Total anomalous pulmonary venous return (TAPVR) is a cyanotic congenital heart anomaly with an abnormal drainage anatomy of the entire pulmonary venous system. This contrasts with partial anomalous pulmonary venous return (PAPVR) where only part of the pulmonary venous anatomy is abnormal.
In TAPVR all systemic and pulmonary venous blood enters the right atrium and nothing drains into the left atrium. A right-to-left shunt is required for survival and is usually via a large patent foramen ovale (PFO) or less commonly atrial septal defect (ASD).
Affected infants develop cyanosis and congestive heart failure in the early neonatal period.
There is embryological failure of pulmonary venous development that results in persistent patency of primitive systemic veins.
TAPVR can be classified into 4 types (in decreasing order of frequency) depending on the site of anomalous venous union:1
Type I (supracardiac)
- commonest type (over 50% of cases)
- anomalous pulmonary veins terminate at the supracardiac level
- pulmonary veins converge to form a left vertical vein which then drains to either brachiocephalic vein, SVC or aygous vein
Type II (cardiac)
- second commonest (~30% of cases)
- pulmonary venous connection at the cardiac level
- drainage is into the coronary sinus and then the right atrium
Type III (infracardiac)
- connection at the infracardiac level
- the pulmonary veins join behind the left atrium to form a common certical descending vein
- the common descending vein courses anterior to the oesophagus, passes through the diaphragm at the oesophageal hiatus and then usually joins the portal system
- drainage is usually into the ductus venosus, hepatic veins, portal vein or IVC
Type IV : mixed pattern
- least common type
- anomalous venous connections at two or more levels
Approximately one-third of those with TAPVR also have other associated cardiac lesions; many have heterotaxy syndrome, particularly asplenia. Type III (infracardiac) is also assocaited with thoracic lymphangiectasia and pulmonary congestion.
The right heart is prominent in TAPVR because of the increased flow volume, but the left atrium remains normal in size. Types I and II result in cardiomegaly.
The supracardiac variant (type I) can classically depict a snowman appearance on a frontal chest radiograph, also known as figure of 8 heart or cottage loaf heart 2-3. The dilated vertical vein on the left, brachiocephalic vein on top, and the superior vena cava on the right form the head of the snowman; the body of the snowman is formed by the enlarged right atrium.
CT / MRA
Direct visualisation of anomalous venous return.
Echocardiography / Ultrasound
May show blind ended left atrium with no connecting veins.
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- 1. Demos TC, Posniak HV, Pierce KL et-al. Venous anomalies of the thorax. AJR Am J Roentgenol. 2004;182 (5): 1139-50. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Ferguson EC, Krishnamurthy R, Oldham SA. Classic imaging signs of congenital cardiovascular abnormalities. Radiographics. 27 (5): 1323-34. doi:10.1148/rg.275065148 - Pubmed citation
- 3. Somerville J, Grech V. The chest x-ray in congenital heart disease 1. Total anomalous pulmonary venous drainage and coarctation of the aorta. Images Paediatr Cardiol. 2009;11 (1): 7-9. - Free text at pubmed - Pubmed citation
Synonyms & Alternative Spellings
|Synonyms or Alternative Spelling||Include in Listings?|
|Total anomalous pulmonary venous return||✓|
|Total annomalous pulmonary venous return||✗|
|Total anomalous pulmonary venous return (TAPVR)||✗|
|Total anomalous pulmonary venous drainage (TAPVD)||✓|