Ultrafast three-dimensional contrast-enhanced magnetic resonance angiography and imaging in the diagnosis of partial anomalous pulmonary venous drainage
Victor A. Ferrari, MD, FACC*,
Craig H. Scott, MD, FACC*,
George A. Holland, MD  ,
Leon Axel, PhD, MD and
Martin St. John Sutton, FRCP, FACC*
* Adult Congenital Heart Disease Program, Cardiovascular Division, Department of Medicine (Cardiovascular Division), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Figure 1 The magnetic resonance angiography 3D data set is collected as a series of contiguous slabs in either the coronal or sagittal plane. The contrast-enhanced data set shown is a coronal acquisition with the most anterior images to the left of the stack and the posterior structures to the right. Selected images from the data set demonstrate an anomalous right upper pulmonary vein entering the superior vena cava just above the junction with the right atrium (arrow, left), and the right lower lobe pulmonary vein entering the left atrium normally (arrow, right). RLL = right lower lobe; RUL = right upper lobe.
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Figure 2 Figure 2 shows a reformatted oblique coronal magnetic resonance angiography (MRA) from the data set in Figure 1 that now demonstrates the more complete course of the right upper lobe pulmonary vein (RUL). In this patient with anomalous pulmonary venous return from one lobe, the RUL enters the superior vena cava at a level 1.4 cm superior to the right atrium (arrow). All MRA images in this report are displayed as reformatted maximal intensity projection images.
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Figure 3 (A) Oblique coronal image through a 3D dataset, showing an anomalous pulmonary vein formed by the right upper and right middle pulmonary veins that courses through the right thorax and enters the inferior vena cava below the level of the diaphragm (arrow). Despite the large field of view and the fact that the vessel crosses the diaphragm, the vessel’s course is clearly depicted. (B) Right lower lobe pulmonary vein enters the left atrium normally (arrow). The right pulmonary artery is identified by the open arrow.
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Figure 4 Reformatted oblique section of a 3D contrast-enhanced magnetic resonance angiography data set demonstrating anomalous connection of the left upper and left middle pulmonary veins to a vertical vein that enters the left brachiocephalic vein (BcphV). Communication between the BcphV and the right superior vena cava (SVC) is seen proximal to the entry of the SVC into the right atrium. The aorta and left pulmonary artery (PA) are also noted. This figure demonstrates the utility of the reformatting technique, which permits reorientation of the data set from a coronal (original) to an oblique parasagittal view and delineation of the course of nearly the entire BcphV. APV = anomalous pulmonary vein.
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Figure 5 Axial spin echo MRI demonstrating a sinus venosus defect (arrow) just caudal to the insertion of the superior vena cava and between the right atrium (RA) and left atrium (LA). Due to its location high in the atrium, it is sometimes difficult to cross with a catheter or to visualize with transesophageal echocardiography (TEE). This defect was misidentified on both catheterization and TEE examinations.
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