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Angiographic Diagnosis of Pulmonary Embolism in the “Mitral Lung”

1966; Radiological Society of North America; Volume: 87; Issue: 4 Linguagem: Inglês

10.1148/87.4.705

1527-1315

Felix G. Fleischner,

Cardiac Valve Diseases and Treatments

Despite considerable advances the diagnosis of pulmonary embolism is often still difficult, even in a patient with previously intact lungs and heart. In chronic heart disease and in dangerous clinical situations in which a correct interpretation is urgent, the diagnosis of embolism may become a great challenge. Unfortunately, the difficulties are sometimes insurmountable both clinically and radiologically whether plain films, angiography, or scintiscanning is employed. Simon and Sasahara (10) have already alluded to the difficulties in mitral stenosis and congestive heart failure. The essence of the clinical problem is to distinguish a particular episode of deterioration in the ups and downs of the clinical course and recognize it as embolic in nature (3). The plain roentgenogram may be very helpful if it shows a consolidation identifiable as an infarct. If no infarct is apparent, plump, enlarged hilar arteries, poor visibility of segmental and subsegmental vessels, and underperfused lower zones are too common a part of the pathophysiology of mitral stenosis and other chronic heart diseases to be of any reliable value in a diagnosis of pulmonary embolism based solely on oligemia and the syndrome of acute and chronic cor pulmonale. The chronic vasculopulmonary changes in heart disease have been poorly understood. Older pathologic studies on the congested lung went hardly beyond a general description of the vascular and parenchymatous changes, and the radiologic interpretation, which lacked sufficient pathophysiologic background, was confused. New radiologic methods, pulmonary angiography, isotope-gas technics, and broadening of physiologic and pathologic experience have thrown new light upon the pathophysiology of the pulmonary circulation in heart disease. Notable contributions have been made by many workers (1, 2, 4, 6, 7, 9, 11, 12). The changes in severe mitral stenosis are the prototype of the pulmonary arterial hypertension called passive pulmonary hypertension or postcapillary hypertension (i.e., hypertension due to a postcapillary cause). It is generally agreed that in this circulatory disturbance the influence of gravity codetermines the preferential location and severity of the changes in the dependent portions of the lung (16). This syndrome of pulmonary vascular and parenchymatous changes as seen on the plain chest roentgenogram has been termed "mitral lung," although it is realized that identical changes, usually of a lesser degree, can occur in several other conditions. These include tumors of the left atrium, compression of the large pulmonary veins in the mediastinum, and left-sided congestive failure from any cause which produces similar hemodynamic conditions, such as hypertensive heart disease and aortic stenosis or insufficiency.