 Good morning, everyone. I'm Dr. Smriti Khasa. Currently, I'm pursuing my third year of residency in radio diagnosis in Maharshi Markandeshwar University, Mulana. Today, I'm here to present a paper on the title, a case report on radiological findings in partial anomalous pulmonary venous drainage. Partial anomalous pulmonary venous connection is a rare cardiac anomaly with prevalence of approximately 0.4 to 0.7%. Patients are usually asymptomatic or mildly symptomatic. Therefore, PAPVC is usually incidentally identified on imaging. 90% of the cases are right-sided when one or more of the right-sided pulmonary veins drain into the right atrium, coronary sinus, or a systemic vein. PAPVC creates a left-to-right shunt in the heart similar to ASD, VSD, or PDA. This causes right-sided fluid overload, pulmonary vascular hypertension, and right-sided heart failure. The most common anomaly is the anomalous drainage of right superior pulmonary vein to the right atrium or superior vena cava. This pattern is commonly associated with sinus venous type of atrial septal defect. 10% of the cases are left-sided. In isolated left-sided PAPVC with an intact atrial septum, the patient is usually asymptomatic in childhood. Only in adulthood can the symptoms appear, which may include dyspnea, fatigue, palpitations, chest pain, or peripheral edema. Left anomalous pulmonary veins commonly drain to the left brachiocephalic vein via a vertical vein or into the coronary sinus. A rare form of PAPVC is scimitar syndrome that involves the right lung and is associated with hypoplasia of the right lung. The key imaging goals in anomalous pulmonary venous drainage are as follows. In total anomalous pulmonary venous drainage, we have to describe the pulmonary venous connection type, which is of four types, supracardiac, infracardiac, and mixed. And we have to identify the areas of pulmonary venous obstruction, confirm the left-to-right shunt, and to identify the associated abnormalities. In partial anomalous pulmonary venous drainage, we have to describe the pulmonary venous connection, assess the branches of pulmonary arteries, quantify the ventricular volume function, and assess the right atrial dilatation. We have to quantify the shunt. Now talking about the case I'm going to present, a 47-year-old female who was on levothyroxine for management of hypothyroidism for the last 20 years, presented for an outpatient appointment with shortness of breath for one year, which had aggravated since the last one week. Shortness of breath was associated with orthopnea and paroxysmal nocturnal dyspnea. She also complained of palpitations and heaviness of chest. On examination, bilateral basal and infra-axillary crepitations were noted, and bilateral pitting type of fetal edema was noted. Laboratory investigations were sent, most of which were normal, except for a low hemoglobin. Chest x-ray findings were suggestive of cardiomegaly and prominent pulmonary arteries. 2D trans thoracic echocardiography was also performed, which had the following findings. Moderate right-sided heart enlargement, diastolic septal flattening, mild pulmonary hypertension, right ventricular systolic pressure was increased, and measures approximately 45 mmHg, intact atrial septum, preserved left ventricular function. Given the patient's complaints of aggravated dyspnea results of the investigations, she was referred to the department of radiodiagnosis for CT pulmonary angiography. CT pulmonary angiography was performed. The first film is an axial section. It shows the main pulmonary artery and its right and left branches to be dilated. The second image shows marked dilatation of the right atrium as well as the right ventricle. Left atrium and left ventricle appear normal. This is a coronal image in which left superior and inferior pulmonary veins drain into the left atrium. That is a normal finding. Right pulmonary veins are not seen to be draining into the left atrium. Right superior and middle pulmonary veins are seen draining into the inferior vena cava. In this image, we see that there is an anomalous drainage of right pulmonary vein. Right superior pulmonary vein here is seen draining into the right atrium, just below the superior vena cava drainage into the right atrium. In this image, another small pulmonary vein from the right middle lobe is seen draining into the inferior vena cava at the level of its drainage into the right atrium. This image, there is a small suspicious communication between the right atrium and the right ventricle at the level of mid atrial septum. However, no defect is seen in the atrial septum at the level of superior vena cava or inferior vena cava drainage into the right atrium. So no sinus venosis type of ASD is seen in this case. This image, right inferior pulmonary vein is seen draining into the supra diaphragmatic part of the IVC at the level of its drainage into the right atrium. Right lung appears normal in size. No hypoplasia is seen. Left atrium and left ventricle appear normal. Left superior and inferior pulmonary veins also appear normal. So this image in the lung window shows marked areas of patchy mosaic attenuation seen in both lungs with marked prominence of pulmonary arteries and veins. Streak of pleural effusion is also seen on the right side as well as on the left side. So the diagnosis in this case was partial anomalous pulmonary venous drainage. Right sided pulmonary veins draining into the right atrium and supra diaphragmatic part of the IVC as described with associated pulmonary artery hypertension. This is being followed by a brief discussion on this topic. Normally the four pulmonary veins drain into the left atrium as we can see in this image. Pulmonary veins may connect abnormally to a site other than the left atrium. Usually right atrium, systemic vein or coronary sinus. If all the veins connect abnormally, then it is described as total anomalous pulmonary venous connection. If less than all the veins connect abnormally, then it is termed as partial anomalous pulmonary venous connection. Now we'll discuss total anomalous pulmonary venous drainage. In TAPVD, a complete left to right shunt causes all of the pulmonary venous return to mix with the systemic venous return. In TAPVD, the pulmonary veins coalesce posterior to the left atrium, but they do not drain into it. Now on the basis of the drainage into the left, into the right atrium, it is divided into four types. Type one is supracardiac, which is the most common. 50% cases are supracardiac type. The drainage is via the left ascending vein to the left brachiocephalic vein and then to the superior vena cava. Type two is cardiac type in which the drainage occurs via enlarged coronary sinus directly into the right atrium. Type three is infracardiac in which the drainage is via a descending vein which passes through the diaphragm, either into the inferior vena cava or into the portal venous system. The infracardiac type is associated with a degree of obstruction as the descending vein passes through the diaphragm and is potentially more severe with superimposed pulmonary venous hypertension. So this results in hepatomagalli and pulmonary edema. On chest x-ray, we see a normal size heart, but interstitial edema is seen. In the supracardiac and cardiac variants, which present with the left to right shunt, intracardiac mixing and cardiac failure, the chest x-ray findings include cardiomagalli and snowman appearance, which is also called as figure of eight appearance. In the first image, this year, chest x-ray film PA view, in which snowman figure appearance is seen. Now discussing the partial anomalous pulmonary venous drainage, it is an asynotic condition which results in a physiology similar to atrial septal defect. The number of veins involved determine the magnitude of the shunt and the clinical symptoms. It is associated with superior and inferior sinus venous atrial septal defects. Now discussing the scimitar syndrome, in this a portion or all of the right lung pulmonary venous blood flow dames into the IVC, azagus system, right atrium, portal venous system or into the hepatic vein. Other findings include right lung hypoplasia. This is a cardinal feature of the scimitar syndrome. Other findings are cardiac dextral position, pulmonary artery hypoplasia or atria. Systemic arterial collateral blood supply to the lateral lung may also be seen arising from the aorta or its branch vessels such as the celiac axis. A curved vessel is seen here mimicking the right in the right lower zone mimicking the scimitar sword, hence the name. Thank you.