Abnormalities of the main systemic and pulmonary veins are arousing increasing interest. The object of this paper is to review our experience of 46 cases of the left-sided superior vena cava, including 4 examples of the much rarer condition where the inferior vena cava is absent. We wish also to discuss the type of cases in which these occur and their clinical significance. Abnormal drainage of the pulmonary veins has been discussed in several recent papersdrainage into the left superior vena cava by Snellen and Albers (1952), Gardner and Oram (1953), and Whitaker (1954), and drainage into the right atrium and the right side generally by Brody (1942), Smith (1951), Edwards (1953), and Swan et al. (1953). These groups will not, therefore, be included here, especially as we have seen few examples of the former.

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The left-sided superior vena cava.

1 From the Department of Radiology, the Hahnemann Medical College and Hospital, Philadelphia, Penna. 2 Submitted to the faculty, Graduate School of Medicine, University of Pennsylvania, in partial fulfillment of requirements for degree of Master of Medical Science. Submitted for publication December 1953. Those who are concerned with the diagnosis and management of congenital cardiovascular lesions will appreciate the need for thoroughness in the study of cardiac and great vessel malformations. Embryologists and anatomists have long been aware that generalized developmental arrests or disturbances of growth may result in combinations of defects including the great veins as well

Persistent left superior vena cava; survey of world literature and report of thirty additional cases.

Total anomalous pulmonary venous connection.

All of our cases of abnormal pulmonary venous connections collected to the middle of 1965 and verified at surgery or autopsy have been reviewed by means of diagrams and tabulations, using a specially devised code to facilitate the survey. The material consisted of 52 autopsy cases (half of them obtained after surgery) and the cases of 72 patients who survived operation. The postmortem group was much younger than the surgical group and differed also from the latter by showing male preponderance as well as relatively many instances of total abnormal pulmonary venous connection and frequently associated cardiac anomalies. Partial anomalous connection of right pulmonary veins was 10 times more frequent than that of the left pulmonary veins. This was caused by (1) the frequent drainage of some of the right pulmonary veins into the junctional area between right atrium and superior vena cava in the presence of normal left pulmonary veins, and (2) the complete absence of isolated left pulmonary venous connection to the right atrium. Abnormal connection of solitary pulmonary veins was always effected to the most proximal venous structure among the four possible ones which are derived from the main embryonic channels (superior vena cava and inferior vena cava on the right side, and left superior vena cava and coronary sinus on the left side). Common pulmonary veins from one lung also drained in accordance with this proximity rule, if this may be taken to apply also to the drainage of right pulmonary veins into the right atrium. The one exception in our material was the drainage of all right pulmonary veins into the portal venous system. Total abnormal pulmonary venous connection may be found with all structures mentioned, but most frequently with the left superior vena cava, or coronary sinus, or both, usually by way of a common pulmonary vein. In a few cases however, drainage into different sites, all of them abnormal, did occur. Then again the proximity rule seemed to apply. A tentative embryological explanation is given for the patterns described.

Patterns of anomalous pulmonary venous drainage.

Three cases of anomalous pulmonary venous return to the inferior vena cava are presented and 18 previously reported cases are also analyzed. The clinical, radiographic, circulatory and pulmonary function, and anatomic features are carefully detailed. In particular, associated vascular and bronchial anomalies in the lungs were found by preparation of vinylite casts of the pulmonary vessels and bronchial casts; they are of great significance in planning and executing surgical therapy.

Bronchial and Arterial Anomalies with Drainage of the Right Lung into the Inferior Vena Cava

Clinical studies are presented in: (a) One case of partial anomalous pulmonary venous drainage (right common pulmonary vein into inferior vena cava), and (b) four cases of total abnormal pulmonary venous drainage (via "left vena cava" and left innominate vein into the superior vena cava on the right side). One of the latter four cases was verified on exploratory thoracotomy. The diagnosis was based on angiocardiography and heart catheterization, but the conventional chest roentgenogram proved to be quite characteristic of both conditions. The relatively slight impairment of health is stressed in the cases reported here.

F. H. Albers

Papers

The Clinical Diagnosis of Anomalous Pulmonary Venous Drainage