A harmless ‘Scimitar’

<span class="paragraphSection">A 45-years-old woman was referred to echocardiography for left bundle branch block on 12-leads ECG. She was completely asymptomatic, mother of two children and practiced regular physical activity. The echocardiographic examination showed normal left ventricular size and function and normal morphology and function of cardiac valves. Right cardiac chambers were enlarged and right ventricular systolic function was normal (<span style="font-style:italic;">Panel A</span>). Doppler analysis revealed an increased pulmonary to systemic cardiac output ratio (Qp/Qs = 1.4). However, color Doppler failed to demonstrate signs of intracardiac shunts. Trivial tricuspid regurgitation was present with a peak velocity of 2.1 m/s. Inferior vena cava was significantly enlarged with only mild inspiratory collapse (<span style="font-style:italic;">Panel B</span>). Magnetic Resonance Imaging with gadolinium (<span style="font-style:italic;">Panel C</span>) and 3D reconstruction (<span style="font-style:italic;">Panel D</span>) eventually revealed a partial anomalous pulmonary venous return. As shown in image the upper and lower right pulmonary veins drained together in the inferior vena cava with the classic radiographic appearance of a ‘scimitar vein’. Patient underwent cardiac catheterization which eventually reported normal pressure in the inferior vena cava and right atrium (mean pressure in both = 2 mmHg), normal right ventricular pressure (16/3 mmHg) and normal pulmonary artery pressure (16/8 mmHg). The clinical case was extensively discussed by the heart team including a radiologist, clinical and interventional cardiologists and cardiac surgeons. In consideration of the absence of clinical symptoms and signs of heart failure, and in the absence of a significant hemodynamic overload surgical correction was not indicated and patient was advised a periodical follow up. </span>

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