Systemic venous anomalies

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Systemic venous anomalies

  1. 1. SYSTEMIC VENOUS ANOMALIES Dr Ranjith MP Senior Resident Department of Cardiology Government Medical college Kozhikode
  2. 2. 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
  3. 3. EMBRYOLOGY
  4. 4. EMBRYOLOGY Changes in the sinoatrial orifice
  5. 5. 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 venosus2. The umbilical veins  originating in the chorionic villi, carrying oxygenated blood to the embryo3. The cardinal veins  draining the body of the embryo proper
  6. 6. EMBRYOLOGYMain components of the venous and arterial systems in a 4-mmembryo (end of the fourth week).
  7. 7. 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
  8. 8. EMBRYOLOGYDevelopment of veins draining upper part of body A. Ducts of Cuvier B. Subclavian veins C. Transverse anastomosis E. Superior venacava F. Right Brachiocephalic vein G. Left Brachiocephalic vein H. Internal Jugular vein External jugular vein arise as secondary channel
  9. 9. 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
  10. 10. 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
  11. 11. EMBRYOLOGYDevelopment of Inferior venacava  Green- Subcardinal  Red- Supracardinal  Yellow- Subcardinal- hepatocardinal anastomosis  Blue- Hepatocardiac channel  White- Supracardinal- Subcardinal anastomosis
  12. 12. 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
  13. 13. 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
  14. 14. EMBRYOLOGYDevelopment of Azygos veins
  15. 15. 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
  16. 16. EMBRYOLOGY.
  17. 17. Anomalies of the Superior Venae Cavae
  18. 18. 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
  19. 19. 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%
  20. 20. Bilateral Superior Venae Cavae with Normal Drainage to the Right Atriumsuperior vena cava A=right B=left A: coronary sinus (enlarged)C: communicating vein, D: aorta B: aorta, C: inferior vena cavaE: pulmonary trunk. D: left pulmonary veins
  21. 21. 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
  22. 22. 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
  23. 23. Bilateral SVC to Right Atrium Diagnostic 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
  24. 24. 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
  25. 25. Bilateral SVC to Right Atrium Diagnostic 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
  26. 26. Bilateral SVC to Right Atrium Diagnostic 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Bilateral SVC with an Unroofed Coronary Sinus Diagnostic FeaturesECG Axis of the P wave may be abnormal in patients with heterotaxy syndromeChest Xray Shadow along the Lt upper border of the mediastinum
  32. 32. Bilateral SVC with an Unroofed Coronary Sinus Diagnostic 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
  33. 33. Bilateral SVC with an Unroofed Coronary Sinus Diagnostic Features B.MR image in a coronal plane A. Injection into the LSVC shows complete unroofing of opacifies CS and shunting of the CS. LSVC connects to the contrast medium into the LA roof of the LA and the CS thorough the defect opening functions as a LA septal defect (Raghib defect)
  34. 34. Bilateral SVC with an Unroofed Coronary Sinus Treatment 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
  35. 35. 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%)
  36. 36. 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
  37. 37. 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
  38. 38. Absent Right SVC in Visceroatrial Situs SolitusTreatment No intervention is indicated when the physiology is normalVenogram in the innominate vein in a patientwith absence of the right SVC and persistence ofthe LSVC, which drains into the RA via the CS
  39. 39. 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
  40. 40. Left Atrial or Biatrial Drainage of Right SVCClinical Manifestations Cyanosis 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Diagnosis Demonstration of a common entrance site of Rt SVC and the RUPV in the roof of the LA by echo or angio
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. Retroaortic Innominate Vein Clinical Manifestations Asymptomatic Surgical importance Diagnosis Echo, 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
  46. 46. 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
  47. 47. Levoatrialcardinal veinThe diagnosis can be established byfollowing the anomalous vein from itsorigin to its termination in a systemicveinUnlike persistent LSVC that coursesanterior to the left pulmonary artery, alevoatrialcardinal vein typically ascendsposterior to it Levoatriocardinal vein in a patient with cortriatriatum. ItIt complicates the completion of a drains the proximal chamber ofFontan-type operation the LA to the innominate vein
  48. 48. 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
  49. 49. Anomalies of the Coronary Sinus
  50. 50. Anomalies of the Coronary SinusCoronary Sinus Defect and Unroofed CSCoronary Sinus Orifice AtresiaCoronary Sinus Aneurysm or Diverticulum
  51. 51. 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
  52. 52. Coronary Sinus Orifice AtresiaIncidence is rareThe CS is usually well formed, the orifice is covered by a thin membrane like tissueAlternative exit for coronary venous blood return- A small LSVC , Large thebesian vein CS septal defect , Connection with the IVC in one case
  53. 53. Coronary Sinus Orifice Atresia Clinical Manifestations  Myocardial ischemia is unlikely as long as there is an alternate egress for 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
  54. 54. 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
  55. 55. 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
  56. 56. Anomalies of the Inferior Vena Cava
  57. 57. Anomalies of the Inferior Vena CavaInterrupted Inferior Vena CavaBilateral Inferior Vena CavaeInferior Vena Cava drainage to the Left Atrium
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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Treatment  No specific treatment of an interrupted IVC with azygos continuation is indicated  Inadvertent ligation of the azygos vein can lead to death
  63. 63. 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
  64. 64. 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
  65. 65. Inferior Vena Cava Drainage to the LAAP venogram in a 15-month-old boy with visceral heterotaxy, asplenia. Contrast injected into thert. iliac vein filled two venous pathways. The rt-sided pathway represents a rt. IVC, whichreceives the rt hepatic vein & then enters the rt side of the common atrium. The lt venouschannel appears to represent a lt. IVC, which connects with the left hepatic vein & then joins theRIVC and drains into the common atrium via a common orifice.
  66. 66. 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
  67. 67. Anomalies of the Ductus Venosus
  68. 68. 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
  69. 69. 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
  70. 70. Anomalous Termination of the Umbilical Veins and Absent Ductus VenosusDiagnosis  Catheterization of the umbilical vein  Cardiac catheterization plus angiography  Prenatal echocardiography  Postnatal echocardiography
  71. 71. 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
  72. 72. 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
  73. 73. THANK YOU
  74. 74. MCQs
  75. 75. MCQ-1 False statement about development of heartA. 21 days - heart tube formsB. 23 days- heart beatsC. Week 6 - cardiac loop formsD. Week 7 - heart fully developed
  76. 76. MCQ-2 False statement about development of Systemic veinsA. Sinus venosus absorbed in to right atriumB. Left horn of sinus venosus form coronary sinusC. SVC derived from rt. Posterior cardinal vein and common cardinal veinD. Lt. brachiocephalic vein derived from the part of left anterior cardinal vein
  77. 77. MCQ-3 All are true statements exceptA. Subclavian vein derived from intersegmental veinB. External jugular derived from anterior cardinal veinC. Lt. Superior intercostal vein formed from lt. anterior and posterior cardinal veinD. Transverse intercardinal anastomosis form part of left brachiocephalic vein
  78. 78. MCQ-4 Inferior venacava formed by all exceptA. Supracardinal veinsB. Subcardinal veinsC. vitelline veinsD. Umbulical veinsE. Posterior cardinal veins
  79. 79. MCQ-5 Bilateral SVC with normal drainage to the RA false statement isA. left innominate vein may be present in 60%B. The LSVC starts at the junction of the left jugular and left subclavian veinsC. In LSVC to an intact coronary sinus the direction of blood flow is into the left innominate veinD. A dilated CS is often the first clue to the diagnosisE. There is an inverse relationship between the caliber of the LSVC and the left innominate vein
  80. 80. MCQ-6 All are true statements exceptA. Visceral heterotaxy with asplenia exhibits the highest incidence of bilateral SVCs with a completely unroofed coronary sinusB. Raghib syndrome characterized by cyanosis with right-to-left shuntingC. In patients with atretic CS ostium & LSVC the only clinical manifestations are cyanosis and its sequelaeD. In bilateral SVC with an Unroofed CS the arterial oxygen saturation ranges between 85% and 95%
  81. 81. MCQ-7False statement about Retroaortic Innominate VeinA. Most patients have associated cardiac malformationsB. Results from failure of the low transverse capillary plexus that forms the left innominate vein to developC. Cine MRI and three-dimensional MRA are particularly useful in depicting the anatomyD. Normal course of the left innominate vein is from left to right, anterior to the aortic arch
  82. 82. MCQ-8 False statement about Levoatrialcardinal veinA. Remnant of an early embryonic venous channel that connects the splanchnic plexus of the lungs with the cardinal systemB. Typically It is associated with severe LA outlet obstructionC. It courses anterior to the left pulmonary arteryD. In the mature heart, it connects the LA or a PV with the Lt innominate or other systemic veins
  83. 83. MCQ-9 False statement regarding Coronary Sinus Defect and Unroofed CSA. A CS defect without an associated LSVC the physiology is the same as in ASDB. Step-up in oxygen saturation between PV & LAC. Surgery is usually performed for associated malformationsD. Unroofed coronary sinus almost always is associated with a persistent LSVC
  84. 84. MCQ-10 False statement about Interrupted IVCA. Interrupted IVC with azygos continuation usually does not result in a physiologic abnormalityB. It is characteristics of the asplenia syndromeC. Absence of the hepatic segment of the IVC with azygos continuation into the right or leftD. No specific treatment of an interrupted IVC with azygos continuation is indicated
  85. 85. Answers
  86. 86. MCQ-1False statement about development of heartA. 21 days - heart tube formsB. 23 days- heart beatsC. Week 6 - cardiac loop formsD. Week 7 - heart fully developed
  87. 87. MCQ-2 False statement about development of Systemic veinsA. Sinus venosus absorbed in to right atriumB. Left horn of sinus venosus form coronary sinusC. SVC derived from rt. Posterior cardinal vein and common cardinal veinD. Lt. brachiocephalic vein derived from the part of left anterior cardinal vein
  88. 88. MCQ-3 All are true statements exceptA. Subclavian vein derived from intersegmental veinB. External jugular derived from anterior cardinal veinC. Lt. Superior intercostal vein formed from lt. anterior and posterior cardinal veinD. Transverse intercardinal anastomosis form part of left brachiocephalic vein
  89. 89. MCQ-4 Inferior venacava formed by all exceptA. Supracardinal veinsB. Subcardinal veinsC. vitelline veinsD. Umbulical veinsE. Posterior cardinal veins
  90. 90. MCQ-5 Bilateral SVC with normal drainage to the RA false statement isA. left innominate vein may be present in 60%B. The LSVC starts at the junction of the left jugular and left subclavian veinsC. In LSVC to an intact coronary sinus the direction of blood flow is into the left innominate veinD. A dilated CS is often the first clue to the diagnosisE. There is an inverse relationship between the caliber of the LSVC and the left innominate vein
  91. 91. MCQ-6 All are true statements exceptA. Visceral heterotaxy with asplenia exhibits the highest incidence of bilateral SVCs with a completely unroofed coronary sinusB. Raghib syndrome characterized by cyanosis with right-to-left shuntingC. In patients with atretic CS ostium & LSVC the only clinical manifestations are cyanosis and its sequelaeD. In bilateral SVC with an Unroofed CS the arterial oxygen saturation ranges between 85% and 95%
  92. 92. MCQ-7False statement about Retroaortic Innominate VeinA. Most patients have associated cardiac malformationsB. Results from failure of the low transverse capillary plexus that forms the left innominate vein to developC. Cine MRI and three-dimensional MRA are particularly useful in depicting the anatomyD. Normal course of the left innominate vein is from left to right, anterior to the aortic arch
  93. 93. MCQ-8 False statement about Levoatrialcardinal veinA. Remnant of an early embryonic venous channel that connects the splanchnic plexus of the lungs with the cardinal systemB. Typically It is associated with severe LA outlet obstructionC. It courses anterior to the left pulmonary arteryD. In the mature heart, it connects the LA or a PV with the Lt innominate or other systemic veins
  94. 94. MCQ-9 False statement regarding Coronary Sinus Defect and Unroofed CSA. A CS defect without an associated LSVC the physiology is the same as in ASDB. Step-up in oxygen saturation between PV & LAC. Surgery is usually performed for associated malformationsD. Unroofed coronary sinus almost always is associated with a persistent LSVC
  95. 95. MCQ-10 False statement about Interrupted IVCA. Interrupted IVC with azygos continuation usually does not result in a physiologic abnormalityB. It is characteristics of the asplenia syndromeC. Absence of the hepatic segment of the IVC with azygos continuation into the right or leftD. No specific treatment of an interrupted IVC with azygos continuation is indicated

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