Additional Cardiovascular Anomalies Research Articles

RARE CASE OF MASSIVE DVT AFTER MRNA COVID-19 VACCINATION IN A PATIENT WITH CONGENITAL IVC ANOMALY

RARE CASE OF MASSIVE DVT AFTER MRNA COVID-19 VACCINATION IN A PATIENT WITH CONGENITAL IVC ANOMALY

22q11.2 Deletion Syndrome: Impact of Genetics in the Treatment of Conotruncal Heart Defects.

Congenital heart diseases represent one of the hallmarks of 22q11.2 deletion syndrome. In particular, conotruncal heart defects are the most frequent cardiac malformations and are often associated with other specific additional cardiovascular anomalies. These findings, together with extracardiac manifestations, may affect perioperative management and influence clinical and surgical outcome. Over the past decades, advances in genetic and clinical diagnosis and surgical treatment have led to increased survival of these patients and to progressive improvements in postoperative outcome. Several studies have investigated long-term follow-up and results of cardiac surgery in this syndrome. The aim of our review is to examine the current literature data regarding cardiac outcome and surgical prognosis of patients with 22q11.2 deletion syndrome. We thoroughly evaluate the most frequent conotruncal heart defects associated with this syndrome, such as tetralogy of Fallot, pulmonary atresia with major aortopulmonary collateral arteries, aortic arch interruption, and truncus arteriosus, highlighting the impact of genetic aspects, comorbidities, and anatomical features on cardiac surgical treatment.

Off-pump ascending aorta or aortic arch to descending aorta bypass with a pericardial roll for the treatment of critically ill infants with interrupted aortic arch.

Standard surgical treatment of the interrupted aortic arch with the use of cardiopulmonary bypass is risky especially in critically ill babies. In this manuscript, we present the results of off-pump pericardial roll bypass for the treatment of aortic interruption. The technique was applied in nine critically ill infants between July 2011 and December 2019. Data were reviewed retrospectively. There were four girls and five boys. The types of the interruption were type B in six cases and type A in three babies. Additional cardiovascular anomalies were ventricular septal defect in all, atrial septal defect or patent foramen ovale in all, single-ventricle pathologies in two and bicuspid aortic valve in three cases. All the patients were in critical situations such as intubated, having symptoms of infection, congestive heart failure or ischaemia and malperfusion leading visceral organ dysfunction. All patients underwent off-pump ascending aorta or aortic arch to descending aorta bypass with a pericardial roll. Post-operative early mortality occurred in one patient with severe mitral regurgitation due to cardio-septic shock. One patient who had single-ventricle pathology underwent bidirectional Glenn and was lost on the post-operative 26th day due to sepsis 2 years after operation. Two patients presented with dilatation of the pericardial tube 18 and 24 months after the operations and one underwent reconstruction of the neo-arch. The remaining patients are asymptomatic, active and within normal limits of body and mental growth. Treatment of interrupted aortic arch with a bypass with an autologous pericardial roll treated with gluteraldehyde without cardiopulmonary bypass seems a safe and reliable technique especially for the treatment of critically ill infants.

Adult interrupted aortic arch with aortic regurgitation: Single-stage repair

Adult patients with interruption of the aorta are an extremely rare occurrence. It is commonly associated with additional cardiovascular anomalies. Surgery is the mainstay in the management of the patients. Interrupted aortic arch and associated cardiac disease is a complex situation that requires correction either simultaneously or in stages. We describe the case of a 32-year-old male patient planned for aortic valve replacement at another center, incidentally diagnosed with interrupted aortic arch Type A. He was managed with single-stage aortic valve replacement and extra-anatomical bypass.

Intermediate-Term Outcomes of Slide Tracheoplasty in Pediatric Patients With Ring-Sling Complex

This study was intended to determine the intermediate-term outcomes after slide tracheoplasty (STP) in patients with ring-sling complex. All children undergoing STP between 2009 and 2018 were included. The patients' baseline characteristics, perioperative management details, and follow-up evaluations were reviewed retrospectively. Median age was 1.2 years (range, 2 months to 9.2 years). Seventy-eight patients had additional cardiovascular anomalies and 7 had unilateral pulmonary hypoplasia. Carina involved in the stenotic lesion was present in 42 patients and carinal compression occurred in 58. Twenty-five (21.6%) patients had a stenosis extending into the main bronchus. Type 2, typically having aberrant tracheobronchial patterns, accounted for nearly two-thirds of the patients according to Wells' classification. There were 7 in-hospital deaths and 8 late deaths. Median follow-up was 2.1 years (range, 1.2 months to 9.2 years). Type 2B patients had a higher incidence of malacia and restenosis. In multivariate analysis, the additional cardiovascular anomaly was significantly associated with postoperative tracheomalacia (P= .037). Carinal stenosis (P = .034) was significantly associated with recurrent stenosis. Bronchial stenosis with concomitant carinal stenosis and compression was significantly associated with postoperative tracheomalacia, restenosis, and mortality (for all comparisons, P < .001). Intermediate outcomes of STP in patients with ring-sling complex is satisfactory. Type 2B is a heterogenous subset patients with more severe tracheobronchial anomalies who will benefit from recognition preoperatively and close surveillance postoperatively.

Cause of Ascending Aortic Dilatation in Patients with Bicuspid Aortic Valves: The Final Link.

This article discusses about the cause of dilatation of the ascending aorta in patients with congenitally bicuspid aortic valves (CBAVs). Some members of the profession believe that it is genetic, while others attribute it to turbulence. The author previously presented in vitro data proving that CBAVs are inherently morphological stenotic, even in the absence of measurable gradient and clinical symptoms. This article reinforces the view that the dilatation of the ascending aorta in patients with CBAV represents a "poststenotic dilatation" by demonstrating that the structure of the aortic wall is normal in infants who have CBAV as a sole cardiac anomaly. The aortic wall was studied in newborns who had CBAV as the sole cardiovascular anomaly and in those where CABV was associated with other inborn cardiovascular defects. We found that in patients where CBAV is the sole cardiovascular anomaly, aortic structure is normal at birth, but abnormal if additional cardiovascular anomalies are present. Dilatation of the ascending aorta in patients, where CBAV is the only cardiovascular anomaly, is caused by turbulence (poststenotic dilatation). If additional cardiovascular anomalies are present, this process may be exaggerated by genetic abnormalities of the aortic wall.

MR imaging of subaortic and retroesophageal anomalous courses of the left brachiocephalic vein in the fetus

The purpose of this study was to report fetal cases of subaortic and retroesophageal anomalous courses of the left brachiocephalic vein (LBCV) evaluated by fetal cardiac magnetic resonance imaging (MRI). A retrospective review of 7282 fetal cardiac MRI from June 2006 to March 2017, nine cases of anomalous courses of the LBCV were correctly diagnosed by fetal cardiac MRI, one case of abnormal subaortic left brachiocephalic vein (ASLBV) missed by fetal MRI was identified postnatally during further imaging of the TOF. The diagnosis was confirmed postnatally by cardiac CT/MRI. An ASLBV was found in 8 cases, a retroesophageal LBCV was found in 2 additional cases with right aortic arch and aberrant left subclavian artery. 3 of 8 ASLBV cases were with a right aortic arch, 4 ASLBV cases had additional cardiovascular anomalies with one case isolated. 7 of 8 ASLBV and 2 retroesophageal LBCV were correctly diagnosed by fetal cardiac MRI; however fetal cardiac MRI missed 2 cases of associated pulmonary atresia (PA). Prenatal echocardiography (echo) correctly diagnosed five ASLBV and one retroesophageal LBCV as well as associated intracardiac anomalies. Fetal cardiac MRI can be a useful adjunct in the identification of subaortic and retroesophageal anomalous courses of the LBCV prenatally.

Low-Dose Computed Tomographic Imaging of Partial Anomalous Pulmonary Venous Connection in Children.

In this study, we aimed to determine lobar distribution, drainage sites, and associated cardiovascular anomalies of partial anomalous pulmonary venous connection in pediatric patients using low-dose multidetector computed tomographic angiography. Sixty-one cases (27 female, mean age: 4.7 years) with partial anomalous pulmonary venous connection diagnosed by multidetector computed tomographic angiography were included in this study. In all patients, multidetector computed tomographic angiography examinations were performed using dual-source 256-slice scanner without sedation. In 61 patients, 73 anomalous pulmonary veins were detected, 56 (77%) of them were right-sided and 17 (23%) were left-sided. Of 56 right-sided anomalous pulmonary veins in 49 patients, 38 (68%) drained into superior vena cava, eight (14%) into atriocaval junction, six (11%) into inferior vena cava, three (5%) into right atrium, and one (2%) into levoatriocardinal vein. Of 17 left-sided anomalous pulmonary veins in 12 patients, 16 (94%) drained into left innominate vein, and one (6%) into coronary sinus. Only seven (12%) patients had isolated partial anomalous pulmonary venous connection, whereas 54 (88%) patients had additional cardiovascular anomalies. The most common (66%) associated anomaly is atrial septal defect. The overall mean effective radiation dose was 1.12 mSv (range: 0.15-7.41 mSv), and it was 0.58 mSv (range: 0.15-0.73) in the patients younger than one-year old. The presence and course of the anomalous pulmonary veins and associated cardiovascular anomalies can be reliably detected by dual-source 256-slice multidetector computed tomographic angiography with low radiation doses.

Intracardiac Eustachian Valve Cyst in an Adult Detected with Other Cardiac Anomalies: Usefulness of Multidetector CT in Diagnosis

We present an unusual case of an intracardiac Eustachian valve cyst observed concurrently with atresia of the coronary sinus ostium, a persistent left superior vena cava (LSVC) and a bicuspid aortic valve. There have been several echocardiographic reports of Eustachian valve cysts; however, there is no report of multidetector computed tomography (MDCT) findings related to a Eustachian valve cyst. Recently, we observed a Eustachian valve cyst diagnosed on MDCT showing a hypodense cyst at the characteristic location of the Eustachian valve (the junction of the right atrium and inferior vena cava). MDCT also demonstrated additional cardiovascular anomalies including atresia of the coronary sinus ostium and a persistent LSVC and bicuspid aortic valve.

Preferential Ductus Venosus Streaming Toward the Right Heart Is Associated with Left Heart Underdevelopment and Aortic Arch Hypoplasia in Human Fetuses

Preferential left heart underdevelopment in human fetuses with diaphragmatic hernia is almost uniformly associated with preferential streaming of the ductus venosus toward the right side of the heart. The purpose of our study was to examine whether this flow anomaly might also be present in other fetuses with hypoplasia of left-sided cardiovascular structures. We studied 32 fetuses with left heart hypoplasia as defined by gestational age-related Z-scores by echocardiography. Apart from defining cardiovascular morphology as detailed as possible, particular focus was put on the presence or absence of preferential streaming of the ductus venosus and inferior caval vein toward the right side of the heart. 8 of 32 fetuses with hypoplasia of one or more left-sided cardiovascular structures exhibited preferential streaming of the ductus venosus toward the right side of the heart. In all eight fetuses, this finding was associated with additional cardiovascular anomalies like aortic valve stenosis, ventricular septal defect, left superior caval vein-to-coronary sinus, pulmonary vein stenosis and/or aortic arch hypoplasia. As in human fetuses with left diaphragmatic hernia, preferential ductus venosus streaming toward the right side of the heart can be found in a subgroup of fetuses with hypoplasia of left-sided cardiovascular structures.

Ductus Venosus Streaming and Left Heart Hypoplasia

Preferential left heart underdevelopment in human fetuses with diaphragmatic hernia is almost uniformly associated with preferential streaming of the ductus venosus toward the right side of the heart. The purpose of our study was to examine whether this flow anomaly might also be present in fetuses with isolated hypoplasia of left-sided cardiovascular structures. We studied 32 fetuses with left heart hypoplasia as defined by gestational-age related Z-scores by echocardiography. Apart from defining cardiovascular morphology as detailed as possible, particular focus was put on the presence or absence of preferential streaming of the ductus venosus and inferior caval vein toward the right side of the heart. Eight of 32 fetuses with hypoplasia of one or more left-sided cardiovascular structures exhibited preferential streaming of the ductus venosus toward the right side of the heart. In all eight fetuses, this finding was associated with additional cardiovascular anomalies like aortic valve stenosis, ventricular septal defect, left superior caval vein-to-coronary sinus, pulmonary vein stenosis and/or aortic arch hypoplasia. As in human fetuses with left diaphragmatic hernia, preferential ductus venosus streaming toward the right side of the heart can be found in a subgroup of fetuses with isolated hypoplasia of left-sided cardiovascular structures.

Chromosome 22q11.2 microdeletion in children with conotruncal heart defects: frequency, associated cardiovascular anomalies, and outcome following cardiac surgery

The association of conotruncal heart defects with 22q11.2 chromosomal microdeletions is well established. However, it is not clear whether particular types of conotruncal malformations or additional cardiovascular anomalies are associated with microdeletions. In addition, cardiac surgery outcome in children with conotruncal defects and del22q11.2 is not well described. We prospectively enrolled 214 children with conotruncal defects: 126 with tetralogy of Fallot (TOF), 18 with pulmonary atresia-ventricular septal defect (PA-VSD), 15 with truncus arteriosus communis (TAC) type I, one with interrupted aortic arch (IAA) type B, and 54 with the transposition of great arteries, who were consecutively hospitalized at the Pediatric Cardiology Department between 2003 and 2005. 22q11.2 microdeletion was identified by fluorescence in situ hybridization. The postoperative course following cardiac surgery was compared in patients with TOF and its more severe form, PA-VSD, with/without del22q11.2 (groups A and B) and TAC with/without del22q11.2 (groups C and D). In 15 of 214 patients, 22q11.2 microdeletion was diagnosed (in 11 with TOF/PA-VSD, in three with TAC, in one with IAA type B). In patients with TOF/PA-VSD and microdeletion anatomic features that were significantly associated with 22q11.2, deletion included right aortic arch (p = 0.018), aberrant right subclavian artery (p < 0.001), and major aortopulmonary collateral arteries (p = 0.016). A complicated postoperative course was more frequent and mortality was higher in patients with conotruncal defects and with/without microdeletion. We conclude that additional cardiovascular anomalies are significantly more frequent in children with 22q11.2 microdeletion and TOF/PA-VSD. Children with conotruncal heart defects and 22q11.2 microdeletion more frequently experienced complicated postoperative course after cardiac surgery.

Cardiac defects and results of cardiac surgery in 22q11.2 deletion syndrome

Specific types and subtypes of cardiac defects have been described in children with 22q11.2 deletion syndrome as well as in other genetic syndromes. The conotruncal heart defects occurring in patients with 22q11.2 deletion syndrome include tetralogy of Fallot, pulmonary atresia with ventricular septal defect, truncus arteriosus, interrupted aortic arch, isolated anomalies of the aortic arch, and ventricular septal defect. These conotruncal heart defects are frequently associated in this syndrome with additional cardiovascular anomalies of the aortic arch, pulmonary arteries, infundibular septum, and semilunar valves complicating cardiac anatomy and surgical treatment. In this review we describe the surgical anatomy, the operative treatment, and the prognostic results of the cardiac defects associated with 22q11.2 deletion syndrome. According to the current literature, in patients with tetralogy of Fallot with/without pulmonary atresia and truncus arteriosus, in spite of the complex cardiac anatomy, the presence of 22q11.2 deletion syndrome does not worsen the surgical prognosis. On the contrary in children with pulmonary atresia with ventricular septal defect and probably in those with interrupted aortic arch the association with 22q11.2 deletion syndrome is probably a risk factor for the operative treatment. The complex cardiovascular anatomy in association with depressed immunological status, pulmonary vascular reactivity, neonatal hypocalcemia, bronchomalacia and broncospasm, laryngeal web, and tendency to airway bleeding must be considered at the time of diagnosis and surgical procedure. Specific diagnostic, surgical, and perioperative protocols should be applied in order to provide appropriate treatment and to reduce surgical mortality and morbidity.

Characteristics, associations and outcome of absent pulmonary valve syndrome in the fetus

To assess in a population of 21 fetuses diagnosed with absent pulmonary valve syndrome (APVS) the accuracy of prenatal diagnosis, the incidence of extracardiac and chromosomal anomalies and the perinatal outcome. This was a retrospective observational study of 21 fetuses with a confirmed diagnosis of APVS. All of them underwent fetal echocardiography and a detailed anatomical scan. Karyotyping was performed in 20/21 cases, with fluorescent in-situ hybridization analysis to detect the 22q11 microdeletion performed in 16/21 cases. The following variables were retrieved from databases and evaluated: indication for referral, gestational age at diagnosis, presence of cardiomegaly, branch pulmonary dilatation, associated anomalies or intrauterine growth restriction, and fetal/neonatal outcome. Autopsy reports and postnatal surgical/medical files were available for confirmation in all cases. Prenatal diagnosis of APVS proved correct in all cases, with only three cases occurring not in association with tetralogy of Fallot. Additional cardiovascular anomalies were present in five cases (24%). Extracardiac anomalies were found in nine cases (42.8%), and were associated with chromosomal anomalies in five cases (24%). The 22q11 microdeletion was present in 4/16 cases (25%). Fetal/neonatal outcome was as follows: nine terminations of pregnancy, three intrauterine deaths, six postnatal deaths. The remaining three (14.3%) neonates were alive after surgery. Cardiomegaly and marked branch pulmonary dilatation were present in 16 and 15 cases, respectively, and were associated with bronchomalacia in virtually all cases. APVS can be reliably diagnosed and characterized prenatally. The association with major chromosomal anomalies or 22q11 microdeletion is consistent with previous findings. The relatively poor survival rate is due to the high rate of terminations, associated genetic anomalies and bronchomalacia. Bronchomalacia is present in the overwhelming majority of cases featuring cardiomegaly and marked branch pulmonary dilatation.

Spectrum of cardiovascular anomalies in Williams-Beuren syndrome

This study is presented to identify and characterize the spectrum of the cardiovascular anomalies in children presenting with Williams-Beuren syndrome and cardiovascular anomalies at The Hospital for Sick Children, Toronto from 1966 to 1988. Forty-nine children were diagnosed and followed. The female to male ratio was 1.2:1. The age ranged from 1 month to 14 years at the time of diagnosis (mean 39 months), and follow-up periods were from 9 months to 20 years (mean 10 years). All patients having the typical features were also evaluated by geneticists. Based on cardiovascular findings four groups were identified. Group 1 had isolated supravalvular aortic stenosis (SVAS) (28 patients). There was follow-up in 24 of these children. Six had worsening of supravalvular narrowing and underwent surgery. One showed an increased gradient from 10-40 mmHg during 7 years. Seventeen had mild narrowing and showed no progression over a period of 75 months. Group 2 had isolated pulmonary artery branch stenosis (8 patients). Seven had mild narrowing which remained unchanged over a mean period of 16 months and one underwent surgery. Group 3 had combined lesions (11 patients). Six showed increased left-side narrowing, while right-side obstruction remained static or improved. Five showed improvement in narrowing in both outflow tracts. Five underwent surgery. Additional cardiovascular anomalies included peripheral artery stenosis in two patients, coronary artery abnormalities in three, mitral valve prolapse in three, and coarctation of the aorta in two. Group 4 had isolated lesions. One patient had isolated coarctation of the aorta and one isolated mitral prolapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of additional cardiovascular anomalies in patients referred for transcatheter closure of patent ductus arteriosus

Catheter closure of the patent ductus arteriosus is now a reality. The purpose of this study was to establish the prevalence of associated cardiovascular defects and the accuracy of echocardiography in patients referred for transvenous ductal closure. This study reviewed 146 patients seen from 1981 to 1988: 126 with only a patent ductus arteriosus (Group I) and 20 with additional cardiovascular anomalies (Group II).Groups I and II did not differ significantly in age, gender or physical examination except for the presence of a continuous murmur (Group I 100% versus Group II 80%, p < 0.001). A left patent ductus arteriosus was visualized by two-dimensional echocardiography in 96% of patients and was evident by Doppler study in 100%. A patent ductus arteriosus was not seen in six patients including a patient who was found to have only a collateral network from the aorta to the main pulmonary artery.The 12 patients with noncardiovascular abnormalities such as Down's syndrome were more likely than the overall group to have additional cardiovascular anomalies (6 of 12, p = 0.001). The cardiovascular anomalies encountered were varied. Eight of the 20 patients with such anomalies had only a restrictive ventricular septal defect in addition to the patent ductus arteriosus. Significant anomalies found at catheterization included two thoracic arteriovenous malformations and an isolated right carotid artery draining into the right pulmonary artery by way of a right ductus arteriosus.This study indicates that echocardiography is an effective diagnostic technique in this patient group. A thorough cardiac catheterization with angiography should be performed before implantation of a ductal device.

Malaligned outlet septum with subpuhnonary ventricular septal defect and abnormal ventriculoarterial connection: A morphologic spectrum defined echocardiographically

A retrospective analysis of 62 echocardiograms from 22 patients with malaligned outlet septum, subpulmonary ventricular septal defect and abnormal ventriculoarterial (VA) connection was performed and the results were confirmed by intraoperative inspection, cardiac catheterization and angiography, or pathologic specimen analysis in 21 of the 22 patients. The purpose of this study was to determine the relative incidence of the primary morphologic features; the correlation between the presence or absence of mitral valve to pulmonary valve fibrous continuity and the type of VA connection; the types and incidence of additional cardiovascular anomalies; and the correlation between the determination of the VA connection by echocardiography versus that ascertained at intraoperative and autopsy inspection.A spectrum of VA connections was found, ranging from double outlet right ventricle (23%) at one extreme, through an intermediate type (64%) in which the pulmonary artery was overriding the ventricular septum, thereby having no consistent and predominant connection to either ventricle, to a discordant VA connection (13%) at the opposite end of the spectrum. All three types of VA connection occurred whether or not there was mitral valve to pulmonary valve fibrous continuity. Additional cardiovascular anomalies were present in 95% of patients, the most common being aortic arch obstructive lesions in 59%, anomalous attachments of the atrioventricular valve tension apparatus in 55% and subaortic stenosis in 50%.A method of echocardiographic determination of the VA connection that correlated with that determined intraoperatively and from pathologic specimen analysis is described.

Displaced Mediastinum and Heart Murmur

History A 6-year-old boy had been referred at age 22 months for evaluation of a grade 2/6 systolic ejection murmur at the upper right sternal border. Cardiac catheterization showed mild pulmonic valvular stenosis, with main pulmonary artery pressure of 35/12 mm Hg and right ventricular pressure of 32/5 mm Hg. Cardiovascular history was negative for tachypnea, cyanosis, or squatting. Diagnosis Congenital absence of the left pulmonary artery. Comment The chest roentgenogram (Fig 1) shows the heart and mediastinal structures displaced into the smaller left hemithorax. The left hilum appears small, and pulmonary vascularity is slightly diminished on the affected side. Cardiac size is within normal limits, but a right-sided aortic arch is noted. Pulmonary angiography (Fig 2) illustrates absence of the left pulmonary artery. Aortic angiography (Fig 3) demonstrates a right-sided aortic arch with bronchial arterial collateral supply to the left lung. No additional cardiovascular anomalies were shown. Pulmonary vascular

Anomalies associated with coarctation of aorta: particular reference to infancy.

One hundred specimens from subjects with coarctation of the aorta were studied with regard to the nature and occurrence of additional cardiovascular anomalies. Seventy-seven were less than 6 months of age at the time of death (group I) and 23 were 6 months of age or older (group II). Exclusive of cases of bicuspid aortic valve, there were one or more associated anomalies in 87 cases, that is 91% of the patients under 6 months of age and in 74% of those in the older group. The various types of additional anomalies in order of decreasing frequency were as follows: (1) tubular hypoplasia of the aortic arch (49 cases); (2) abnormal communications (mainly ventricular septal defect and patent ductus arteriosus) (49 cases); (3) left ventricular outflow obstruction (mainly subaortic stenosis) (37 cases); (4) left ventricular inflow obstruction (26 cases); and (5) positional anomalies of the great vessels (mainly transpositions) (13 cases). More than one anomaly in addition to the coarctation was commonly present. The overall incidence of congenital bicuspid aortic valve was 46%. Among 71 cases in which the relationship to the ductus could be determined, the coarctation was proximal or opposite the ductus in 62 cases and distal to the ductus in nine cases.

Anomalous pulmonary veins

The literature now embodies 133 case reports of anomalous drainage of pulmonary veins. Of these patients, partial drainage into the right atrium occurred in 75, and complete drainage into this chamber or its tributaries occurred in 56. Additional cardiovascular anomalies were present in 23 of the latter group of patients. Partial drainage of pulmonary veins into the right atrium is consistent with long life. In 56 reported cases of complete drainage of pulmonary veins into the right atrium, only 10 patients lived beyond the age of 8 months. The clinical diagnosis of complete drainage of pulmonary veins into the right atrium can be established by use of the cardiac catheter and the angiocardiogram. An additional case is described in which all of the pulmonary veins emptied into the superior vena cava in a male infant who lived to the age of 8 weeks.