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VALUE OF 64 SLICE MULTIDETECTOR CT IN

ANOMALOUS PULMONARY VENOUS RETURN (APVR) IN

NEONATES AND INFANTS

H MIZOUNI, M JRAD,E MENIF

Service d’Imagerie MédicaleHôpital la Rabta. TUNIS - TUNISIE

Correspondance: Dr Habiba MIZOUNIhabiba_mizouni@yahoo.fr

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INTRODUCTION

Abnormal pulmonary venous return (APVC) correspond to an abnormal connection of one or all the pulmonary veins (PV) in the circulation systemic vein. They can be total or partial.

The purpose of this presentation is to illustrate aspects CT anatomy of different varieties of APVC in a pediatric population.

All cases which were verified surgically

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NORMAL PULMONARY VENOUS DRAINAGE

Figures of normal pulmonary venous drainage

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Partial APVR

Is defined as a left-to-right shunt where one or more pulmonary veins drain into a systemic vein or the right atrium.

Represent 70% of total APVR

All PAPVRs are left-to-right shunts, but more than 50% of the pulmonary flow drains to the right side of the heart.

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Partial APVR

Can be associated with other congenital cardiac anomalies ( 15%) ; a sinus venosus atrial septal defect (ASD) located near the SVC orifice is the more frequent one

Clinical manifestations , such us :Dyspnea, fatigue, exercise intolerance, palpitations, syncope, atrial arrhythmias, right heart failure, and pulmonary hypertension, are rare.

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Different types of partial APVR

PARTIAL APVR

RIGHT LEFT

SUPRA CARDIAC CARDIAC INFRA CARDIAC

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Different types of partial APVR

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Total AVPR (TAVPR)

Is a congenital heart defect in which the pulmonary veins fail to connect to the left atrium during cardiac development and instead drain into the right atrium or one of its venous tributaries.

Accounts for approximately 1.5% of all cardiovascular anomalies

Has an incidence of 1/15,000 live births

No sex predilection has been observed

All total AVPR are associated with a septal atrium defect

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Total APVR

TAPVR usually has no effect during fetal development due to high pulmonary vascular resistance and shunting of blood through the foramen ovale.

At birth the pulmonary vascular resistance drops and increased blood flow to the right heart and lungs results in progressive congestive heart failure and pulmonary arterial hypertension.

If not surgically corrected, TAPVR has a high mortality rate in the first year of life.

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Total AVPR

The pulmonary venous return can be :

- Supra cardiac venous return 50%- Cardiac venous return 25% - Infra cardiac venous return 20 %- Mixed venous return 5%

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Infra Cardiac TAVPR

Cardiac TAVPR

Supra Cardiac TAVPR

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Multidetector CT technique

We perform a spiral acquisition without cardiac gating using 0.6- or 0.7-mm collimation

To minimize radiation exposure of the patients, we use an 80-kV tube with high pitch (1.2–1.5)

Mean radiation dose is estimated in millisieverts (mSv) from the dose-length product after correction for body size.

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Multidetector CT technique

Non-ionic low-osmolar contrast medium (300 mg I/ml) in a dosage of 1.5- 2 ml/kg is injected into a peripheral vein ( 22 -24 G) at a low rate (0.5–1 ml/s) to avoid streak artifacts in the SVC.

None of the patients receive anesthesia. Sedation is given if needed.

Time from injection to scanning initiation

was set at 40 s to ensure homogenous contrast at the venous phase.

Experienced staff and readers were required to manage children and reading images.

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CASES

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CASE 1

Infant aged 14 mouths Dyspnea Echocardiography:- Enlargement of right heart chambers- Sinus venosus atrial septal defect

(ASD)

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Fig.1a et 1b: • Right Superior pulmonary vein ( VPS Drt) draining into

superior vena cava ( VCS) at the top of the azygos vein in maximum intensity projection (MIP)

• The SVC is expanded above the mouth of the azygous

1a 1b

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Right superior pulmonary vein

Right supra cardiac partial APVR in volume rendering (VR) technique.

This type of APVC is usually associated with a CIA-type high sinus venosus

The Right Superior pulmonary vein is draining into superior vena cava

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Case 2

Daughter of 3 months Dyspnea Echocardiography :- CIA - Doubt on the presence of AVRP

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Right pulmonary venous return in the inferior vena cava

Right pulmonary vein

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Hypo vascularization of the right lung

Ipsilateral pulmonary artery of small caliber

Controlateral pulmonary artery of normal caliber

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Systemic vasculature for the right lung from:

The celiac In the abdominal aorta

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Hypoplastic right lung field

Anomaly of the bronchial systematization

Hypoplastic right lung reduced to one lobe

Absence of visualization of the right scissure

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Dextroversion heart

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Right pulmonary venous return in the inferior vena cava

Dextroversion heartHypo vascularization of the right lung

Hypoplastic right lung field

Scimitar syndrome

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Case 3

Daughter of one month Dyspnea and cyanosis Echo: CIA and dilatation of the right

cavities

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The right pulmonary veins draining into the right atrium

Partial APVC  of the total right lung draining into the right atrium

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Dilatation of right cavities

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Double left superior vena cava draining ina dilated coronary sinus

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Associated skeletal malformations

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Cardiac partial APVR

The entire right lung draining in the right atrium

Form infrequent Form almost always associated with a

CIA Sometimes associated malformations

skeletal

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Case 4

8 years-old daughter Dyspnea Echo: dilated right cavities

associated with CIA CT scan in search of APVR

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The left superior pulmonary vein flows through a collector into the Venous trunk left brachiocephalic

Superior vena cava dilated

Venous trunk left brachiocephalic Collector

SVC The superior left pulmonary vein

A supra cardiac partial AVPR of the superior left lung lobe

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Venous trunk left brachiocephalic

Collector

Anomaly aortic arch  associated  :right subclavian artery in retroaortic course esophageal

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Case 5

Infants 3 months Cyanosis and tachypnea Echocardiography: - Dilatation of the

RV with a paradoxical septal kinetics.- Expansion of the OD and trunk of the pulmonary

artery- Severe PAH- Shunt right / left through a CIA- Absence of pulmonary veins abouchant in OG.- Viewing a supra cardiac collector vein - Doubt on a second infra cardiac collector vein

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A left supra cardiac AVPR

Volume rendering  reconstruction (VR) showing theFirst collector (  ) draining the left superior pulmonary vein is abouchnat in the venous trunkinnominate ( )

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Infra cardiac APVR

Second collector draining the entire venous return right lung ( ) and the left lower lobe ( ): vertical path ( ) is abouchant the trunk door ( )• Absence of stenosis of the collector

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Diagnosis :Mixed supra cardiac and infra

cardiac total APVR

First collector  draining the left superior pulmonary vein is abouchant in the venous trunk innominate 

Second collector draining the entire venous return right lung and the left lower lobe in the portal vein.

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Case 6

Daughter of three months Dyspnea Chest X-Ray and Echocardiography: Dilatation of right cavities

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Venous collector ( ) opening the posterior surface of the OD and the roof of coronary sinus

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Venous collector ( ) opening in the faceposterior OD and the roof of the coronary sinus

Total cardiac APVC

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Conclusion Echocardiography remains the first-line choice

for diagnostic imaging in all patients with pulmonary venous anomalies.

However, when echo diagnosis is inconclusive, CT and not catheterization should be considered the next imaging modality of choice which is less invasive and more precise.

Three-dimensional reformatting provided additional assistance with surgical planning.