Adult Partial Anomalous Pulmonary Venous Connection: Case Reports (Including a Case of Scimitar Syndrome)

Partial anomalous pulmonary venous connection (PAPVC) is a congenital heart defect in which one or more pulmonary veins drain abnormally into the systemic venous circulation, leading to the development of pulmonary arterial hypertension. It can be supracardiac type, draining into the superior vena cava or right atrium (also called cardiac type) and infracardiac type with drainage into the inferior vena cava (IVC). We present two cases-supracardiac and infracardiac types of PAPVC in this case report.

Isolated Partial Anomalous Pulmonary Veins: A 10-Year Experience at a Single Center

INTRODUCTION

Isolated partial anomalous pulmonary venous connection (PAPVC) is difficult to diagnose, and surgical indications remain controversial. We reviewed 10 y of isolated PAPVC cases.

METHODS

The data of patients with isolated PAPVC admitted to the Anzhen Congenital Heart Disease Department from 2010 to 2019 were reviewed retrospectively.

RESULTS

Thirty patients, aged between 4 mo and 32 y, were included in this study. Significant correlations were found between the right ventricle (RV), end-diastolic dimension Z-score (RVED-z) and age (r = 0.398, P = 0.03), and between estimated pulmonary pressure and age (r = 0.423, P = 0.02). However, no significant correlations were found between the RVED-z and the number of anomalous pulmonary veins (r = 0.347, P = 0.061), between estimated pulmonary pressure and the RVED-z (r = 0.218, P = 0.248), and between estimated pulmonary pressure and the number of anomalous veins (r = 0.225, P = 0.232). Transthoracic echocardiography (TTE) confirmed 90% of isolated PAPVC cases. Surgical repair was performed in 29 patients with RV enlargement, persistent low weight, pulmonary hypertension, or respiratory symptoms. Among the surgical patients, nine had elevated pulmonary pressure before surgery, which decreased postoperatively; no mortality or reintervention was observed. The mean duration of echocardiographic follow-up was 1.9 y.

CONCLUSIONS

TTE is recommended for routine assessments, and further clarification can be obtained with computed tomography when TTE proves inconclusive for diagnosis. Transesophageal echocardiography and computed tomography are further recommended for adult patients if TTE fails to provide clear results. PAPVC should be considered as an underlying cause when unexplained RV enlargement is observed. Surgery is recommended for patients with RV enlargement, pulmonary hypertension, or respiratory symptoms.

Reintervention and mortality risk after total anomalous pulmonary venous connection repair

BACKGROUND

Management of total anomalous pulmonary venous connections has been extensively studied to further improve outcomes. Our institution previously reported factors associated with mortality, recurrent obstruction, and reintervention. The study purpose was to revisit the cohort of patients and evaluate factors associated with reintervention, and mortality in early and late follow-up.

METHODS

A retrospective review at our institution identified 81 patients undergoing total anomalous pulmonary venous connection repair from January 2002 to January 2018. Demographic and operative variables were evaluated. Anastomotic reintervention (interventional or surgical) and/or mortality were primary endpoints.

RESULTS

Eighty-one patients met the study criteria. Follow-up ranged from 0 to 6,291 days (17.2 years), a mean of 1263 days (3.5 years). Surgical mortality was 16.1% and reintervention rates were 19.8%. In re-interventions performed, 80% occurred within 1.2 years, while 94% of mortalities were within 4.1 months. Increasing cardiopulmonary bypass times (p = 0.0001) and the presence of obstruction at the time of surgery (p = 0.025) were predictors of mortality, while intracardiac total anomalous pulmonary venous connection type (p = 0.033) was protective. Risk of reintervention was higher with increasing cardiopulmonary bypass times (p = 0.015), single ventricle anatomy (p = 0.02), and a post-repair gradient >2 mmHg on transesophageal echocardiogram (p = 0.009).

CONCLUSIONS

Evaluation of a larger cohort with longer follow-up demonstrated the relationship of anatomic complexity and symptoms at presentation to increased mortality risk after total anomalous pulmonary venous connection repair. The presence of a single ventricle or a post-operative confluence gradient >2 mmHg were risk factors for reintervention. These findings support those found in our initial study.

Better Late Than Never – A Case of a Congenital Left Partial Anomalous Pulmonary Venous Drainage Diagnosed and Treated in The Sixth Decade of Life

Partial anomalous pulmonary venous drainage (PAPVD) is a relatively uncommon cardiac anomaly. The diagnosis might be challenging as are the presenting symptoms. Its clinical course mimics more familiar diseases, e.g., pulmonary artery embolism. We present a case of PAPVD, which had been misdiagnosed for more than two decades. After establishing the correct diagnosis, the patient got his congenital anomaly surgically corrected and showed excellent cardiac recovery in the six months follow up.

Fetal Doppler Echocardiographic Assessment Predicts Severe Postnatal Obstruction in Total Anomalous Pulmonary Venous Connection

BACKGROUND

Obstructed total anomalous pulmonary venous connection (TAPVC) is a form of critical congenital heart disease that usually requires urgent postnatal intervention. Knowing which patients have severe obstruction can aid delivery planning. The authors previously developed a novel quantitative metric of pulmonary venous flow, the pulmonary venous variability index (PVVI). The aim of this study was to test the hypothesis that fetal PVVI and vertical vein Doppler velocities are associated with severe pulmonary vein obstruction postnatally.

METHODS

A retrospective cohort study of neonates with prenatally diagnosed TAPVC was performed. Patients who underwent fetal echocardiography at the Children's Hospital of Philadelphia with Doppler interrogation of the vertical vein were included for analysis. Twenty-nine patients met criteria (21 with heterotaxy, 18 with supracardiac TAPVC). The latest gestation fetal echocardiogram was used. Severe pulmonary vein obstruction was defined as preoperative death or urgent surgery or catheter-based intervention (first day of life). Measurements of PVVI, defined as (maximum velocity - minimum velocity)/mean velocity, were made offline. Wilcoxon rank sum models were used to assess the associations of severe obstruction and PVVI and maximum, mean, and minimum velocities.

RESULTS

The mean gestational age at the latest fetal echocardiographic examination was 35 weeks (range, 30-39 weeks). Twelve of the 29 patients (41%) met criteria for severe pulmonary vein obstruction. Lower PVVI was associated with greater risk for severe pulmonary venous obstruction (P = .008). The maximum, mean, and minimum velocities in the vertical vein were all significantly associated with severe pulmonary venous obstruction (P = .03, P = .03, and P = .007, respectively). Qualitative assessment of obstruction was not significantly associated with the outcome. Interobserver reliability for all vertical vein Doppler metrics was high (intraclass correlation coefficient > 0.9).

CONCLUSIONS

Fetal PVVI and maximum, mean, and minimum velocities are associated with severe postnatal pulmonary vein obstruction in TAPVC. Accurate prediction of obstructed TAPVC could allow safer delivery planning. Further research with larger sample sizes is needed to identify the ideal cutoff values for these Doppler measures.

Impact of total anomalous pulmonary venous connection in staged single ventricle palliation

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) with a functional single ventricle is a risk factor for mortality during staged palliation. This study aimed to assess TAPVC's impact on staged palliation outcomes.

METHODS

In a total of 602 patients with a functional single ventricle who underwent stage 1 palliation (S1P) at our center between 2001 and 2020, 39 (6.5%) patients were associated with TAPVC. Median age at S1P was 12.0 (interquartile range, 7-21) days with a body weight of 3.1 (interquartile range, 2.8-3.6) kg. Outcomes during staged palliation were compared with the remaining 563 patients without TAPVC. Risk factors for mortality were identified using a Cox proportional hazards regression model.

RESULTS

Primary diagnosis in functional single-ventricle patients with TAPVC included hypoplastic left heart syndromes (n = 13), unbalanced atrioventricular septal defects (n = 12) tricuspid atresias (n = 2), double inlet left ventricle (n = 1), and others (n = 11). Types of TAPVC were supracardiac (n = 21), cardiac (n = 10), infracardiac (n = 6), and mixed (n = 2). Pulmonary venous obstruction (PVO) was associated in 19 (49%) patients. S1Ps included Norwood (n = 13), aortopulmonary shunt (n = 21), and pulmonary artery banding (n = 5). Thirty-day mortality after S1P was significantly increased in patients with TAPVC vs without TAPVC (43.6% vs 16.3%; P < .001). After bidirectional cavopulmonary shunt and total cavopulmonary connection procedures, mortality was low in both groups, and no statistically significant differences were found. Correction of TAPVC at the time of S1P was not found to be a significant risk factor in univariable Cox regression analysis. In univariate and multivariate analysis, PVO was identified as an independent risk factor for mortality in patients with TAPVC (P < .001).

CONCLUSIONS

Overall survival is lower in TAPVC single-ventricle patients than in non-TAPVC patients. Most deaths after S1P were associated with TAPVC, but not after S2P. PVO is a mortality risk factor in TAPVC patients.

A Rare Variant of Hypogenetic Lung Syndrome Mimicking Scimitar Vein

Hypogenetic lung syndrome, also known as scimitar syndrome, is a rare and well-known congenital condition that includes hypoplastic right pulmonary artery and lung, right displacement of the heart, anomalous systemic arterial supply to the lung, and a characteristically curved anomalous right pulmonary vein draining into the inferior vena cava. In exceptional cases, the anomalous pulmonary vein may drain into left atrium. We here report a case of a 17-year-old girl with a rare variant of hypogenetic lung syndrome diagnosed by means of multimodality imaging and treated with percutaneous occlusion of the aortopulmonary collateral.

Robotic Repair of Adult Left-Sided Partial Anomalous Pulmonary Venous Connection

Isolated anomalous drainage of the left pulmonary vein to the left innominate vein is a rare variant of partial anomalous pulmonary venous connection. Here, we describe 2 adult patients with this variant who underwent successful robotic totally endoscopic repair with anastomosis of the pulmonary vein to the left atrial appendage.

It is not asthma! An arcane case of 'Scimitar' syndrome: A case report

'Scimitar' syndrome in adulthood is usually asymptomatic. Significant structural abnormalities symptoms usually manifest early during infancy or young childhood with features of congestive heart failure from significant shunting of the anomalous pulmonary venous drainage. Diagnosis of 'Scimitar' Syndrome in adults is rare and usually an incidental finding on chest radiograph. Here, we report a case of an adult who presented with symptoms in her 40's. This syndrome has never been reported nor discussed in Malaysia. This is the first case report of 'Scimitar' Syndrome in Malaysian literature. The diagnostic dilemma, medical management, and multi-disciplinary management by cardiology, physiotherapy and pulmonary rehabilitation teams are discussed.

Partial anomalous pulmonary venous connection associated with hemoptysis: A case report

RATIONALE

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital anomaly characterized by the failure of fusion of embryologic pulmonary venous system with left atrium.

PATIENT CONCERNS

A 45-year-old male patient with PAPVC who was hospitalized because of mild hemoptysis. Images showed the anomalous vein originated from the left upper pulmonary vein and flowed into the left brachiocephalic vein. No other underlying causes for hemoptysis were detected.

DIAGNOSIS

After multi-disciplinary discussion, the patient was diagnosed as PAPVC of left upper pulmonary vein draining into the left brachiocephalic vein with intact atrial septum.

INTERVENTIONS

Although surgical correction of PAPVC was feasible, left upper lobectomy was performed as the definitive treatment for both hemoptysis and PAPVC.

OUTCOMES

The patient had an uneventful postoperative hospital course and was followed up for nearly 2 years without recurrence of hemoptysis.

LESSONS

PAPVC is associated with atrial septal defect in 80% to 90% of cases while isolated PAPVC with intact atrial septum is an extremely rare entity. We present a rare isolated PAPVC patient with hemoptysis. To our best knowledge, PAPVC associated with hemoptysis has never been reported before.

Asymptomatic atresia of the anomalous pulmonary vein in a patient with scimitar syndrome presenting in childhood

An asymptomatic 6-year-old boy with a history of right lung hypoplasia was referred for cardiology evaluation. Echocardiography demonstrated right pulmonary artery hypoplasia with flow reversal in that vessel. The right pulmonary veins were not visualised in the echocardiogram. Cardiac catheterisation confirmed the diagnosis of scimitar syndrome with a characteristic large vertical vein; however, the right pulmonary veins were found to be atretic with no connection to the heart with decompression through the azygos vein. In all, four systemic to pulmonary arterial collaterals were identified, supplying the right lung, which were occluded using embolization coils. This case demonstrates the potential for progressive stenosis and atresia of the so-called "scimitar vein" without previous surgical instrumentation, and that this can occur without haemodynamic embarrassment or development of pulmonary vascular disease.

Infantile scimitar syndrome with unusual associations

Scimitar syndrome is a variant of partial anomalous pulmonary venous connection (PAPVC), in which all or part of the right lung is drained by right pulmonary veins that anomalously connect to the inferior vena cava (IVC). The affected lung and its associated airways are often hypoplastic. In addition, aortopulmonary collateral vessels may be involved on the affected side, causing sequestration of that side; such involvement is commonly associated with cardiac defects. We report a case of infantile scimitar syndrome that involved a typical association with the right lung, but with extremely unusual associations with congenital hydrocephalus and heart blockage. The presentation of this case and the role of different diagnostic approaches and management are discussed.

[Partial anomalous pulmonary venous return in a 64-year-old woman]

Partial anomalous pulmonary venous return (PAPVR) represents 3 % of the congenital cardiopathies. Diagnosis in adults is challenging as clinical symptomatology is non-specific and echocardiographic signs are discrete and misleading potentially confusing with idiopathic pulmonary hypertension. We report the case of a 64-year-old woman in whom we diagnosed PAPVR associated with sinus venosus atrial septal defect. We describe medical history, clinical signs, investigations and postoperative evolution.

[Total isolated anomalous pulmonary venous return: Are there any clues for prenatal screening?]

Total anomalous pulmonary venous connection (TAPVC) is a serious congenital anomaly. TAPVC with obstruction of pulmonary venous return is an emergency requiring urgent intervention. Before 2010, very few isolated TAPVC were diagnosed prenatally. It has been suggested in the past literature that the use of Color flow Doppler is particularly useful for the screening of TAPVC prenatally. In fact, although color-Doppler is often useful to confirm a TAPVC diagnosis, it can be quite misleading in the screening process of the condition. Looking at data of missed TAPVC, we describe how to identify TAPVC during routine cardiac screening. Since 2010, our isolated TAPVC prenatal diagnosis rate is more than 40%.

Scimitar syndrome: the curved Turkish sabre

Scimitar syndrome is a rare association of congenital cardiopulmonary anomalies characterized by an anomalous pulmonary vein (scimitar vein) that drains into the inferior vena cava, a hypogenetic right lung, and dextroposition of the heart. It has been reported in 3% to 6% of patients with partial anomalous pulmonary venous connection. Patients are either diagnosed early with severe symptoms (infantile type) or late with minimal symptoms (childhood/adult type). In this chapter we reviewed the history, pathophysiology, presentation, diagnosis, and treatment methods of Scimitar syndrome in the current era.

Outcome predictors and implications for management of scimitar syndrome

BACKGROUND

Scimitar syndrome is a rare congenital anomaly. We evaluated risk factors for postoperative pulmonary vein stenosis or death and predictive factors for survival without scimitar vein surgery in patients with scimitar syndrome.

METHODS

The records of patients with scimitar syndrome evaluated at our medical center between 1964 and 2011 were reviewed.

RESULTS

Scimitar syndrome was identified in 80 patients, with a median follow-up of 4.5 years. Patients presenting less than 1 year of age had a higher incidence of symptoms, aortopulmonary collaterals, coexisting congenital heart disease (CHD), extracardiac anomalies, and pulmonary hypertension. Of 36 patients having scimitar vein surgery, 18 had postoperative pulmonary vein obstruction that occurred with similar frequency after baffle or reimplantation procedures, early or late in the study period, and tended to be more common in infants (P = .10). Overall, 19 (24%) of 80 died. Multivariate risk factors for death included systolic pulmonary pressure >0.5 systemic level (P = .007) and left pulmonary vein stenosis (P = .009). Pulmonary artery systolic pressure <0.5 systemic level (P = .01) and absence of CHD excluding atrial septal defect (P = .01) were predictive factors in 28 patients who survived and did not have scimitar vein surgery; these patients had no or mild right ventricular dilation and a ratio of pulmonary-to-systemic flow <1.6 either at baseline, after coiling aortopulmonary collaterals or nonscimitar vein intervention.

CONCLUSIONS

Postoperative pulmonary vein obstruction is common after scimitar vein surgery regardless of redirection technique. Pulmonary hypertension and left pulmonary vein stenosis are risk factors for death, whereas patients without significant pulmonary hypertension or associated CHD did well without scimitar vein surgery. These observations may guide management decisions in patients with scimitar syndrome.

[Total anomalous pulmonary venous connection: a 17-years experience of a single pediatric cardiology center]

OBJECTIVE

We reviewed our patients who underwent surgical repair for total anomalous pulmonary venous connection at our hospital.

MATERIAL AND METHODS

All patients with total anomalous pulmonary venous connection who underwent correction from February 1995 to October 2012 were included in this retrospective analysis. Clinical data was collected on presentation,morphology, associated cardiac lesions, echocardiography and cardiac cathetherization results, surgical repair and postoperative course.

RESULTS

There were 25 patients in the cohort, median age 19 days. The type of total anomalous venous connection was supracardiac in fifteen, cardiac in five, infracardiac in four, mixed-type in one patient. Six patients had single-ventricle anatomy with atrial isomerism in five. All patients with biventricular anatomy had cardiac defects associated: interauricular communication(17), patent arterial duct (9), tricuspid insufficiency (3), pulmonary stenosis (2), interventricular communication (1), mitral valve atresia (1), aortic arch hypoplasia (1). Nine patients (36%) presented with pulmonary venous obstruction. Respiratory distress was the most frequent symptom on presentation (80%), five patients were invasively ventilated. One patient was treated with extracorporeal membrane oxygenation prior to surgical correction. Twenty four cases were diagnosed with transthoracic echocardiography alone. Nine patients were evaluated with angiography that confirmed the echocardiographic diagnosis in eight patients; it allowed diagnosis of total anomalous pulmonary venous connection in one patient. Twenty four patients were submitted to surgery in the first six months of live (68% in neonatal period), one patient was operated at 27 years. Total anomalous pulmonary venous connection was corrected at first surgery in 22 patients. Two patients died after surgical correction,one with infracardiac total anomalous pulmonary venous connection with obstruction and another with supracardiac type with complex cardiac anomaly. There were no deaths in the last eleven years (14 patients). Postrepair pulmonary venous obstruction was diagnosed in one patient who was reoperated successfully.

CONCLUSION

Echocardiography provides adequate diagnostic data on total anomalous pulmonary venous connection so that surgery can be performed without angiography in most cases. Early surgical correction of total anomalous pulmonary venous connection has acceptable mortality and good long-term postrepair outcome.

Scimitar syndrome in an older adult

Scimitar syndrome is a rare congenital heart disease. It is divided into subgroups of infantile, adult, and multiple cardiac and extracardiac malformation. Most patients are diagnosed during infancy and occasionally in adolescence, but very few patients are older than 20 years of age, and only some cases have severe symptoms that require surgical correction. We report a case of a man 54 years of age who was diagnosed with asymptomatic scimitar syndrome with insignificant left-to-right shunt (Qp/Qs = 1.51) with a medical history of type 2 diabetes mellitus and hyperlipidemia. Related literature on scimitar syndrome, particularly on older adults, is also reviewed.