining into the left innominate vein thus creating left-to-right shunt. There was no associated pulmonary hypertension on echocardiography. The edema resolved after fluid removal with hemodialysis and CHF optimization. The remainder of the patient's hospital course was uneventful.

DISCUSSION: Pulmonary veins bring oxygenated blood from lungs to the left atrium. Anomalous pulmonary veins can cause total or partial return of the blood to the right side, thus creating left-to-right shunt. PAPVR is a rare congenital anomaly with incidence of about 0.7% of the population. Asymptomatic mostly, it is often an incidental finding. Echocardiography is the initial diagnostic test of choice. If echocardiography is inconclusive, CT angiography serves as a rapid, safe and non-invasive modality to confirm the diagnosis, with three-dimensional reconstruction images providing more details on vascular anatomy. Surgery is the definitive treatment for PAPVR, but asymptomatic patients with insignificant left-to-right shunt do not require intervention. Localized pulmonary edema is even rarer that may respond to fluid removal with diuretics or dialysis as in our case.

CONCLUSIONS: PAPVR commonly manifests in children, and rarely in adults with pulmonary hypertension secondary to left to right shunt. Absence of pulmonary hypertension and presence of localized lobar edema, makes our case unique.

Reference #1: Demos TC, Posniak HV, et al. Venous Anomalies of the Thorax. American Journal of Roentgenology. 2004;182:1139-1150.

Reference #2: Lakshminrusimha S, Wynn RJ, et al. Use of CT angiography in the diagnosis of total anomalous venous return. J Perinatol. 2009;29(6):458-61.

Reference #3: Agarwal R, Aggarwal AN, Gupta D. Other causes of unilateral pulmonary edema. Am J Emerg Med 2007;25:129-31.

DISCLOSURE: The following authors have nothing to disclose: Lakshya Chandra, Ahmar Malik, Fatima Khan, Anjum Anwar, Wayne Davis, Vishal Poddar

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