 Good morning one and all present here. I am Dr. Jayashree doing second year DMP radiology in Belruth hospitals Chennai Today, I am here to share my knowledge on an interesting case dual drainage one conduit charting the bi-HL passage Moving on to the case report a 65 year old female who was a known diabetic and hypertensive presented with complaints of bilateral leg swelling for one week She also had dyspnea and exertion which had aggravated over the past one month and she had a long-standing issue of orthopneurotube The patient was initially suspected to have deep venous thrombosis and a bilater low volume venous dopula worsten But the venous Doppler however showed no evidence of deep venous thrombosis Cellulitis of bilater lower limbs noted and in view of persistent dyspnea a pulmonary thromboembolism was suspected and a pulmonary angiogram worsten Moving on to the CT pulmonary angiogram findings axial images at the level of liver showing reflex of iodinated contrast into the hepatic veins via the inferior vena cava indicating right heart strain Axial images showing cardiomegaly with predominant enlargement of the right-sided chambers the right atrium and the right ventricle We can also note the right and left loval of pulmonary veins as depicted by the green arrows normally draining into the left atrium Axial angiogram and 3D reformated images showing grossly dilated main pulmonary artery and right and left pulmonary arteries and their branches respectively The main pulmonary artery measured around 4.7 cm Axial angiogram images again showing the right and left pulmonary arteries which measured around 3 cm and 2.8 cm respectively Axial and sagittal angiogram images showing an anomalous whistle as depicted by the blue arrow Coursing around the right pulmonary artery as depicted by the yellow arrow connecting between the right-sided superior vena cava as depicted by the green arrow and the left atrium as depicted by the red arrow Axial images at higher section showing the anomalous vascular channel joining the superior vena cava medially Here the superior vena cava is depicted by the red arrow and anomalous channel is depicted by the yellow arrow and we can also note that laterally the right upper-low pulmonary veins as seen draining into the superior vena cava depicted by the green arrow so diagnosis of partial and anomalous pulmonary venous communication was made Reformated and labeled virtual reconstruction images viewed from laterally showing the course of the vessel around the right pulmonary artery between the superior vena cava and the left atrium We can also see the other pulmonary veins normally draining into the left atrium Reformated, subtracted virtual reconstruction images showing the abnormal vessel coursing between SVC and the left atrium and we can also posteriorly note that the upper-low pulmonary veins are anomalously draining into the superior vena cava Schematic representation showing the anomalous vascular channel as depicted by the red dot coursing between the SVC and the left atrium The yellow arrows are showing that the other pulmonary veins are normally draining into the left atrium The green arrow is showing that the right upper-low pulmonary veins are anomalously draining into the superior vena cava and incidentally it visualized upper sections of abdomen showed nodular contour of liver with heterogeneous pan-camel density suggesting cirrhosis correlating with our case a diagnosis of a chronic hepatic contusion leading to cardiac cirrhosis was made Diagnosis in summarizing the imaging findings, the patient had an anomalous vascular channel connecting the right SVC and the left atrium The course of which morphologically correlated with that of the right upper-low pulmonary vein However, the right upper-low pulmonary veins were seen anomalously draining into the superior vena cava and the interatial septum was also found to be intact and a diagnosis of biatial drainage of right superior vena cava with partial anomalous pulmonary venous rhythm was made The anomalous vascular channel between the superior vena cava and the left atrium has resulted in a left to right shunt leading to volume overload and significant pulmonary hypertension and this led to chronic hepatic contusion resulting in cardiac cirrhosis Moving on to discussion, biatrial or left atrial drainage of right superior vena cava is a rare form of interatrial communication caused by defect in the wall between the right superior vena cava and the right upper-low pulmonary vein This type of defect is also described as biatrial drainage of the right SVC or Kevo pulmonary venous defect or Veno venous bridge However, it is not a true atrial septal defect, it is just an interatrial communication This entity is closely related to the more common SVC type sinus venous defect If the superior vena cava drains into both atria, it may be either due to abnormal connection as was in our case or more precision of interatrial septum or superior sinus venous atrial septal defects In this entity, the pulmonary vein maintains its normal connection to the left atrium allowing a left to right shunt from the left atrium through the right upper-low pulmonary vein into the right atrium If the defect is associated with stenosis or atria of right superior vena cava or of us to the right atrium predominantly the drainage will be into the left atrium leading to a right to left shunt leading in devastating events Kevo pulmonary venous defects are commonly associated with anomalous pulmonary venous most common on the right side to the superior vena cava at the right atrium How to differentiate between the sinus venous defect and biatrial drainage of SVC It is based on the location of shunting between the right upper-low pulmonary vein and superior vena cava If the defect is located close to the Kevo atrial junction, SVC type sinus venous defect diagnosis is made If the defect is located relatively superior to the Kevo atrial junction, biatrial drainage of SVC can be made Summarizing all the findings and the key points to take home are The key imaging features include the defect between the right SVC and right upper or middle-low pulmonary vein that is due to androofing of right pulmonary vein or indicating a venous-venous bridge the normal course and connection of the right pulmonary vein to the left atrium If in case of there is stenosis or atria of the right SVC orifice to the right atrium there will be predominant drainage into the left atrium Here are my references. Thank you