Scimitar syndrome: the curved Turkish sabre

Scimitar Syndrome in a Pediatric Cohort

BACKGROUND

Scimitar syndrome is a rare form of congenital heart disease (CHD) characterized by anomalous pulmonary venous drainage of the right lung to the inferior vena cava. We describe the presentation, diagnosis, therapeutic management and long-term follow-up of 10 pediatric patients with Scimitar Syndrome.

METHODS

We performed a retrospective observational study of all pediatric patients from our institution with scimitar syndrome (March 1996-July 2023). Patients underwent systematic evaluation including medical and family history, chest x-ray, 12-lead electrocardiogram, echocardiogram, angiography and/or computed tomography; or magnetic resonance angiography.

RESULTS

Ten patients with scimitar syndrome were included. The median age at diagnosis was 10.4 [0.1-150.2] months and the median follow-up time was 7.7 [1.3-15.3] years. Eight patients presented with aortopulmonary collateral arteries which were embolized. Two patients had dual connections to the inferior vena cava and left atrium; embolization of the inferior vena cava connection was only feasible in one of them. No patients underwent surgery of the scimitar vein. Three patients had surgical correction of CHDs. There were no deaths related to scimitar syndrome during follow-up.

CONCLUSIONS

All patients with scimitar syndrome need prompt cardiovascular evaluation and follow-up. Our study demonstrates that a conservative approach with aortopulmonary collateral artery embolization, scimitar vein embolization when dual drainage to the left atrium is identified, along with correction of concomitant CHDs might have good results in patients with scimitar syndrome in order to postpone surgical correction of the anomalous pulmonary venous return to an older age when clinically or hemodynamically indicated. Further studies with longer-term follow-up and a larger sample size are needed to more effectively determine treatment strategy.

Clinical characteristics, imaging findings, management, and outcomes of patients with scimitar syndrome at a tertiary referral healthcare center in Colombia

Scimitar Syndrome is part of a complex spectrum of congenital cardiovascular anomalies related to anomalous pulmonary venous return. Depending on the extent of involvement, treatment can be either expectant or surgical. Prognosis and survival have been controversial, with some results supporting early surgical management. This research aims to disclose the outcomes and describe the management, clinical and imaging characteristics of patients diagnosed with Scimitar Syndrome treated in a tertiary referral healthcare center. Longitudinal descriptive observational study. The study included all patients diagnosed with scimitar syndrome in our institution between January/2011 and December/2022. A description of the sociodemographic and clinical characteristics, diagnostic tools used, treatment features, and patient outcomes is provided. Eleven patients were included, with a mean age at diagnosis of five years (CI 0-17), six of which were female (54.55%). Nine (81.82%) patients had evidence of a scimitar vein on the chest radiograph, six (54.55%) cardiac dextroposition, six (54.55%) pulmonary hypoplasia, five (45.45%) right pulmonary artery hypoplasia, and three (27.27%) had aortopulmonary collaterals. Four (36.36%) patients had horseshoe lungs, and four (36.36%) had bronchopulmonary sequestration. In the associations, two (18.18%) patients were found to have an atrial septal defect, three (27.27%) ventricular septal defect, and one (9%) had Tetralogy of Fallot. Pulmonary hypertension was demonstrated in two (18.18%) patients. Seven (63.64%) required surgical management to correct the scimitar vein, and two patients died due to unrelated complications. Scimitar syndrome presents diagnostic and treatment challenges, necessitating a multidisciplinary approach for timely care. Chest radiography and CT scans are primary diagnostic tools, with surgical intervention often warranted alongside other heart defects or significant hemodynamic repercussions. Medical management is effective for mild to moderate cases. Long-term patient outcomes remain uncertain due to study limitations, but improved life expectancy is anticipated with ongoing care.

Unveiling a Unique Case of Scimitar Syndrome: Clinical Significance and Multidisciplinary Management Challenges in Pakistan

Scimitar syndrome, a rare congenital cardiac anomaly, involves abnormal pulmonary vein drainage into systemic veins, leading to distinct imaging features resembling a curved-blade sword. This case report presents a unique instance of scimitar syndrome in Pakistan, emphasizing its clinical importance and the challenges of management. A 26-year-old female with a history of recurrent pulmonary infections and respiratory symptoms since childhood was diagnosed with scimitar syndrome. Radiological assessments, including chest X-rays, computed tomography pulmonary angiograms (CTPA), and transthoracic echocardiography, confirmed the presence of a curved vessel originating from the right hemidiaphragm and connecting with the inferior vena cava (IVC). The patient and her medical team opted for conservative management, involving multidisciplinary care, tailored treatment for infections, and regular monitoring. The rarity of Scimitar syndrome necessitates careful diagnosis and management decisions. While surgical intervention is often recommended, this case demonstrates the complexities of choosing conservative management based on patient preferences and the evolving clinical course. A literature review reveals varied outcomes of surgical and conservative approaches, emphasizing the need for personalized strategies. Radiological techniques, such as CTPA and MRI, play pivotal roles in diagnosis and monitoring. This case report underscores the clinical significance of scimitar syndrome, particularly in regions with limited reported cases, like Pakistan. The multidisciplinary management approach, the decision-making process regarding conservative treatment, and the unique radiological findings contribute to the medical community's understanding of this rare condition.

Bronchial Asthma With Scimitar Syndrome: A Case Report

Scimitar syndrome is a rare congenital cardiopulmonary anomaly; it is also called venolobar syndrome, hypogenic lung syndrome, and Halasz syndrome. The syndrome is characterized by cardiac dextroposition, right lung and pulmonary artery hypoplasia as well as complete or partial anomalous pulmonary venous drainage of the right lung. We report a case of a 22-month-old full-term male child with a severe form of scimitar syndrome diagnosed at birth. The X-ray demonstrated dextrocardia and right lung hypoplasia, while the echocardiography clearly illustrated the scimitar vein. The patient had multiple ER visits and hospitalizations due to asthma exacerbation that was aggravated by recurrent respiratory tract infections; he responded well to asthma medications during his admissions yet compliance to his prophylactic asthma medications was poor at home.

Scimitar syndrome with large atrial septal defect and a rare partial anomalous venous drainage in an adult: a case report

Background

Scimitar syndrome is a very rare congenital cardio-pulmonary disease with anomalous right pulmonary vein draining either partially or completely into the inferior vena cava. It is called Scimitar syndrome due to the classical appearance in the chest X-ray, which resembles the curved blade of Turkish sword 'Scimitar'. It commonly associates with atrial septal defect (ASD), hypoplasia of the right lung, dextroposition of the heart, and pulmonary hypertension (PHT).

Case summary

A 67-year-old lady, diagnosed with atrial fibrillation and moderate PHT 3 years ago, presented with worsening bilateral ankle oedema and New York Heart Association class III shortness of breath. Chest X-ray showed the Scimitar appearance. The trans-thoracic and trans-oesophageal echocardiograms revealed a 46 mm ASD and a partial anomalous pulmonary venous drainage (PAPVD) of the right upper pulmonary vein (RUPV) into the right atrium at the junction of the atria. Three-dimensional reconstruction of the computed tomographic pulmonary angiogram confirmed Scimitar syndrome of the right lower pulmonary vein (RLPV). We managed her conservatively on her wish. After 13 months, she succumbed due to a massive stroke.

Discussion

We describe a very rare case of an elderly lady who has Scimitar syndrome with an ASD and evidence of PAPVD of the RUPV; thus, we intend to provide an antecedent for further cases, for prompt and accurate diagnosis and timely interventions in order to prevent life-threatening complications.

Surgical and Cardiac Catheterization Outcomes of Scimitar Syndrome Patients: A Three Decade Single-Center Experience

Scimitar syndrome (SS) is a rare congenital condition which includes partial anomalous pulmonary venous return (PAPVR) and a variable degree of pulmonary hypoplasia. We describe the clinical features, therapeutic approach and outcomes of patients who underwent cardiac catheterization and/or surgical repair of the scimitar vein at a single institution in the United States. This retrospective cohort study included all patients with SS who underwent scimitar vein surgical repair or cardiac catheterization from October 1989 through August 2021 in a tertiary care center. A total of 84 patients with SS were included and median follow-up time was 74 months. Patients diagnosed with SS under the age of one year had a significantly greater incidence of congenital heart defects (CHD) (p < 0.001), non-cardiac anomalies (p = 0.02), pulmonary hypertension (p = 0.02), and mortality (p = 0.04) compared to those diagnosed over the age of 1 year. Twenty-eight patients underwent surgical repair of the scimitar vein. Overall, eight (10%) patients died. Compared to surviving patients, deceased patients had a significantly higher incidence of pulmonary hypertension (PH), neonatal SS diagnosis, and extracorporeal membrane oxygenation (ECMO) support. Median scimitar vein pressure (20 mmHg) of deceased patients was significantly higher compared to pressures in surviving patients (11 mmHg; p = 0.02). PH, CHD, neonatal SS diagnosis, ECMO support, and markedly elevated scimitar vein pressure are associated with mortality. Scimitar vein surgical repair during infancy is commonly associated with PH and restenosis that requires re-intervention.

Anesthesia management of living donor liver transplantation in a patient with scimitar syndrome

Scimitar syndrome is a rare congenital anomaly with a hallmark of an abnormal drainage of pulmonary veins into inferior vena cava instead of the left atrium; this creates a curvilinear radiological pattern resembling a sword (scimitar) on a chest radiograph, thus attracting the name. This case report highlights the challenges during liver transplantation, and perioperative anesthetic management of a patient with an uncorrected Scimitar Syndrome.

Scimitar syndrome – An incidental diagnosis in a case of fibroadenoma

Scimitar syndrome is a rare congenital anomaly which is characterised by anomalous pulmonary venous drainage of the either entire right lung or part of it into the inferior vena cava or portal vein or hepatic vein or right atrium occasionally. This can be associated with hypoplasia of the right lung, dextroposition, underdevelopment of right pulmonary artery and anomalous systemic arterial supply from the descending aorta to the hypoplastic lung. A 36 year old female came with history of swelling in the right breast which turned up to be right breast fibroadenoma. Routine chest radiograph revealed scimitar syndrome which was confirmed on CECT chest.

Diaphragmatic eventration as a first sign of Scimitar syndrome

Diaphragmatic eventration is an anomaly of the diaphragm. In Scimitar syndrome, a curved-shaped anomalous pulmonary venous drainage is seen. Association between these conditions is rare. We present a newborn with diaphragmatic eventration, whose diagnosis of Scimitar syndrome was made after surgical repair. Scimitar syndrome is a congenital disorder often associated with other heart and lungs anomalies. Diagnosis can be fortuitous but with important prognostic features.

A late presentation of scimitar syndrome in adult

Scimitar Syndrome is a rare congenital disorder and a variant of partial anomalous pulmonary venous connection (PAPVC) in which part or even the entire right lung is drained by right pulmonary veins that connect anomalously to the Inferior Vena Cava (IVC). It has various presentations including exertional dyspnea, recurrent chest infection, pulmonary artery hypertension, and hemoptysis. The initial diagnosis of PAPVC may be made by echocardiography and is typically confirmed by magnetic resonance imaging, computed tomography, or cardiac catheterization.We report a 69-year-old man with progressive dyspnea on exertion associated with palpitations of five years of evolution. The patient was diagnosed with cardiomyopathy, pulmonary hypertension and was started on treatment with anticoagulation, digoxin, and metoprolol for his atrial fibrillation. Despite the treatment, the dyspnea did not improve. The patient underwent cardiac catheterization, where the anomalous venous drainage was confirmed. Scimitar syndrome was corrected by surgical intervention with complete resolution of symptoms.

A Very Rare Combination: two Scimitar Veins and a Myocardial Bridge

Scimitar syndrome is a rare congenital anomaly characterized by partial or complete anomalous pulmonary venous drainage of the right (rarely left) lung into the inferior vena cava. This anomalous vein resembles the curved Turkish sword “scimitar”^[1]. Only few cases were reported with two scimitar veins^[2]. “Myocardial bridge” constitutes a portion of the myocardial tissue that bridges a segment of the coronary artery, mostly the left anterior descending coronary artery . For the first time, a combination of double scimitar vein and a myocardial bridge was described in this study.

Scimitar sign in the absence of anomalous pulmonary venous drainage: a case report

Background

Scimitar syndrome consists of anomalous pulmonary vein drainage to the inferior vena cava. Its name derives from the image this anomalous pulmonary vein creates on a chest radiograph. We describe a case of normal venous pulmonary vein drainage that also presented the scimitar sign due to an aorto-collateral vessel.

Case summary

A 15-month-old girl presented with mild dyspnoea and fever. Control chest X-ray showed an image of cardiac dextroposition, hypoplastic right lung, and the ‘scimitar sign’. Although the transthoracic echocardiogram confirmed the initial suspicion of anomalous pulmonary venous drainage, the computed tomography (CT) scan showed normal right pulmonary veins connected to the left atrium and revealed that an aorto-collateral vessel caused the scimitar sign.

Discussion

Although the patient had several typical alterations of the scimitar syndrome, the pulmonary venous connection was normal, and the scimitar sign was due to an aorto-collateral vessel. It might be difficult to describe venous pulmonary connections on the basis of echocardiography, so an angio CT scan proved to be a valuable tool in this scenario.

An Unusual Neonatal Presentation of Scimitar Syndrome

Scimitar syndrome is characterized by partial or total anomalous pulmonary venous return from the right lung along with pulmonary hypoplasia. We present a case of a 37 weeks' gestation male infant with antenatal ultrasound findings of suspected partial anomalous pulmonary venous return (PAPVR) and coarctation of the aorta. The newborn presented with respiratory distress, a chest X-ray and chest computed tomography (CT) angiogram confirmed the diagnosis of scimitar syndrome. The combination of scimitar syndrome with aortic coarctation is extremely rare with only a few cases previously reported.

Thoracoscopic treatment of left-to-right shunt in a child with scimitar syndrome

Scimitar syndrome represents a rare variant of partial anomalous pulmonary venous connection with right lung hypoplasia, dextrocardia, and concomitant airway-vessel abnormalities. Surgical correction is preferred in symptomatic patients or in patients with increased left-to-right shunt. In this report, the first case of scimitar syndrome with dual arterial supply and venous drainage to be treated with thoracoscopic approach is presented.

Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.

Partial anomalous pulmonary venous return: Scimitar vein

Scimitar syndrome is a rare association of congenital cardiopulmonary anomalies characterized by partial anomalous pulmonary venous return, in which an abnormal right pulmonary vein drains into the inferior vena cava. This case exemplifies the role of transesophageal echocardiography in perioperative management and surgical decision-making.

Scimitar Syndrome Associated With Abnormal Hepatic Venous Drainage

Scimitar syndrome is a rare congenital cardiopulmonary anomaly. We describe a 1.5-year-old boy with this uncommon malformation and an unusual hepatic venous drainage, which allows atypical surgical repair.

A 55-year-old man with a small right lung and a right-sided heart

A healthy 55-year-old man without known medical problems presented for a routine physical examination and was found to have an abnormal ECG. He denied chest pain, dyspnea, palpitations, dizziness, or syncopal episodes. He also denied orthopnea, paroxysmal nocturnal dyspnea, and lower-extremity edema. His exercise capacity had been excellent. He was a lifelong nonsmoker and never had lung problems.

Abnormal location of umbilical venous catheter due to Scimitar syndrome

Scimitar syndrome is a rare congenital anomaly where the right pulmonary veins return to the inferior vena cava (IVC) just below the diaphragm. On chest X-ray (CXR), an IVC catheter will be in a bizarre location outside the heart if it inadvertently passes into the scimitar vein rather than into the right atrium.