Discussion:
The diagnosis of mixed type TAPVC and its surgical repair are
challenging, however; it is the least common type of TAPVC, accounting
for about 5% of cases (3). Our patient had mixed type of TAPVC (cardiac
and supracardiac) associated with VSD. There was two cites of
obstruction in our patient, the first was at the connection of the
vertical vein with the left innominate vein which was through a very
small vein branch (Figure 1), and the second was due to the very small
PFO. The majority of TAPVC cases are diagnosed by TTE which is the
preferred diagnostic tool, but sometimes additional images modalities
are required such as CTA, angiography via cardiac catheterization or MRI
(7, 8). The main management of TAPVC patients is primary surgical
repair, however; a transcatheter palliative shunt may be considered in
patients with other important comorbidities such as prematurity, low
birth weight, multisystem organ dysfunction, multiple congenital
anomalies (9, 10). Our patient was managed surgically and did not need
primary transcatheter palliation. It has been reported that the
mortality of obstructed TAPVC had decreased over the eras from 42.1% in
the seventies to 7.4% after 2010. The worst prognosis is predicted in
patients with pulmonary obstruction and suprasystemic PH preoperatively
in which the patient might have been intubated. Patients who underwent
emergent surgery with significant pulmonary vein obstruction still have
the worst scenario despite the progress in the field of TAPVC surgery
(11).