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SYSTEMIC VENOUS ANOMALIES. Dr Ranjith MP Senior Resident Department of Cardiology Government Medical college Kozhikode. EMBRYOLOGY. Heart- First organ to start functioning & the 1st organ to fully develop in the fetus First seen as 2 endothelial heart tube. 21 days - heart tube forms - PowerPoint PPT Presentation
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SYSTEMIC VENOUS ANOMALIES
Dr Ranjith MPSenior Resident
Department of CardiologyGovernment Medical college
Kozhikode
EMBRYOLOGY
Heart- First organ to start functioning & the 1st organ to fully
develop in the fetus First seen as 2 endothelial heart tube
21 days - heart tube forms
23 days- heart beats
Week 4 - cardiac loop forms
Week 7 - heart fully developed
EMBRYOLOGY
EMBRYOLOGY
Changes in the sinoatrial orifice
EMBRYOLOGY
In the fifth week, three pairs of major veins can be distinguished:
1. The vitelline veins (omphalomesenteric veins)carrying blood from the yolk sac to the sinus venosus
2. The umbilical veinsoriginating in the chorionic villi, carrying oxygenated blood to the embryo
3. The cardinal veinsdraining the body of the embryo proper
EMBRYOLOGY
Main components of the venous and arterial systems in a 4-mm embryo (end of the fourth week).
EMBRYOLOGY
Cardinal Veins
The anterior cardinal veins drains the cephalic part of the embryo
The posterior cardinal veins drains the rest of the embryo
The anterior and posterior veins join before entering the sinus horn and form the short common cardinal veins (ducts of Cuvier)
During the fourth week, the cardinal veins form a symmetrical system
EMBRYOLOGY
Development of veins draining upper part of body
A. Ducts of CuvierB. Subclavian veinsC. Transverse anastomosisE. Superior venacavaF. Right Brachiocephalic veinG. Left Brachiocephalic veinH. Internal Jugular vein External jugular vein arise as secondary channel
EMBRYOLOGY
Development of Inferior venacava
B. Vitelline and umbulical vein broken in to numerous channel
C. Formation of Hepatocardiac channel
D. Formation of Common hepatic vein & Ductus venosus
EMBRYOLOGY
Development of Inferior venacava
During the fifth to the seventh week a number of additional veins are formed:
1.The subcardinal veins, mainly drain the kidneys
2.The sacrocardinal veins, drain the lower extremities
3.The supracardinal veins, drain the body wall by way of the intercostal veins, taking over the functions of the posterior cardinal veins
EMBRYOLOGYDevelopment of Inferior venacava
Green- Subcardinal Red- Supracardinal Yellow- Subcardinal-
hepatocardinal anastomosis
Blue- Hepatocardiac channel
White- Supracardinal-Subcardinal anastomosis
EMBRYOLOGY
Development of Inferior venacava
The anastomosis between the subcardinal veins forms the left renal vein
The left subcardinal vein disappears, and only its distal portion remains as the left gonadal vein
The right subcardinal vein becomes the main drainage channel and develops into the renal segment of the inferior vena cava
EMBRYOLOGY
Development of Inferior venacava
The anastomosis between the sacrocardinal veins forms the left common iliac vein
The right sacrocardinal vein becomes the sacrocardinal segment of the inferior vena cava
When the renal segment of the IVC connects with the hepatic segment, the IVC (consisting of hepatic, renal, and sacrocardinal segments) is complete
EMBRYOLOGYDevelopment of Azygos veins
EMBRYOLOGY
Development of Azygos veins
The 4thto 11th right intercostal veins empty into the right supracardinal vein, which together with a portion of the posterior cardinal vein forms the azygos vein
On the left the 4th to 7th intercostal veins enter into the left supracardinal vein, and the left supracardinal vein, then known as the hemiazygos vein, empties into the azygos vein
EMBRYOLOGY
.
Anomalies of the Superior Venae Cavae
Anomalies of the SVC
Bilateral SVC with normal drainage
Bilateral SVC with an Unroofed Coronary Sinus
Absent Right SVC in Visceroatrial Situs Solitus
Left Atrial or Biatrial Drainage of Right SVC
Retroaortic Innominate Vein
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
Result from failure of the left anterior and left common cardinal veins to involute
The incidence is 0.3%
LSVC drains into RA through CS in 92% -in to LA by unroofed CS in 8%
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
superior vena cava A=right B=leftC: communicating vein, D: aortaE: pulmonary trunk.
A: coronary sinus (enlarged) B: aorta, C: inferior vena cava D: left pulmonary veins
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
Anatomy
The size of the LSVC varies
left innominate vein may be present in 60%
The LSVC starts at the junction of the left jugular and left subclavian veins
Joins the CS in the posterior left AV groove
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
Clinical Manifestations
Physiology is usually normal & no clinical manifestations
Enlargement of the CS may interfere with blood flow from the LA into the LV
An increase in the magnitude of the Lt to Rt shunt at the atrial level was found in patients with secundum ASD persistent LSVC, and dilated coronary sinus
Bilateral SVC to Right AtriumDiagnostic Features
Chest Xray
Shadow along the Lt upper border of the mediastinum
2D echo 100% specificity & 96% sensitivity
A dilated CS is often the first clue to the diagnosis
Imaged from the suprasternal notch or from the high left parasternal/subclavicular windows
Presence & size of the Lt innominate vein can also be imaged
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
2D echo
There is an inverse relationship between the caliber of the LSVC and the left innominate vein
May confuse with a TAPVC or PAPVC, left superior intercostal vein, and a levoatrialcardinal vein
In contrast to a LSVC to an intact coronary sinus, however, the direction of blood flow in these veins is expected to be into the left innominate vein
Bilateral SVC to Right AtriumDiagnostic Features
A: Subcostal long-axis view
B: Parasternal long-axis view
C: The LSVC is seen anterior to LPA in the parasternal short-axis view
D: The drainage of the LSVC to the CS and to RA seen in parasternal sagittal view
Bilateral SVC to Right AtriumDiagnostic Features
Cardiac catheterization
LSVC can be suspected by the presence of higher-than-expected CS oxygen saturation
The LSVC can be approached either through the right SVC (when the innominate vein is present) or through the coronary sinus
Left innominate vein angiography with balloon occlusion proximal to the injection site is diagnostic
Bilateral Superior Venae Cavae with Normal Drainage to the Right Atrium
Treatment- No treatment is necessary for an isolated LSVC to an intact coronary sinus
Bilateral SVC with an Unroofed Coronary Sinus
Anatomy
Common wall between the LA & CS absent
Persistent LSVC drains into the left atrium
In patients with a normal inter atrial septum, the orifice of the unroofed CS will function as an interatrial communication
Visceral heterotaxy with asplenia exhibits the highest incidence of bilateral SVCs with a completely unroofed coronary sinus
Bilateral SVC with an Unroofed Coronary Sinus
Clinical Manifestations
Most patients have a large CS ostium that functions as an interatrial communication (Raghib syndrome)
Cyanosis and left-to-right shunting
In most patients, the arterial oxygen saturation ranges between 85% and 95%
They are at risk for complications of right-to-left shunting, including paradoxical emboli, brain abscess, strokes, and death
Bilateral SVC with an Unroofed Coronary Sinus
Clinical Manifestations
In patients with atretic CS ostium the only clinical manifestations are cyanosis and its sequelae
When right atrial outflow stenosis or atresia coexists with a persistent LSVC to an unroofed coronary sinus, the shunt is exclusively from right to left
Bilateral SVC with an Unroofed Coronary SinusDiagnostic Features
ECGAxis of the P wave may be abnormal in patients with
heterotaxy syndrome
Chest XrayShadow along the Lt upper border of the mediastinum
Bilateral SVC with an Unroofed Coronary SinusDiagnostic Features
Echocardiography-the definitive imaging modality
The posterior left AV groove is examined in detail to ascertain the extent of deficiency of the CS septum
When the CS septum is completely unroofed, the LSVC terminates in the upper Lt posterior corner of the LA between the LUPV posteriorly and the LA appendage anteriorly
Color Doppler or contrast injection demonstrates flow from the LSVC into LA
Cardiac catheterization
Step-down in oxygen saturation between PV & LA
LSVC selective angiocardiography
Bilateral SVC with an Unroofed Coronary SinusDiagnostic Features
A. Injection into the LSVC opacifies CS and shunting ofcontrast medium into the LA thorough the defect
B.MR image in a coronal plane shows complete unroofing of the CS. LSVC connects to the roof of the LA and the CS opening functions as a LA septal defect (Raghib defect)
Bilateral SVC with an Unroofed Coronary SinusTreatment
Repair is done to avoid complications of cyanosis
If the LSVC is relatively small and there is an adequate-sized left innominate vein, the LSVC can be ligated and the interatrial communication closed
In the absence of an adequate-sized bridging left innominate vein, the coronary sinus is reroofed
Baffling the LSVC along the posterior wall of the LA in to RA
ASD device closure of CS defect
Absent Right SVC in Visceroatrial Situs Solitus
0.07% to 0.13% of cardiovascular malformations
Characterized by persistence of the LSVC draining to the RA via the CS and by left-sided azygos vein draining into the LSVC
Less constant features Additional cardiovascular malformations (46%) Rhythm abnormalities (35%)
Absent Right SVC in Visceroatrial Situs Solitus
Clinical Manifestations
Usually asymptomatic
Rhythm disturbances Atrioventricular block sinoatrial node dysfunction ventricular tachycardia Left and right bundle-branch block supraventricular tachycardia Sudden death
Absent Right SVC in Visceroatrial Situs Solitus
Diagnostic Features
Issues that make diagnosis important are
– Implantation of transvenous pacemaker– Placement of a pulmonary artery catheter for intraoperative or
postoperative monitoring without the use of fluoroscopy– Systemic venous cannulation for extracorporeal membrane
oxygenation– Systemic venous cannulation for cardiopulmonary bypass– Partial or total cavopulmonary anastomosis– Orthotopic heart transplantation and endomyocardial biopsies
Diagnosis established by echocardiography, MRI, CT, or angiography
Absent Right SVC in Visceroatrial Situs Solitus
Treatment No intervention is indicated when the physiology is normal
Venogram in the innominate vein in a patient with absence of the right SVC and persistence of the LSVC, which drains into the RA via the CS
Left Atrial or Biatrial Drainage of Right SVC
It represents a sinus venosus defect of the SVC type in association with atresia of the right SVC orifice
It results from the deficiency of the common wall between the SVC & RUPV
This defect unroofs the RUPV & its branches into the right SVC
The unroofed RUPV then drains into the SVC, and its LA orifice becomes the interatrial communication
Left Atrial or Biatrial Drainage of Right SVC
Clinical ManifestationsCyanosis is the dominant clinical feature symptoms may not develop until late childhood or
adolescence The risks of Rt to Lt shunt sequelae increase with age
DiagnosisDemonstration of a common entrance site of Rt SVC
and the RUPV in the roof of the LA by echo or angio
Left Atrial or Biatrial Drainage of Right SVC
Treatment
The right SVC flow is surgically diverted into the RA
In the past, this was done by creating an ASD and redirecting SVC flow into RA and the pulmonary blood flow into LA
Preferred surgical approach is transection of the right SVC above the entrance of the RUPV and anastomosis of the transected caval end to the RA appendage
Retroaortic Innominate Vein
First reported in 1888, and 62 cases have been reported to date
Also known as postaortic innominate vein
Anatomy Characterized by an abnormal position of the left innominate vein behind
the ascending aorta Normal course of the left innominate vein is from left to right, anterior to
the aortic arch In RAIV it is horizontally behind the ascending aorta to reach the SVC
below the insertion of the azygos vein
Retroaortic Innominate Vein
Most patients have associated cardiac malformations
Embryology
Results from failure of the high transverse capillary plexus that forms the left innominate vein to develop
In such circumstance, venous blood returning from the Lt side of the head and the Lt arm may drain through a lower venous plexus that communicates between the Lt & Rt anterior cardinal veins
This lower venous plexus then forms the RAIV
Retroaortic Innominate Vein
A: Diagram showing a RAIV associated with a . right aortic arch in a patient with TOF, RSVC
B: Gadolinium-enhanced MR angiogram showing a . retroaortic innominate vein
Retroaortic Innominate Vein
Clinical ManifestationsAsymptomaticSurgical importance
DiagnosisEcho, angio or MRI Accurate echocardiographic diagnosis is based on tracking the left
innominate vein from its origin through its retroaortic course to the SVC Cine MRI and three-dimensional MRA are particularly useful in depicting
the anatomy
Treatment-No treatment is necessary
Levoatrialcardinal vein
First described Edwards and DuShane in 1950 as a vein connecting the rt. SVC and LA
Remnant of an early embryonic venous channel
that connects the splanchnic plexus of the lungs with the cardinal system
In the mature heart, it connects the LA or a PV with the Lt innominate or other systemic veins
Typically It is associated with severe LA outlet obstruction
Levoatrialcardinal vein
The diagnosis can be established by following the anomalous vein from its origin to its termination in a systemic vein
Unlike persistent LSVC that courses anterior to the left pulmonary artery, a levoatrialcardinal vein typically ascends posterior to it
It complicates the completion of a Fontan-type operation
Levoatriocardinal vein in a patient with cortriatriatum. It drains the proximal chamber of the LA to the innominate vein
Levoatrialcardinal vein
Multiplanar reformated image showing a levoatriocardinal vein (arrow) connecting an anomalous vein draining into the IVC and a pulmonary vein draining in to LA
Anomalies of the Coronary Sinus
Anomalies of the Coronary Sinus
Coronary Sinus Defect and Unroofed CS
Coronary Sinus Orifice Atresia
Coronary Sinus Aneurysm or Diverticulum
Coronary Sinus Defect & Unroofed CS
Unroofed coronary sinus almost always is associated with a persistent LSVC
A CS defect without an associated LSVC, and the physiology is the same as in ASD
Diagnosis- Echo, Color Doppler, Contrast echo
Surgery is usually performed for associated malformations
Coronary Sinus Orifice Atresia
Incidence is rareThe CS is usually well formed, the orifice is covered
by a thin membrane like tissueAlternative exit for coronary venous blood return-
A small LSVC , Large thebesian vein CS septal defect , Connection with the IVC in one case
Coronary Sinus Orifice Atresia
Clinical Manifestations
Myocardial ischemia is unlikely aslong as there is an alternate egressfor the coronary sinus blood
Diagnostic Features
Suspected by the echo demonstration of a persistent LSVC to an intact CS with retrograde flow
Angiographic demonstration of retrograde flow in the coronary sinus and a small caliber LSVC is suggestive of the diagnosis
Coronary Sinus Aneurysm or Diverticulum
First described in 1983 by Ho et al
It is a pouch with its neck originating in the CS proximal to the entrance of the middle cardiac vein. The pouch, 2 to 5 cm in diameter, extends into the LV wall
It may be associated with WPW syndrome (posteroseptal accessory pathways)
Diagnostic Features
diagnosed by echocardiography Imaged from the subcostal, apical, and parasternal windows Seen as an outpouch, typically with a distinct neck, which extends behind the LV or into the
ventricular myocardium
Coronary Sinus Aneurysm or Diverticulum
Treatment
Intervention indicated in patients with arrhythmia
Conduction abnormality disappears only after separation or ablation of the CS diverticulum neck
The CS was dissected away from the LV and the AV junction and that site was cryoablated
No postoperative recurrences or complications occurred
Anomalies of the Inferior Vena Cava
Anomalies of the Inferior Vena Cava
Interrupted Inferior Vena Cava
Bilateral Inferior Vena Cavae
Inferior Vena Cava drainage to the Left Atrium
Interrupted Inferior Vena Cava
Anatomy
Absence of the hepatic segment of the IVC with azygos continuation into the right or left
Rarely the infrahepatic segment of the IVC may continue to both right and left SVC via bilateral azygos veins
One of the characteristics of the polysplenia syndrome
Also has been reported in patients with normal hearts and rarely in patients with asplenia
Interrupted Inferior Vena Cava
Posterior view of the heart, lungs, liver, and kidneys of a 6 1/2-month-old boy with visceral heterotaxy and left-sided polysplenia. There is interruption of the right-sided IVC with bilateral azygos veins connecting with bilateral superior venae
Interrupted Inferior Vena Cava
Clinical Manifestations
Interrupted IVC with azygos continuation usually does not result in a physiologic abnormality
Can complicate cardiac catheterization and interventional procedures
Diagnostic Features
Diagnosed readily by echocardiography
Diagnosis is based on imaging of the size, location, and course of the IVC and the azygos vein
Interrupted Inferior Vena Cava
Diagnostic Features
Normally, in the subcostal short-axis view, the renal-to-hepatic segment of the IVC is seen as an oval blood vessel located anterior and to the right of the abdominal aorta
In heterotaxy syndrome, the IVC may be juxtaposed to the abdominal aorta either to the left or to the right of the spine
When the renal-to-hepatic segment of the IVC is absent, no IVC is seen below the liver
Drainage of the azygos vein to the SVC- can be imaged from the parasternal and suprasternal windows
Interrupted Inferior Vena Cava
three-dimensional MRA is accurate and effective in delineating normal and abnormal systemic venous anatomy
During cardiac catheterization, venous angiography from the lower extremity is diagnostic
TreatmentNo specific treatment of an interrupted IVC with azygos
continuation is indicated
Inadvertent ligation of the azygos vein can lead to death
Bilateral Inferior Venae Cavae
Anatomy
Bilateral suprahepatic IVCs (i.e., a normal IVC and a contralateral hepatic vein) a frequent finding in cases of visceral heterotaxy with asplenia
Bilateral suprahepatic IVCs also can occur rarely in patients with normal visceral situs
The left-sided hepatic vein in those cases drains into a normal coronary sinus
Do not produce any hemodynamic disturbance
Inferior Vena Cava Drainage to the LA
Anatomy
During fetal life, about half of the IVC blood that enters the RA is directed toward the LA with the help of two venous valves: the eustachian valve & valve of the foramen ovale
A left atrial IVC also occur in cases in which all the systemic and all the PVs drained into a left-sided atrium
Inferior Vena Cava Drainage to the LA
AP venogram in a 15-month-old boy with visceral heterotaxy, asplenia. Contrast injected into the rt. iliac vein filled two venous pathways. The rt-sided pathway represents a rt. IVC, which receives the rt hepatic vein & then enters the rt side of the common atrium. The lt venous channel appears to represent a lt. IVC, which connects with the left hepatic vein & then joins the RIVC and drains into the common atrium via a common orifice.
Inferior Vena Cava Drainage to the LA
Clinical Manifestations
Partial or complete drainage of the IVC into the left atrium results in cyanosis
The clinical manifestations are the result of right-to-left shunting, including polycythemia, brain abscess, and paradoxical emboli
Treatment
Inferior vena cava blood is surgically redirected into the right atrium
Anomalies of the Ductus Venosus
Anomalies of the Ductus Venosus
Anomalous Termination of the Umbilical Veins and Absent Ductus Venosus
Postnatal Persistence of the Ductus Venosus
Persistent Valves of the Sinus Venosus
Anomalous Termination of the Umbilical Veins and Absent Ductus Venosus
Anatomy
Persisted left umbulical vein terminates directly into the CS , to the CS by way of the left portal vein or into the iliac vein
Persisted right umbilical vein terminates directly into the RA, into the IVC, into the rt portal vein & into the right SVC
Clinical Manifestations
Usually do not produce symptoms
Intrauterine obstruction of the umbilical vein flow and postnatal intestinal obstructions secondary to the anomalous termination of the umbilical veins have been reported
Anomalous Termination of the Umbilical Veins and Absent Ductus Venosus
Diagnosis
Catheterization of the umbilical vein
Cardiac catheterization plus angiography
Prenatal echocardiography
Postnatal echocardiography
Postnatal Persistence of the Ductus Venosus
Anatomy
Congenital postnatal persistence of the ductus venosus because the shunt was away from the portal venous septum proximally to the distal hepatic veins or IVC distally
These intrahepatic portal-systemic shunts are due to abnormal persistence of elements of the omphalomesenteric system
Clinical Manifestations
Three of the ten cases reported resulted in portal-systemic encephalopathy
Postnatal Persistence of the Ductus Venosus
Diagnosis
Ultrasound or computed tomography - demonstrates a large tortuous vessel originating from the portal vein that connected to the hepatic vein or IVC
Treatment
In the absence of encephalopathy, treatment may not be indicated
If ligation of the ductus venosus is contemplated, one should establish the integrity of the portal system. If it is not intact, ligation could lead to mesenteric venous congestion and ultimately bowel ischemia
THANK YOU
MCQs
MCQ-1
False statement about development of heart
A. 21 days - heart tube forms
B. 23 days- heart beats
C. Week 6 - cardiac loop forms
D. Week 7 - heart fully developed
MCQ-2
False statement about development of Systemic veins
A. Sinus venosus absorbed in to right atrium
B. Left horn of sinus venosus form coronary sinus
C. SVC derived from rt. Posterior cardinal vein and common cardinal vein
D. Lt. brachiocephalic vein derived from the part of left anterior cardinal vein
MCQ-3
All are true statements except
A. Subclavian vein derived from intersegmental vein
B. External jugular derived from anterior cardinal vein
C. Lt. Superior intercostal vein formed from lt. anterior and posterior cardinal vein
D. Transverse intercardinal anastomosis form part of left brachiocephalic vein
MCQ-4
Inferior venacava formed by all except
A. Supracardinal veins
B. Subcardinal veins
C. vitelline veins
D. Umbulical veins
E. Posterior cardinal veins
MCQ-5
Bilateral SVC with normal drainage to the RA false statement is
A. left innominate vein may be present in 60%
B. The LSVC starts at the junction of the left jugular and left subclavian veins
C. In LSVC to an intact coronary sinus the direction of blood flow is into the left innominate vein
D. A dilated CS is often the first clue to the diagnosis
E. There is an inverse relationship between the caliber of the LSVC and the left innominate vein
MCQ-6
All are true statements except
A. Visceral heterotaxy with asplenia exhibits the highest incidence of bilateral SVCs with a completely unroofed coronary sinus
B. Raghib syndrome characterized by cyanosis with right-to-left shunting
C. In patients with atretic CS ostium & LSVC the only clinical manifestations are cyanosis and its sequelae
D. In bilateral SVC with an Unroofed CS the arterial oxygen saturation ranges between 85% and 95%
MCQ-7
False statement about Retroaortic Innominate Vein
A. Most patients have associated cardiac malformations
B. Results from failure of the low transverse capillary plexus that forms the left innominate vein to develop
C. Cine MRI and three-dimensional MRA are particularly useful in depicting the anatomy
D. Normal course of the left innominate vein is from left to right, anterior to the aortic arch
MCQ-8
False statement about Levoatrialcardinal vein
A. Remnant of an early embryonic venous channel that connects the splanchnic plexus of the lungs with the cardinal system
B. Typically It is associated with severe LA outlet obstruction
C. It courses anterior to the left pulmonary artery
D. In the mature heart, it connects the LA or a PV with the Lt innominate or other systemic veins
MCQ-9
False statement regarding Coronary Sinus Defect and Unroofed CS
A. A CS defect without an associated LSVC the physiology is the same as in ASD
B. Step-up in oxygen saturation between PV & LA
C. Surgery is usually performed for associated malformations
D. Unroofed coronary sinus almost always is associated with a persistent LSVC
MCQ-10
False statement about Interrupted IVC
A. Interrupted IVC with azygos continuation usually does not result in a physiologic abnormality
B. It is characteristics of the asplenia syndrome
C. Absence of the hepatic segment of the IVC with azygos continuation into the right or left
D. No specific treatment of an interrupted IVC with azygos continuation is indicated
Answers
MCQ-1
False statement about development of heart
A. 21 days - heart tube forms
B. 23 days- heart beats
C. Week 6 - cardiac loop forms
D. Week 7 - heart fully developed
MCQ-2
False statement about development of Systemic veins
A. Sinus venosus absorbed in to right atrium
B. Left horn of sinus venosus form coronary sinus
C. SVC derived from rt. Posterior cardinal vein and common cardinal vein
D. Lt. brachiocephalic vein derived from the part of left anterior cardinal vein
MCQ-3
All are true statements except
A. Subclavian vein derived from intersegmental vein
B. External jugular derived from anterior cardinal vein
C. Lt. Superior intercostal vein formed from lt. anterior and posterior cardinal vein
D. Transverse intercardinal anastomosis form part of left brachiocephalic vein
MCQ-4
Inferior venacava formed by all except
A. Supracardinal veins
B. Subcardinal veins
C. vitelline veins
D. Umbulical veins
E. Posterior cardinal veins
MCQ-5
Bilateral SVC with normal drainage to the RA false statement is
A. left innominate vein may be present in 60%
B. The LSVC starts at the junction of the left jugular and left subclavian veins
C. In LSVC to an intact coronary sinus the direction of blood flow is into the left innominate vein
D. A dilated CS is often the first clue to the diagnosis
E. There is an inverse relationship between the caliber of the LSVC and the left innominate vein
MCQ-6
All are true statements except
A. Visceral heterotaxy with asplenia exhibits the highest incidence of bilateral SVCs with a completely unroofed coronary sinus
B. Raghib syndrome characterized by cyanosis with right-to-left shunting
C. In patients with atretic CS ostium & LSVC the only clinical manifestations are cyanosis and its sequelae
D. In bilateral SVC with an Unroofed CS the arterial oxygen saturation ranges between 85% and 95%
MCQ-7
False statement about Retroaortic Innominate Vein
A. Most patients have associated cardiac malformations
B. Results from failure of the low transverse capillary plexus that forms the left innominate vein to develop
C. Cine MRI and three-dimensional MRA are particularly useful in depicting the anatomy
D. Normal course of the left innominate vein is from left to right, anterior to the aortic arch
MCQ-8
False statement about Levoatrialcardinal vein
A. Remnant of an early embryonic venous channel that connects the splanchnic plexus of the lungs with the cardinal system
B. Typically It is associated with severe LA outlet obstruction
C. It courses anterior to the left pulmonary artery
D. In the mature heart, it connects the LA or a PV with the Lt innominate or other systemic veins
MCQ-9
False statement regarding Coronary Sinus Defect and Unroofed CS
A. A CS defect without an associated LSVC the physiology is the same as in ASD
B. Step-up in oxygen saturation between PV & LA
C. Surgery is usually performed for associated malformations
D. Unroofed coronary sinus almost always is associated with a persistent LSVC
MCQ-10
False statement about Interrupted IVC
A. Interrupted IVC with azygos continuation usually does not result in a physiologic abnormality
B. It is characteristics of the asplenia syndrome
C. Absence of the hepatic segment of the IVC with azygos continuation into the right or left
D. No specific treatment of an interrupted IVC with azygos continuation is indicated