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Posts Tagged ‘right upper pulmonary vein’

The most famous and popular view in clinical echocardiography is para sternal long axis view.It gives us an instant information about the status of left atrium , left ventricle and aorta.Left atrium appears to be seen in full. Still , one should realise it is far from truth.There is a huge blind spot  for left atrium in this view .

For a complete imaging of LA one need to do a short axis view at aortic level, and of course a 4 chamber view . All these three views put together , can at best give a 80%  exploration of LA .The rest of the  20%(  some times vital !) can be seen only be transesophageal echo .

Why para sternal long axis fail to give even glimpse of the 4 pulmonary veins ?

  • Pulmonary veins are probably ,  the most vital structure  in LA . There are 4 veins , generally  arranged in 2 pairs
  • Unfortunately all these 4 veins does  not  interrupt the ultrasound beam in this view .The beam in para sternal view crosses  the anterior and lateral surfaces and to a  very small area of inter atiral septum(  IAS )
  • These enter  the posterior surface of the LA in an oblique angle . The angle of entry is widely variable .Some times they need to run a parallel course with LA posterior wall . This makes recognition and delineation  of PV from LA very difficult ..
  • Since all   4 pulmonary veins are located in the posterior aspect of LA ,  they  are best visualized either in apical 4 chamber (Right pulmonary veins) or short axis views(Left pulmonary veins)

When can pulmonary veins visible in PS- LAX view ?

When PVs take an abnormal course like in TAPVC or when they enter coronary sinus etc .

Rarely ,  huge LA enlargement may pull or push the PVs and make them visible in LAX view.

See the link

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Even though it is a great vein , often the imaging pulmonary veins by echocardiography is a not a pleasant excercise.

This is due to the following facts

  • The pulmonary veins are posterior structures
  • They occupy the far field of echocardiographic window
  • The pulmonary veins often enter obliquely into the LA
  • The course of PVs are highly variable ( Like RCA origin !) especially in ASDs ,where identifying PVs becomes all the more important

Hence no fixed imaging angle can be advised . But generally a pattern is observed.

  • Right pulmonary veins are best viewed in apical 4 chamber or 5 chamber or in between (Especially RUPV is  seen best in 4.5 chamber view !)
  • Left pulmonary vein , can be seen in apical 4 chamber but best visualised in  Para sternal short axis view.

Other modalities for imaging pulmonary veins

TEE : Can be  very useful since it is brings the vein closer to the probe .But needs more expertice.

Contrast echo :Probably a simple and best modality often underutilised.

Very useful to clinch the diagnosis when PVs take abnormal course as in PAPVC .

MDCT , Spiral CT, MRI  are the new age modalities that can provide us  with dramatic  3d images of PVs.

The  echocardiogram will always prevail over these sophisticated gadgets for its simplicity and also it’s ability to give us the physiology of pulmonary venous flow which is vital in many diseases(Constriction, Diastolic function etc)

The following illustration is a gross attempt to simplify the imaging of PVs.Please note the rules may not be applicable in all.

Left upper and lower pulmonary veins in short axis view will be posted shortly .

Reference

The images are  based on  personal observations and  an  excellent insight  on the topic from  Department of Cardiovascular Medicine, Guangdong Provincial People’s Hospital, Guangzhou , China

http://ejechocard.oxfordjournals.org/content/9/5/655.full

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