Radionuclide diagnosis of infradiaphragmatic total anomalous pulmonary venous drainage

We hypothesized that infradiaphagmatic total anomalous pulmonary venous drainage (ITAPVD), because of its unique physiology, could be diagnosed with radionuclide angiography. Seven neonates with severe respiratory distress were injected intravenously with 3 mCi technetium-99m pertechnetate. In each of four neonates demonstrated to have ITAPVD by pulmonary angiography, nuclide recirculation through the right atrium occurred 3-6 s after initial passage. In addition, direct visualization of the anomalous common pulmonary trunk with nuclide as a "tail" below the diaphragm was obvious in the third infant studied. This prompted review of the first two infants with ITAPVD; in retrospect the anomalous trunk was also visualized with nuclide in both of these infants. All three were injected via the upper extremity. In the fourth ITAPVD infant, nuclide was injected via the lower extremity. In that infant, preferential streaming of the inferior vena caval flow and nuclide across the foramen ovale into the left heart led to simultaneous opacification of anomalous trunk and descending aorta, obscuring the "tail" sign.