The "broken ring" sign in magnetic resonance imaging of partial anomalous pulmonary venous connection to the superior vena cava

Partial anomalous pulmonary venous connection: diagnosis by transesophageal echocardiography

OBJECTIVE

This study sought to demonstrate that with proper technique, identification of the normal and abnormal pulmonary venous connection can be made with confidence using transesophageal echocardiography (TEE).

BACKGROUND

Partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly whose diagnosis has classically been made using angiography.

METHODS

We performed a retrospective review of all patients of all ages with PAPVC diagnosed at the Mayo Clinic who had undergone TEE because of either right ventricular volume overload or suspected intracardiac shunting by transthoracic echocardiography or intraoperatively.

RESULTS

A total of 66 PAPVCs were detected in 43 patients (1.5/patient); in 2 additional patients, TEE suggested, but did not diagnose, PAPVCs. Shortness of breath was the most common presenting symptom (42.2%), followed by heart murmur and supraventricular tachycardia. Right-sided anomalous veins were identified in 35 patients (81.4%), left-sided in 7 (16.3%) and bilateral in 1 (2.3%). There was a single anomalous connecting vein in 23 patients (53.5%), two in 18 (41.9%), three in 1 (2.3%) and four in 1 (2.3%). The connecting site was the superior vena cava (SVC) in 39 veins (59.1%), right atrial-SVC junction in 6 (9.1%), right atrium in 8 (12.1%), inferior vena cava in 1 (1.5%) and the coronary sinus in 2 (3.0%). Ten anomalous left pulmonary veins were connected by a vertical vein to the innominate vein (15.1%). Sinus venosus atrial septal defect (ASD) was the most common associated anomaly in 22 patients (49%), followed by ostium secundum ASD in 6 and patent foramen ovale in 4. Fifteen patients had an intact atrial septum. Thirty-one patients (68.8%) underwent surgical repair. PAPVC was confirmed in all patients, including the two whose TEE results were suggestive of PAPVC. All 49 PAPVCs detected by TEE preoperatively were confirmed at the time of operation.

CONCLUSIONS

TEE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence the need for medical and surgical management. TEE should be performed in patients with right ventricular volume overload when the precordial examination is inconclusive.

Assessment of anomalous systemic and pulmonary venous connections by transoesophageal echocardiography in infants and children

OBJECTIVE

To assess the value of transoesophageal echocardiography in the preoperative definition of systemic and pulmonary venous connections.

DESIGN

Transoesophageal echocardiographic studies were performed prospectively under general anaesthesia in 76 consecutive unoperated children. Results were compared with those obtained by earlier transthoracic ultrasound studies (n = 76), cardiac catheterisation (n = 62), and subsequent surgical inspection (n = 58).

SETTING

Two tertiary referral centres.

PATIENTS

76 unoperated infants and children (age 0.2-14.8 years, mean age 4.1 years) with congenital heart disease.

MAIN OUTCOME MEASURE

Identification of anomalous systemic and pulmonary venous connections.

RESULTS

Transoesophageal studies showed anomalous venous connections in 14 patients. Two had both anomalous systemic and pulmonary venous connections. Transoesophageal studies showed 12 anomalous systemic venous connections in nine patients. In eight patients these were confirmed at operation or catheterisation: one patient is awaiting operation. Six anomalous systemic venous connections were missed during earlier transthoracic studies. Anomalous pulmonary venous connections (one mixed total, six partial) were shown in seven patients. These were confirmed at operation in six and by cardiac catheterisation in one. Four of these patients were missed during earlier transthoracic ultrasound studies. No patient defined as having normal venous connections by the transoesophageal study was subsequently shown to have anomalous venous connections at operation or angiography.

CONCLUSIONS

Transoesophageal echocardiography is a highly sensitive tool for the preoperative definition of systemic and pulmonary venous connections. In this series it was better than transthoracic ultrasound and complemented cardiac catheterisation and angiocardiography.

Anomalous pulmonary venous connection. Medical therapy

Anomalous pulmonary venous connection is a congenital defect which may first be diagnosed in the adult who has developed lung disease or pulmonary vascular obstructive disease. Surgical repair may be inadvisable in such a case. To date, little attention has been paid in the literature to medical management. A case is presented in which medical palliation with nitrate therapy was successful.