Clarifying the Anatomy of Tetralogy of Fallot with S-shaped Ascending Aorta

We recently encountered several cases of tetralogy of Fallot with an abnormally oriented S-shaped ascending aorta. In this retrospective study, we sought to clarify morphology of this unusual under-recognized variant. Databases were reviewed to identify all patients with tetralogy of Fallot having an S-shaped ascending aorta. Computed tomographic angiography was used for the assessment of cardiac morphology. Out of the 21 patients, 18 (86%) had a right aortic arch, 2 (9%) had a left aortic arch, and the remaining patient (5%) had a double aortic arch. Patients with a right aortic arch, compared to age and sex-matched patients with a right aortic arch but normally oriented ascending aorta, had lesser aortic override (29.3 ± 14% vs 54.8 ± 13.2%; p = 0.0001) and a wider ascending aorta (25.2 ± 6.9 vs 18.0 ± 3.2 mm; p = 0.0003). The S-shaped ascending aorta was located posteriorly, with a higher sterno-aortic distance (25.5 ± 7.7 vs 9.9 ± 4.5 mm; p = 0.0001). The ascending aorta among patients with tortuosity was longer (4.12 ± 1.7 vs 3.07 ± 0.82, p = 0.03) but with similar tortuosity index (1.22 ± 0.19 vs 1.15 ± 0.17, p = 0.23). Of the cases with right aortic arch and S-shaped ascending aorta, 16 (89%) had extrinsic compression of the right pulmonary artery (p = 0.0001), while 7 (39%) had crossed pulmonary arteries (p = 0.008), with no such findings among those with normally oriented ascending aorta. Tetralogy of Fallot with an S-shaped ascending aorta is a variant with lesser aortic override and a more posteriorly located ascending aorta. Compression of the right pulmonary artery and crossed pulmonary arteries is frequent in the presence of a right-sided aortic arch. These findings have important implications for optimal diagnosis and surgical repair.

Dermoscopy of hypopigmented macules unveiling genetic diagnosis of tuberous sclerosis complex type 2 in an infant presenting with sacral chordoma

A 2-month-old male with surgically resected sacral chordoma presented with multiple hypopigmented macules showing characteristic patchy, sharply demarcated areas of pigment network on dermoscopy. These dermoscopic findings were suggestive of the ash-leaf macules of tuberous sclerosis over other common hypopigmented macules in neonates. Chordomas presenting in early childhood in the sacral location have been reported as a rare manifestation of tuberous sclerosis complex. The combination of these findings led to a diagnosis of tuberous sclerosis, confirmed with the finding of a heterozygous TSC2 gene deletion; treatment with sirolimus resulted in regression of cardiac rhabdomyomas and hypopigmented macules.

Low-dose, high-pitch, spiral (FLASH) mode versus conventional sequential method for coronary artery calcium scoring: A derivation-validation study

Introduction

The present study sought to compare the diagnostic accuracy and radiation dose of ECG-gated, ultra-fast, low-dose, high-pitch, spiral (FLASH) mode versus conventional, ECG-gated, sequential coronary artery calcium (CAC) scoring in patients with suspected coronary artery disease (CAD).

Methods

The study included 120 patients who underwent both conventional scanning and FLASH mode scanning and were subdivided into derivation and validation cohorts. In the conventional sequential (step-and-shoot) protocol, prospective ECG-gated, non-contrast acquisition was performed at 70% of R-R interval. The spiral (FLASH) mode utilized a high-pitch and high-speed gantry rotation scanning mode where acquisition of the entire heart was done within a single cardiac cycle with prospective ECG-gating at 70% of R-R interval.

Results

Correlation between CAC scores derived from conventional (cCAC) and FLASH mode (fCAC) in derivation cohort was excellent (r=0.99; P<0.001). A linear regression model was used to develop a formula for deriving the estimated CAC score (eCAC) from fCAC (eCAC=0.978 x fCAC). In validation cohort, eCAC showed excellent agreement with cCAC (ICC=0.9983; 95%CI: 0.9972 - 0.9990). Excellent agreement for risk classification (weighted kappa=0.93898; 95%CI: 0.86833 - 1.0000) was observed with 95% (57/60) scores falling within the same risk category. Effective dose was significantly lower in FLASH mode (conventional, 0.58±0.21 mSv vs. FLASH, 0.34±0.12 mSv; P<0.0001).

Conclusion

CAC scoring using FLASH mode is feasible with high accuracy and shows excellent agreement with conventional CAC scores at significantly reduced radiation doses.

An unusual case of duplicated left brachiocephalic vein with right sided aortic arch and aberrant origin of LSCA in a patient undergoing implantable cardioverter defibrillator (ICD) implantation

BACKGROUND

Anomalous left brachiocephalic vein (ALBCV) is a rare venous anomaly. Double Left brachiocephalic vein is the rarest type of ALBCV anomaly.

CASE REPORT

Here we report a case of gentleman with post myocardial infarction ventricular tachycardia who underwent ICD implantation, where we could not place the lead initially through left side. CT angiography revealed presence of a duplicated circumaortic left BCV. It's cranial limb coursing normally anterior to arch and compressed at its confluence with RBCV and the caudal limb with a subaortic course draining into the RSVC. We report this first case of double LBCV along with right sided aortic arch and aberrant origin of LSCA arising from Kommerel's diverticulum.

CONCLUSION

This case highlights that interventional cardiologists should be aware of these venous anomalies for proper planning and implantation of CIED successfully via transvenous approach.

Bariatric arterial embolization in patients with body mass index ranging from 25 to 40 kg/m2: A systematic review & meta-analysis

The present review sought to evaluate by meta-analysis the efficacy of bariatric arterial embolization (BAE) in promoting weight loss in patients with body mass index (BMI) ranging from 25-40 kg/m2. This study was performed and reported according to Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. A systematic literature search of MEDLINE, Embase Google Scholar, and World Health Organization Library database was done for studies evaluating BAE for promoting weight loss in patients with BMI ranging from 25-40 kg/ m2 published up to March 10, 2021. Primary outcome measure included weight loss after the embolisation procedure. Three single-arm studies comprising of a total of 28 patients (BMI: 25- 40 kg/m2) were found eligible for meta-analysis. All patients underwent embolization with either Embosphere microspheres or PVA particles. The predominant artery embolised was left gastric artery (in all patients). Additional arteries embolised included gastroepiploic artery (8 patients), or accessory left gastric artery (1 patient), or short gastric artery (1 patient). Pooled absolute mean weight loss was 7.854 kg (95% CI: 6.103-9.605). No significant statistical heterogeneity was detected (I2=51.75%, P=0.126) among pooled studies. In conclusion, limited single-arm studies report BAE as an effective, and relatively safe procedure for promoting weight loss in patients with BMI ranging from 25-40 kg/m2, although the number of patients included is very small. Initial results of BAE in promoting weight loss are promising with no major/severe complications reported; however, long term follow-up is required to see the sustainability of the effects.

Distinguishing 'dual' from 'duplicated' right coronary artery: Revisiting the nomenclature

We report a case of a 53-year-old man with a "short RCA" seen coursing within the proximal part of the right atrioventricular (AV) groove and terminating in the mid-portion of the right AV groove and a "long RCA" seen to have a proximal course outside the right AV groove, over the free wall of the right ventricle, where it gave rise to the right ventricular and acute marginal branches before returning to the right AV groove in its distal course. The discussion highlights the need for revisiting the nomenclature of "dual RCA and drawing a distinction between "dual" and "duplicated" RCA.

The so-called "one-and-a-half" ventricular repair: where are we after 40 years?

OBJECTIVES

The indications, timing, and results of the so-called "one-and-a-half ventricle repair", as a surgical alternative to the creation of the Fontan circulation, or high-risk biventricular repair, currently remain nebulous. We aimed to clarify these issues.

METHODS

We reviewed a total of 201 investigations, assessing selection of candidates, the need for atrial septal fenestration, the fate of an unligated azygos vein and free pulmonary regurgitation, the concerns regarding reverse pulsatile flow in the superior caval vein, the growth potential and function of the subpulmonary ventricle, and the role of the superior cavopulmonary connections as an interstage procedure prior to biventricular repair, or as a salvage procedure. We also assessed subsequent eligibility for conversion to biventricular repair and long-term functional results.

RESULTS

Reported operative mortalities ranged from 3% to 20%, depending on the era of surgical repair with 7% risk of complications due to a pulsatile superior caval vein, up to one-third incidence of supraventricular arrhythmias, and a small risk of anastomotic takedown of the superior cavopulmonary connection. Actuarial survival was between 80% and 90% at 10 years, with two-thirds of patients in good shape after 20 years. We found no reported instances of plastic bronchitis, protein-losing enteropathy, or hepatic cirrhosis.

CONCLUSIONS

The so-called "one-and-a-half ventricular repair", which is better described as production of one-and-a-half circulations can be performed as a definitive palliative procedure with an acceptable risk similar to that of conversion to the Fontan circulation. The operation reduces the surgical risk for biventricular repair and reverses the Fontan paradox.

Coronary artery disease and its vascular associates in patients with chronic nonsurgical hypoparathyroidism

OBJECTIVE

Patients with chronic hypoparathyroidism (cHypoPT) are prone to intracranial-calcification, cataract and nephrocalcinosis. In this study, we systematically investigated the possibility of increased coronary artery calcification (CAC) and coronary artery disease (CAD) in them.

DESIGN

Cross-sectional.

PATIENTS AND MEASUREMENTS

Ninety-four nonsurgical cHypoPT (M:F = 50:44; age = 45 ± 15 years) with 18.6 ± 9.3 years of illness were assessed. Those with dyspnoea, angina, syncope, abnormal electrocardiogram, echocardiography or significant CAC underwent coronary angiography or myocardial-perfusion-stress imaging. Their lipid parameters and high-sensitivity C-reactive protein (hsCRP) were compared with age-matched healthy controls (Group A, n = 101). The prevalence of CAC in cHypoPT was compared with that of subjects referred from cardiology-clinics (Group B, n = 148, age = 52 ± 11 years).

RESULTS

One of 94 cHypoPT had known CAD. On screening, 17 cHypoPT required evaluation for CAD. Two of 17 had severe coronary stenosis, and 12 showed subclinical CAD. CAC and aortic-valve calcification occurred in 21.5% and 11.8%. Clinical and subclinical CAD, CAC and aortic-valve calcification in cHypoPT ≥50 years of age was 8.1%, 27.0%, 52.8% and 27.8%, respectively. Frequency of age-adjusted CAC was comparable between cHypoPT and control Group B (30.2% vs. 30.7%, p = .93). Elevated hsCRP was higher in cHypoPT than in controls A (52% vs. 32%, p < .01). Factors associated with CAD in cHypoPT were CAC and hypertension. However, CAD and CAC showed no association with long-term calcemic or phosphatemic control and intracranial-calcification in cHypoPT.

CONCLUSIONS

Clinical and subclinical CAD was observed in 3.2% and 12.8% of cHypoPT patients. The increased prevalence of CAD, CAC and aortic-valve calcification in cHypoPT above 50 years of age suggested their careful cardiac evaluation during follow-up.

Lung water estimation on cardiac magnetic resonance imaging for predicting adverse cardiovascular outcomes in patients with heart failure

Objectives:

Pulmonary congestion is a central feature of heart failure (HF), seen in acute decompensated state as well as in chronic stable disease. The present study sought to determine whether simplified cardiac magnetic resonance imaging (CMR)-derived lung water density (LWD) measurement has prognostic relevance in predicting adverse cardiovascular outcomes in patients with HF and left ventricular ejection fraction (LVEF) <50%.

Methods:

Eighty consecutive patients referred for CMR with HF and LVEF <50% along with 22 healthy age- and sex-matched controls were prospectively recruited. LWD was the lung-to-liver signal intensity ratio multiplied by 70% (estimated hepatic water density). The primary endpoint was composite of all-cause mortality or HF-related hospitalisation within 6 months from CMR.

Results:

The mean LWD was significantly higher in HF patients compared to healthy controls (19.78 ± 6.1 vs 13.6 ± 2.3; p < 0.001). The mean LWD was significantly different among patients with NYHA class I/II and NYHA class III/IV (17.88 ± 4.8 vs 21.77 ± 1.08; p = 0.004). At 6 months, the primary endpoint was reached in 12 (15%) patients. Patients with “wet lungs” (LWD > 18.1%) had higher incidence of adverse cardiovascular outcomes compared to patients with “dry lungs”. LWD was an independent predictor of adverse cardiovascular outcomes in multivariable analysis. At the optimal cut-off of LWD > 23.38%, the sensitivity and specificity were 91.67 and 91.18%, respectively to predict adverse cardiovascular outcomes.

Conclusion:

LWD on CMR is independently associated with increased risk of mortality and HF-related hospitalization in HF patients with LVEF <50%.

Advances in knowledge:

Non-invasive quantitative estimation of LWD on CMR can improve risk stratification and guide management in HF patients.

Split right coronary artery with split posterior descending artery

We report a case of an 87-year-old man where coronary CT angiography incidentally demonstrated a "split" right coronary artery (RCA) featuring a "split" posterior descending artery. This case focusses on the morphological description of this variant as well as its differentiation from a "dual" or "duplicated" RCA.

Long-Term Surgical Outcomes of Patients With Isomeric Right and Left Atrial Appendages

Objectives: To compare the long-term outcomes of biventricular, univentricular, and so-called one-and-one-half ventricular repairs in patients with left and right isomerism. Methods: Surgical correction was undertaken, between 2000 and 2021, in 198 patients with right, and 233 with left isomerism. Results: The median age at operation was 24 days (interquartile range [IQR]: 18-45) and 60 days (IQR: 29-360) for those with right and left isomerism, respectively. Multidetector computed-tomographic angiocardiography demonstrated more than half of those with right isomerism had superior caval venous abnormalities, and one-third had a functionally univentricular heart. Almost four-fifths of those with left isomerism had an interrupted inferior caval vein, and one-third had complete atrioventricular septal defect. Biventricular repair was achieved in two-thirds of those with left isomerism, but under one-quarter with right isomerism (P < .001). Hazard regression for mortality revealed odds for prematurity at 5.5, pulmonary atresia at 2.81, atrioventricular septal defect with a common valvar orifice at 2.28, parachute mitral valve at 3.73, interrupted inferior caval vein at 0.53, and functionally univentricular heart with a totally anomalous pulmonary venous connection at 3.77. At a median follow-up of 124 months, the probability of survival was 87% for those with left, and 77% for those with right isomerism (P = .006). Conclusions: Multimodality imaging characterizes and delineates the relevant anatomical details, facilitating surgical management of individuals with isomeric atrial appendages. Continuing higher mortality despite surgical intervention in those with right isomerism points to the need for the reassessment of strategies for management.

Idiopathic focal fibrosing mediastinitis with unilateral pulmonary arterial and venous involvement

We report a case of a 1-year-old girl where computed tomography (CT) angiography demonstrated presence of ill-defined heterogenous soft tissue thickening obliterating the mediastinal fat planes in right peri-hilar region and encasing the hilar right pulmonary artery and its segmental branches leading to marked narrowing with nonvisualization of the right-sided pulmonary veins. The case highlights the features of fibrosing mediastinitis as well as the role of CT angiography in the diagnosis and accurate depiction of the extent of involvement of the mediastinal vasculature and airways.

Evaluation of aortopulmonary window using virtual dissection of multidetector computed tomography angiography data sets

AIM

The present study sought to evaluate the morphology and associated cardiovascular anomalies in patients with aortopulmonary window on virtual dissection of multidetector computed tomography (CT) angiography data sets.

MATERIAL AND METHODS

We conducted a retrospective search of our departmental database from January 2014 to September 2021 to identify patients with aortopulmonary window and relevant information was extracted from the electronic case records and from routine examination as well as virtual dissection of CT data sets.

RESULTS

An aortopulmonary window was observed in 26 patients (20 males; 6 females). Based on location of the defect, a distal aortopulmonary window was the most common subtype, seen in 13/26 (50%) patients followed by a proximal, complete and intermediate subtypes seen in 7/26 (27%), 5/26 (19%) and 1/26 (4%) patients respectively. Associated ventricular septal defect was observed in 9/26 (34.6%) patients while an interrupted aortic arch was present in 5/26 (19.2%) patients. Tetralogy of Fallot was seen in 5/26 (19.2%) patients. Anomalous origin of right pulmonary artery from ascending aorta and crossed pulmonary arteries were seen in 2/26 (7.6%) patients each. An isolated aortopulmonary window without any simple/complex congenital anomaly was seen in 10/26 (38.5%) patients.

CONCLUSION

Aortopulmonary window is associated with a wide gamut of cardiovascular lesions, with ventricular septal defect being the commonest associated anomaly followed by tetralogy of Fallot and interrupted aortic arch respectively. Virtual dissection of multidetector CT angiography allows detailed anatomical evaluation of aortopulmonary window, allowing a clear visualization of the defect and associated cardiovascular anomalies.

Sporadic occurrence of multiple paragangliomas causing carotid and coronary arterial encasement

We describe a case of a 32-year-old man with a paraganglioma causing encasement of ostioproximal segments of the left internal carotid artery and left external carotid artery with concurrent presence of bilobulated mediastinal paraganglioma, with similar imaging characteristics, causing encasement of the coronary arteries.

Efficacy and Safety of Venous Sac Embolization With or Without Feeding Artery Embolization Versus Feeding Artery Embolization Alone in the Management of Pulmonary Arteriovenous Malformations: A Systematic Review and Meta-analysis

PURPOSE

To evaluate by meta-analysis the safety and efficacy of venous sac embolization (VSE) with or without feeding artery embolization versus feeding artery embolization (FAE) alone in the management of pulmonary arteriovenous malformations (PAVMs).

METHODS

This systematic review and meta-analysis was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was performed in MEDLINE, Embase, and Scopus till August 31, 2021 to identify studies comparing the safety and efficacy of VSE with or without FAE versus FAE alone in PAVMs. The success of treatment was assessed by comparing the number of PAVMs with ≥70% decrease in the size of draining vein/sac between the 2 groups. The pooled odds ratio (OR) and 95% confidence interval (95% CI) were calculated using the random-effects inverse-variance model and were used to compare pooled therapeutic efficacy between the groups.

RESULTS

Three studies were found eligible for the meta-analysis. The included studies had a total of 169 patients (119 females and 50 males). The total number of PAVMs was 298, and hereditary hemorrhagic telangiectasia was present in 119 patients. The success of treatment was higher with VSE as compared to FAE (OR=3.54, 95% CI=1.66-7.56). The minor complications were similar in both groups, and one major complication occurred in the FAE group. More coils were used in the VSE group.

CONCLUSIONS

The present systematic review and meta-analysis has consolidated the evidence that VSE with or without FAE is more efficacious than FAE alone in the management of PAVMs without any increase in the associated risk of sac rupture or coil migration.

CLINICAL IMPACT

Until high-quality data from a prospective, multicentric, randomized controlled trial becomes available, the evidence consolidated by the present systematic review and meta-analysis showing the efficacy of venous sac embolization (with or without feeding artery embolization) over feeding artery embolization alone, can be used for clinical decision-making in the management of pulmonary arterio-venous malformations.

Left pulmonary veins draining into persistent left superior caval vein in presence of unroofed coronary sinus

We report a case of 5-year-old girl with double outlet right ventricle with a rare combination of partial anomalous pulmonary venous drainage into a persistent left superior caval vein in the presence of an unroofed coronary sinus while highlighting its possible embryological origins and therapeutic implications.

External iliac artery Endofibrosis in a professional cyclist

We present a case of a 30-year-old female professional cyclist who presented with right thigh claudication while performing high-intensity efforts. Based on the typical clinical history and the presence of a smooth long segment diffuse narrowing in the right external iliac artery on non-contrast magnetic resonance angiography, a diagnosis of external iliac artery endofibrosis or "cyclist's iliac syndrome" was made.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01349-8.

Separate origin of left external and internal carotid arteries directly from aortic arch in a patient with double outlet right ventricle

We report a case of a 1-year-old boy with double outlet right ventricle where computed tomography (CT) angiography incidentally demonstrated the separate origin of the left external and internal carotid arteries directly from the left-sided aortic arch with absence of a left common carotid artery. The case highlights the underlying embryological hypothesis as well as the importance of CT angiography in identifying anomalies of the aortic arch and arch vessels in the setting of complex congenital heart defects.

Is it really a levoatrial cardinal vein?

With the advent of computed tomographic interrogation, it is increasingly frequent to find venous channels that provide direct connections between the pulmonary and systemic veins. These channels, before the introduction of three-dimensional techniques for clinical imaging, were usually found providing an "overflow" for the obstructed left atrium in settings such as hypoplastic left heart syndrome, or divided left atrium. Similar channels, however, had been described almost 100 years ago, with one accurately described as a jugulo-pulmonary vein. Nowadays, however, it is much more usual to find the channels described as levoatrial cardinal veins, even though it is recognized that they are not "levo," often not "atrial," and for sure not "cardinal." In this review, we assemble the evidence supporting the notion that they are better considered as pulmonary-to-systemic collateral channels. We emphasize their similarity, in terms of development, to the sinus venosus and coronary sinus defects.

Atresia of the coronary sinus ostium with persistent left superior caval vein

We describe a case of a 33-year-old woman with congenitally corrected transposition where computed tomography angiography incidentally detected ostial atresia of the coronary sinus with dilatation of the terminal parts of the middle cardiac vein and great cardiac vein and retrograde drainage of the coronary sinus into the persistent left superior caval vein, the intercommunicating vein, then to the right superior caval vein, and ultimately into the right atrium.

Incidentally detected Vieussens' arterial ring-to-pulmonary trunk fistula in a patient with aortic stenosis

We report a case of a 45-year-old man with severe aortic stenosis where computed tomography angiography incidentally revealed a fistulous communication between the conal branches of the right coronary artery and anterior interventricular artery and the left anterolateral aspect of the pulmonary trunk with a conglomerate of nondilated tortuous vessels along the anterior surface of right ventricular outflow tract.

Partial anomalous pulmonary venous drainage to persistent left superior caval vein: Or is it a "levoatriocardinal vein"?

We report a case of a 3-month-old girl with pulmonary atresia and intact ventricular septum where computed tomography (CT) angiography demonstrated an anomalous venous channel connecting the left brachiocephalic vein to the left atrium and all the pulmonary veins draining the left lung were seen draining individually into this channel. The case highlights the differential diagnosis of such veno-venous connections between the systemic and pulmonary venous circulations as well as the growing role of CT angiography in the understanding of these venous anomalies in the setting of complex congenital heart diseases.

Stent-Graft Migration Post-Endovascular Repair of Thoracic Aorta: A Retrospective Cohort Study

Background Migration of the stent-graft post-thoracic endovascular aortic repair (TEVAR) is not uncommon; however, it is sparsely reported. The objective of this study was to assess the incidence, risk factors, and complications of stent-graft migration post-TEVAR.

Materials and Methods Thirty-one patients who underwent TEVAR were retrospectively analyzed. The demographic, anatomical, and procedure-related factors were assessed. The measurements were done along the greater curvature of aorta around two fixed anatomic landmarks, that is, left common carotid artery or neoinnominate artery (hybrid repair) proximally and celiac artery distally. Aortic elongation and migration at proximal, distal, as well as at overlapping zone were measured. More than 10 mm of migration was considered significant.

Results Significant migration was observed in six (19%) patients. No significant migration was observed in the overlapping zone. The proximal landing zone 3 (odds ratio [OR] 12.78, p 0.01) was a significant risk factor, whereas landing zone 2 was a protective factor against the migration (OR 0.08, p 0.02). The odds for migration were more in segments I/3 and II/3 compared with I/2 and II/2, respectively, as per Modified Arch Landing Areas Nomenclature. A single complication was seen in the migration group which was treated by an overlapping stent graft.

Conclusion The stent-graft migration after TEVAR is not uncommon. Type 3 proximal landing zone was a significant risk factor for migration with an increased risk toward I/3 and II/3. Proximal landing zone 2 as well as adequate overlapping distance in multiple stent grafts can prevent migration.

Ethical Approval No IECPG-227/24.06.2020

Developmental Anomalies of the Inferior Vena Cava and its Tributaries: What the Radiologist Needs to Know?

Inferior vena cava (IVC) can be involved by a wide gamut of developmental anomalies owing to its complex embryogenesis. Developmental anomalies of the IVC are not infrequent, seen in approximately 8.7% of the general population. Although most of the anatomical variations are asymptomatic, identification of these variations is important before planning any vascular surgery or interventional procedure in relation to the IVC to avoid inadvertent complications. Conventional venography has largely been replaced by noninvasive cross-sectional imaging modalities for detecting IVC abnormalities. Ultrasonography, often used for initial evaluation, is highly operator-dependent and the infrarenal part of IVC is often obscured by bowel gases. While magnetic resonance imaging is devoid of radiation risks, its use is limited due to limited availability and the frequent need for sedation. Computed tomography (CT) venography plays a pivotal role in the detection of these anomalies as it has an excellent spatial resolution along with availability of multiple postprocessing tools such as multiplanar reconstruction with generation of maximum intensity projection and volume-rendered images. This pictorial review focuses on the embryogenesis of IVC, various developmental anomalies of the IVC and its tributaries, their appearance on CT venography and conceivable clinical relevance.

Superior sinus venosus defect with partial anomalous pulmonary venous return in a patient with tetralogy of Fallot

We report a case of a 2-year-old boy with tetralogy of Fallot-pulmonary atresia where CT angiography additionally demonstrated the presence of superior sinus venosus defect with partial anomalous pulmonary venous return. Our case highlights the role of CT angiography in the preoperative evaluation in patients with tetralogy of Fallot in identifying such uncommon anomalies, which would help avoid postoperative complications and re-exploration in these patients.

Intrapulmonary course of superior caval vein associated with azygos lobe

We report a case of a 4-month-old boy with tetralogy of Fallot where computed tomography angiography incidentally revealed the presence of a unique extra-mediastinal and intrapulmonary course of the superior caval vein within the anterior portion of the azygos fissure.

Technical Details of Rechanneling of Obstructive Coronary Sinus Type of Totally Anomalous Pulmonary Venous Connection Using Malm's Coronary Sinus Cutback Technique and Left Atrial Augmentation: A Video Presentation

Obstructive coronary sinus totally anomalous pulmonary venous connection although rare, is associated with a high mortality. A 2-month-old female child diagnosed with obstructive coronary sinus type of totally anomalous pulmonary venous connection and severe pulmonary arterial hypertension underwent complete unroofing of the coronary sinus by the “coronary sinus cutback technique” of Malm with left atrial augmentation and atrial septal fenestration.

Technical Details of Redo Aortic Valve Replacement Using St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Aortic Mechanical Prosthesis: A Video Presentation

Current consensus guidelines of the American Heart Association and European Society of Cardiology uniformly recommend either type of prosthetic valve for patients aged between 60 and 70 years and mechanical prosthesis for patients aged less than 60 years. These recommendations are based on the results of randomized controlled trials that demonstrated no significant difference in late survival. Two of these trials compared mechanical and bioprosthetic valve models implanted in 1970s and 1980s. The other two trials included patients undergoing aortic valve replacement. Contemporary data are limited to small single-center studies

Technical Details of Transwindow Fenestrated, Unidirectional, Valved, Aorticopulmonary Fabric Patch Closure of Aortopulmonary Window (UKC's Modification): A Video Presentation

A 10-year-old female patient diagnosed with isolated type I aortopulmonary window and severe pulmonary arterial hypertension who underwent repair of the aortopulmonary window via Johansson's transwindow approach using a unidirectional, fenestrated, valved, aorticopulmonary patch. The preoperative pulmonary vascular resistance was 9.0 Woods units/m2 that reduced to 4.0 Woods units/m2 after oxygen (100%) and nitric oxide (80 ppm) administration. The postoperative recovery was uneventful.

Transposition physiology in the setting of concordant ventriculo-arterial connections

BACKGROUND AND AIM

To review the anatomical details, diagnostic challenges, associated cardiovascular anomalies, and techniques and outcomes of management, including re-interventions, for the rare instances of transposition physiology with concordant ventriculo-arterial connections.

METHODS

We reviewed clinical and necropsy studies on diagnosis and surgical treatment of individuals with transposition physiology and concordant ventriculo-arterial connections, analyzing also individuals with comparable flow patterns in the setting of isomerism.

RESULTS

Among reported cases, just over two-thirds were diagnosed during surgery, after initial palliation, or after necropsy. Of the patients, four-fifths presented in infancy with either cyanosis or congestive cardiac failure, with complex associated cardiac malformations. Nearly half had ventricular septal defects, and one-fifth had abnormalities of the tricuspid valve, including hypoplasia of the morphologically right ventricle. A small minority had common atrioventricular junctions We included cases reported with isomerism when the flow patterns were comparable, although the atrioventricular connections are mixed in this setting. Management mostly involved construction of intraatrial baffles, along with correction of coexisting anomalies, either together or multistaged. Overall mortality was 25%, with one-fifth of patients requiring pacemakers for surgically-induced heart block. The majority of survivors were in good functional state.

CONCLUSIONS

The flow patterns produced by discordant atrioventricular and concordant ventriculo-arterial connections remain an important, albeit rare, indication for atrial redirection or hemi-Mustard's procedure with bidirectional Glenn. The procedure recruits the morphologically left ventricle in the systemic circuit, producing good long-term functional results. The approach can also be used for those with isomeric atrial appendages and comparable hemodynamic circuits.

Levoatriocardinal vein in a patient with transposition of great arteries and pulmonary stenosis

We report a case of a 3-month-old boy transposition of great arteries, ventricular septal defect, and pulmonary stenosis where computed tomography (CT) angiography detected a "levoatriocardinal vein" connecting the left superior pulmonary vein and the left brachiocephalic vein with a preserved normal connection between the left superior pulmonary vein and left atrium. This case highlights the hemodynamic implications of a "levoatriocardinal vein" as well as the role of CT angiography in detecting such associated cardiovascular anomalies in patients with complex congenital heart defects.

Anomalous great cardiac vein draining into juxtaposed right atrial appendage

We present a case of a 2-year-old boy with a double outlet right ventricle and juxtaposed atrial appendages with anomalous drainage of the great cardiac vein into the aneurysmally dilated juxtaposed right atrial appendage. The case highlights the role of computed tomography (CT) angiography in depicting anomalous coronary venous anatomy and guiding therapeutic interventions involving the coronary venous approach.