Selecting optimal imaging modalities for total anomalous pulmonary venous connection visualization

Abstract In healthy individuals, pulmonary veins drain oxygenated blood from the lungs into the left atrium. Total anomalous pulmonary venous connection (TAPVC) disrupts this process, causing severe clinical issues. TAPVC is classified into four types based on drainage site: supracardiac, cardiac, infracardiac, and mixed. Untreated, TAPVC is life-threatening with high neonatal mortality, though surgical advances have lowered mortality rates to below 10%. Early diagnosis and intervention are critical for better outcomes, especially in obstructed cases. Transthoracic echocardiography (TTE) is the primary diagnostic tool for TAPVC, identifying the absence of pulmonary venous connection to the left atrium and the presence of a common pulmonary venous trunk. However, TTE’s limitations, such as poor acoustic windows and inadequate spatial resolution, often necessitate advanced imaging like computed tomography angiography (CTA) and magnetic resonance imaging (MRI). CTA offers high spatial and temporal resolution, providing detailed anatomical information crucial for preoperative planning. Although it involves radiation exposure, it outperforms TTE in visualizing extracardiac vascular structures. MRI provides comprehensive anatomical and functional assessments without radiation, making it ideal for younger patients. It evaluates ventricular function, shunt ratios, and vascular anomalies but requires longer acquisition times. Cardiac catheterization remains the reference standard for diagnosing complex TAPVC, offering direct hemodynamic assessment despite being invasive. TTE is the first-line diagnostic tool for neonates, while CTA and MRI are preferred for detailed anatomical and functional assessments in adults. The manuscript reviews and compares these imaging techniques for optimal TAPVC diagnosis and management.