‘Left Right Out’: A Rare Case of Left Superior and Inferior Anomalous Pulmonary Venous Return Diagnosed with Transoesophageal Echocardiography

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We present the case of a 31-year-old woman who was referred to our institution for transoesophageal echocardiography to investigate the cause of right ventricular volume overload seen on transthoracic echocardiography, investigating exertional dyspnoea. On transoesophageal echocardiogram, close examination of the interatrial septum did not reveal any atrial septal defect. Similarly, the right superior and inferior pulmonary veins were unremarkable. However, the left superior and inferior pulmonary veins were noticeably absent. Careful observation of colour Doppler applied to the right atrium during the assessment of the inter-atrial septum revealed colour aliasing and increased flow velocity at the entry of the superior vena cava (SVC) into the right atrium. On further inspection, there was evidence of a communication to the SVC 3.6 cm above the connection with the right atrium, receiving flow from a confluence of the left-sided pulmonary veins. Cardiac magnetic resonance imaging confirmed the finding of anomalous left superior and inferior pulmonary veins draining into the SVC. The most common form of anomalous pulmonary venous connection is the connection of the left upper pulmonary vein to the left innominate vein. Less commonly, the right-sided pulmonary veins can drain into the SVC or the IVC (‘Scimitar syndrome’). Anomalous connection of both left-sided pulmonary veins is an extremely rare finding, and represents a very small proportion of anomalous drainage cases. This case demonstrates the value of simple and inexpensive transoesophageal echocardiography for the diagnosis of congenital heart disease in an era where there still remains high demand on cardiac MRI and computed tomography services.