Presentation on theme: "1 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 Médicale."— Presentation transcript:
1 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 Médicale Hôpital la Rabta. TUNIS - TUNISIE Correspondance: Dr Habiba MIZOUNI
2 INTRODUCTION Abnormal pulmonary venous return (APVC) correspond to. They can be total or partial. 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 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
3 NORMAL PULMONARY VENOUS DRAINAGE Figures of normal pulmonary venous drainage
4 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,. All PAPVRs are left-to-right shunts, but more than 50% of the pulmonary flow drains to the right side of the heart.
5 Partial APVR ; a located near the SVC orifice is the more frequent one 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 : Clinical manifestations, such us :Dyspnea, fatigue, exercise intolerance, palpitations, syncope, atrial arrhythmias, right heart failure, and pulmonary hypertension, are rare.
6 Different types of partial APVR PARTIAL APVR RIGHT LEFT SUPRA CARDIAC CARDIAC INFRA CARDIAC
7 Different types of partial APVR
8 Total AVPR (TAVPR) Is a congenital heart defect in which during cardiac development and instead drain into the right atrium or one of its venous tributaries. 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 Accounts for approximately 1.5% of all cardiovascular anomalies Has an incidence of 1/15,000 live births has been observed No sex predilection has been observed All total AVPR are associated with a septal atrium defect
9 Total APVR TAPVR usually has due to high pulmonary vascular resistance and shunting of blood through the foramen ovale. 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 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 If not surgically corrected, TAPVR has a high mortality rate in the first year of life.
10 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%
11 Infra Cardiac TAVPR Cardiac TAVPR Supra Cardiac TAVPR
12 Multidetector CT technique We perform a spiral acquisition using 0.6- or 0.7-mm collimation 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 Mean radiation dose is estimated in millisieverts (mSv) from the dose-length product after correction for body size.
13 Multidetector CT technique Non-ionic low-osmolar contrast medium (300 mg I/ml) in a dosage of ml/kg is injected into a peripheral vein ( 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.
15 CASE 1 Infant aged 14 mouths Dyspnea Echocardiography: - - Enlargement of right heart chambers - - Sinus venosus atrial septal defect (ASD)
16 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
17 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
18 Case 2 Daughter of 3 months Dyspnea Echocardiography : - CIA - CIA - Doubt on the presence of AVRP
19 Right pulmonary venous return in the inferior vena cava Right pulmonary vein
20 Hypo vascularization of the right lung Ipsilateral pulmonary artery of small caliber Controlateral pulmonary artery of normal caliber
21 Systemic vasculature for the right lung from: The celiac In the abdominal aorta
22 Hypoplastic right lung field Anomaly of the bronchial systematization Hypoplastic right lung reduced to one lobe Absence of visualization of the right scissure
23 Dextroversion heart
24 Right pulmonary venous return in the inferior vena cava Dextroversion heart Hypo vascularization of the right lung Hypoplastic right lung field Scimitar syndrome
25 Case 3 Daughter of one month Dyspnea and cyanosis Echo: CIA and dilatation of the right cavities
26 The right pulmonary veins draining into the right atrium Partial APVC of the total right lung draining into the right atrium
27 Dilatation of right cavities
28 Double left superior vena cava draining in a dilated coronary sinus
29 Associated skeletal malformations
30 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
31 Case 4 8 years-old daughter Dyspnea Echo: dilated right cavities associated with CIA CT scan in search of APVR
32 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
33 Venous trunk left brachiocephalic Collector Anomaly aortic arch associated : right subclavian artery in retroaortic course esophageal
34 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
35 A left supra cardiac AVPR Volume rendering reconstruction (VR) showing the First collector ( ) draining the left superior pulmonary vein is abouchnat in the venous trunk innominate ( )
36 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
37 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.
38 Case 6 Daughter of three months Dyspnea Chest X-Ray and Echocardiography: Dilatation of right cavities Dilatation of right cavities
39 Venous collector ( ) opening the posterior surface of the OD and the roof of coronary sinus
40 Venous collector ( ) opening in the face posterior OD and the roof of the coronary sinus Total cardiac APVC
41 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.