Normative Analysis of Pulmonary Vein Drainage Patterns on Multidetector CT With Measurements of Pulmonary Vein Ostial Diameter and Distance to First Bifurcation

Rationale and Objectives

To document the frequency of normal and anomalous drainage patterns of the pulmonary veins, and to establish normal values for pulmonary vein ostial diameters, and distance to first bifurcation using multidetector computed tomography, as pertinent to ablation procedures for atrial fibrillation.

Materials and Methods

Two cardiothoracic radiologists retrospectively reviewed thin-section contrast material–enhanced multidetector computed tomography examinations of the thorax in 200 consecutive patients (38 females and 162 males), age 24–79 years (mean 52.8) referred for imaging before radiofrequency ablation therapy for atrial fibrillation. Pulmonary vein anatomy was based on both the number of venous ostia and the drainage patterns of pulmonary veins. Pulmonary vein ostial diameters and distance to first bifurcation of the four major pulmonary veins (right inferior and superior, left inferior and superior) and any additional pulmonary veins were measured at a workstation using both axial images and multiplanar reconstructions by two experienced cardiothoracic radiologists; the mean pulmonary vein diameter and the shortest distance to first bifurcation of the two measurements are reported.

Results

The majority of patients, 82% (164 patients) had four pulmonary veins, with a superior and inferior ostium on the right and a superior and inferior ostium on the left. Of the remainder, 9% (18 patients) had five veins, 4.5% (9 patients) had three veins, 3% (6 patients) had two anomalies each, and 0.5% (1 patient) had three anomalies. The middle lobe pulmonary vein drained into the right superior pulmonary vein in 83.5% of patients, directly into the left atrium in 11% of patients, and into the right inferior pulmonary vein in 5.5% of patients; 6.5% of patients had a single left pulmonary vein ostium. Mean pulmonary vein diameters with 95% confidence intervals at the ostia were as follows: right superior 17.6 (13.64–15.36) mm; left superior 16.6 (16.03–17.08) mm; right inferior 17.1 (16.58–17.55) mm; left inferior 14.8 (14.25–15.27) mm, and independent middle lobe 8.6 (8.27–8.86) mm. Mean distance to first bifurcation with 95% confidence intervals were: right superior 14.5 (17.02–18.23) mm; left superior 17.6 (16.63–18.53) mm; right inferior 7.0 (6.49–7.46) mm; left inferior 13.5 (12.83–14.16) mm, and independent middle lobe 8.4 (7.7–9.17) mm.

Conclusion

Thin-section thoracic computed tomography demonstrates a greater variability of pulmonary venous drainage than previously described. There is greater variability of the right lung venous drainage compared to the left lung. Eighty-two percent of people have four standard pulmonary veins. There is significant variability in pulmonary vein diameter and distance to first bifurcation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and is a major cause of stroke ( ). Treatment is directed at three major objectives: controlling the ventricular response, preventing thromboembolism, and maintaining normal sinus rhythm ( ). In the past few years, radiofrequency ablation of the pulmonary veins has been performed to disconnect the pulmonary veins electrically from the left atrium. Knowledge of ostial diameter facilitates catheter size selection during the ablation procedure. Furthermore, because pulmonary vein narrowing is critically dependent on catheter proximity to a bifurcation and not on duration of radiofrequency energy application, knowledge of the distance from each ostium to the first bifurcation of each pulmonary vein is important to prevent postablation pulmonary vein stenosis ( ). The purpose of our study was twofold: to establish the normative distribution of pulmonary venous drainage and categorize anatomic variations in venous drainage, and to establish normative values for pulmonary vein ostial diameters and distance to first pulmonary venous bifurcation.

Materials and methods

Subjects

Two hundred consecutive pulmonary vein mapping computed tomography (CT) examinations performed before radiofrequency ablation therapy for atrial fibrillation were retrospectively reviewed by two cardiothoracic radiologists. Of the 200 subjects (38 women and 162 men), women ranged in age from 24 to 73 years (mean age 56.8 years), and men ranged in age from 28 to 79 years (mean age 51.8 years). There was no statistically significant difference in ages between genders. This study was approved by our institutional review board.

Imaging

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Statistical Analysis

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Results

Pulmonary Vein Anatomy

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Table 1a

Pulmonary Venous Drainage Patterns by Total Number of Pulmonary Veins

Number with 6 veins or more = 0 Number with 5 veins = 21 18 = Normal + MLPV 1 = MLPV + accessory RIPV + CLT 2 = Normal + accessory RIPV Number with 4 veins = 170 164 = Normal 1 = RCT + MLPV draining into LA 1 = LCT + MLPV draining into LA 1 = RSPV to SVC + MLPV draining into LA 3 = CLT + accessory RIPV Number with 3 veins = 9 1 = CRT 8 = CLT Number with 2 veins or less = 0

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Table 1b

Pulmonary Venous Drainage Patterns by Number of Pulmonary Veins Separated by Side

Number of Right Veins Number of Left Veins Number with greater than 4 veins = 0 Number with greater than 4 veins = 0 Number with 4 veins = 1 Number with 4 veins = 0 1 = MLPV + accessory RIPV + CLT Number with 3 veins = 24 Number with 3 veins = 0

Number with 2 veins = 174 Number with 2 veins = 187

Number with 1 vein = 1 Number with 1 vein = 13 1 = CRT 8 = CLT 3 = CLT + accessory RIPV 1 = MLPV + accessory RIPV + CLT 1 = CLT + MLPV draining into LA

RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein; LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein; MLPV: middle lobe pulmonary vein; LA: left atrium; CRT: common right trunk; CLT: common left trunk; Acc RIPV: accessory right inferior pulmonary vein; SVC: superior vena cava.

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Pulmonary Vein Ostial Diameter

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Table 2

Comparison of Pulmonary Vein Ostial Diameters by Gender

Mean Pulmonary Vein Diameter_P_ Value Men Women Right superior pulmonary vein 17.8 16.7 .13 Left superior pulmonary vein 16.7 15.9 .13 Middle lobe pulmonary vein 8.6 8.2 .14 Right inferior pulmonary vein 17.3 15.9 .04 Left inferior pulmonary vein 15.1 13.4 .007

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Table 3

Mean Pulmonary Vein Ostial Diameters

Superior and Inferior Pulmonary Vein Ostial Diameters (mm) Minimum Mean Maximum SD 95% CI All SPV 6.00 17.00 30.00 4.12 16.70–17.50 RSPV 6.00 17.63 30.00 4.36 17.02–18.23 LSPV 9.00 16.56 26.70 3.80 16.03–17.08 All IPV 5.20 15.90 28.20 3.78 15.50–16.30 RIPV 8.50 17.06 28.20 3.50 16.58–17.55 LIPV 5.20 14.76 23.50 3.70 14.25–15.27

Middle Lobe Pulmonary Vein Ostial Diameter (mm) Minimum Mean Maximum SD 95% CI All MLPV 3.00 8.56 14.00 2.16 8.27–8.86 Drain to RSPV 3.00 8.50 14.00 2.10 8.27–8.82 Drain to RIPV 5.00 8.82 13.00 2.09 7.58–10.05 Drain to LA 4.00 8.60 14.00 2.67 7.50–9.73

Other Pulmonary Vein Ostial Diameters (mm) Minimum Mean Maximum SD 95% CI Common trunks 12.00 24.29 44.00 7.45 20.52–28.06 Accessory veins 6.00 7.70 9.70 1.44 6.60–8.91

SD: standard deviation; RSPV: right superior pulmonary vein; LSPV: left superior pulmonary vein; MLPV: middle lobe pulmonary vein; RIPV: right inferior pulmonary vein; LIPV: left inferior pulmonary vein.

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Table 4

Comparison of Pulmonary Vein Ostial Diameters

Pulmonary Vein Diameter Comparison Means (mm)P Value All SPV vs. All IPV

<.001 All SPV vs. ML PV

<.001 All IPV vs. ML PV

<.001 RSPV vs. RIPV

.15 RSPV vs. MLPV

<.001 RIPV vs. MLPV

<.001 LSPV vs. LIPV

<.001 RSPV vs. LSPV

.009 RIPV vs. LIPV

<.001 MLPV drains to RSPV vs. MLPV drains to RIPV

.68 MLPV drains to RSPV vs. MLPV drains to LA

.90 MLPV drains to RIPV vs. MLPV drains to LA

.81 Common trunk vs. all SPV

<.001 Common trunk vs. all IPV

<.001 Common trunk vs. RSPV

<.001 Common trunk vs. RIPV

<.001 Common trunk vs. LSPV

<.001 Common trunk vs. LIPV

<.001 Accessory PV vs. all SPV

<.001 Accessory PV vs. all IPV

<.001 Accessory PV vs. RSPV

<.001 Accessory PV vs. RIPV

<.001

All SPV: all superior pulmonary vein; all IPV: all inferior pulmonary vein; RSPV: right superior pulmonary vein; LSPV: left superior pulmonary vein; MLPV: middle lobe pulmonary vein; RIPV: right inferior pulmonary vein; LIPV: left inferior pulmonary vein.

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Distance to First Bifurcation

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Table 5

Distance from Ostium to First Bifurcation of Pulmonary Veins

Superior and Inferior Pulmonary Vein Distance to First Bifurcation (mm) Minimum Mean Maximum SD 95% CI All SPV 1.00 16.00 43.00 6.70 15.30–16.70 RSPV 1.00 14.50 36.00 6.21 13.64–15.36 LSPV 1.60 17.58 43.00 6.48 16.63–18.53 All IPV 0.30 10.20 30.00 5.32 9.70–10.70 RIPV 0.30 6.97 21.00 3.51 6.49–7.46 LIPV 0.80 13.50 30.00 4.80 12.83–14.16 MLPV 1.00 8.43 29.00 5.31 7.70–9.17

Other Pulmonary Vein Distance to First Bifurcation (mm) Minimum Mean Maximum SD 95% CI Common trunks 1.00 9.76 26.00 7.10 6.16–13.35 Accessory veins 2.00 7.71 17.00 5.43 3.37–12.06

RSPV: right superior pulmonary vein; LSPV: left superior pulmonary vein; MLPV: middle lobe pulmonary vein; RIPV: right inferior pulmonary vein; LIPV: left inferior pulmonary vein.

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Table 6

Comparison of Pulmonary Vein Distance To First Bifurcation

Distance to First Bifurcation Comparison Means (mm)P Value All SPV vs. All IPV

<.001 All SPV vs. ML PV

<.001 All IPV vs. ML PV

<.001 RSPV vs. RIPV

<.001 RSPV vs. MLPV

<.001 RIPV vs. MLPV

.001 LSPV vs. LIPV

<.001 RSPV vs. LSPV

<.001 RIPV vs. LIPV

<.001 Common trunk vs. All SPV

.008 Common trunk vs. All IPV

.96 Common trunk vs. RSPV

.043 Common trunk vs. RIPV

.089 Common trunk vs. LSPV

.002 Common trunk vs. LIPV

.11 Accessory PV vs. all SPV

.02 Accessory PV vs. all IPV

.51 Accessory PV vs. RSPV

.046 Accessory PV vs. RIPV

.48

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Discussion

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Conclusion

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References

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Normative Analysis of Pulmonary Vein Drainage Patterns on Multidetector CT With Measurements of Pulmonary Vein Ostial Diameter and Distance to First Bifurcation

Rationale and Objectives

Materials and Methods

Results

Conclusion

Materials and methods

Subjects

Imaging

Statistical Analysis

Results

Pulmonary Vein Anatomy

Pulmonary Vein Ostial Diameter

Distance to First Bifurcation

Discussion

Conclusion

References

Further Reading

A Quality Assurance Elective for Radiology Residents

Abstracts of Funded National Institutes of Health Grants

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