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PRACTICE: P Kojodjojo, T Wong, A R Wright, O M Kon, W Oldfield, P Kanagaratnam, D W Davies, and N S Peters Pulmonary venous stenosis after treatment for atrial fibrillation BMJ 2008; 336: 830-832 [Full text]

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Referrer beware

Peter D Strouhal   (15 April 2008)

Referrer beware 15 April 2008
Peter D Strouhal, Consultant, Radiology/Nuclear Imaging Royal Wolverhampton Hospitals Trust, WV10 0QP Send response to journal: Re: Referrer beware	I read the St Mary's collaborators article with interest and dismay in about equal measure. They certainly raise excellent points about the need to think carefully about this new, iatrogenic type of pulmonary veno- occlusive disease (PVOD) that's set to become more prevalent and highlight how difficult it can be to diagnose. If one does not know something exists, one cannot make the diagnosis; so articles such as this raising awareness are invaluable, like those in past years in various European cardiology journals have been too. However, I was surprised to see them describe the (Perfusion/Ventilation) V/Q scan illustrated as high probablility since both Biello and modified PIOPED criteria would rate it as indeterminate/intermediate probability - the patient would still need the Computed Tomography Pulmonary Angiogram (CTPA) that ensued. This was all the more surprising given that PVOD would need to be severe enough to cause pulmonary arterial hypertension (PAH) to get any significant V/Q mismatches [as <<1% of the injected perfusion isotope typically reaches the capillaries/venules from a V/Q preparation] and these findings of PAH seem notable by their absence from the descriptions given. Secondly, they make light of the fact that a CT Pulmonary Venogram (CTPV) is an extra 'sequence' to standard CTPA; additional time and radiation is required since the chest is scanned again later in the study protocol. Thus, it is hardly 'free' additional information available from the scan and I felt this was not stressed enough, but perhaps reflects the surplus of CT scanners available in a London Teaching Hospital over what happens in the provinces! Moreover, how much stenosis in the veins is significant and likely to cause symptoms and how much is venous narrowing of uncertain significance? I don't think we know this yet. Perhaps the most important learning point, picked up in the discussion but worth reiterating, is that the referring clinicians asking for any scans need to let their imaging colleagues know their patients have had pulmonary venous isolation and all of us clinicians need to therefore consider some of the rarer causes of commoner pulmonary symptoms in such patients. Competing interests: None declared