Materiały źródłowe

• #1 Partial Anomalous Pulmonary Venous Return (PAPVR)

  https://my.clevelandclinic.org/health/diseases/24580-partial-anomalous-pulmonary-venous-return

  Partial anomalous pulmonary venous return (PAPVR) is a congenital heart disorder that causes abnormal blood flow from your lungs to your heart. One or more pulmonary veins return oxygen-rich blood to the wrong side of your heart. This blood recirculates through your lungs instead of out to your body. […] PAPVR, like other forms of congenital heart disease, happens when a fetal heart doesnt form properly in the uterus. […] Normally, during the early weeks of pregnancy, four pulmonary veins form out of a common pulmonary vein. These veins connect with the fetal left atrium. However, changes in this process cause the pulmonary veins to connect to the right atrium or nearby veins (like the superior vena cava or left brachiocephalic vein). […] Researchers estimate that about 4 to 7 in 1,000 people have PAPVR. This number may be higher, though, since some people never show symptoms and therefore may never receive a diagnosis.

• #2 250. ACHD: Partial Anomalous Pulmonary Venous Return (PAPVR) with Dr. Ian Harris

  https://www.cardionerds.com/250-achd-partial-anomalous-pulmonary-venous-return-papvr-with-dr-ian-harris/

  Partial anomalous pulmonary venous return refers to anomalies in which one or more (but not all) of the pulmonary veins connects to a location other than the left atrium. This causes left to right shunting which may have hemodynamic and therefore clinical significance, warranting repair in some patients. […] PAPVR refers to anomalies in which one or more (but not all) of the pulmonary veins connects to a location other than the left atrium. Often, this means one or more pulmonary veins empty into the right atrium or a systemic vein such as the superior vena cava or inferior vena cava. Physiologically, this produces a left-to-right shunt, allowing for already-oxygenated blood to recirculate into the lungs and result in excessive pulmonary blood flow. […] We know that the pulmonary veins originate from the posterior aspect of the left atrium. Meanwhile, the lung buds that arise from the lung parenchyma canalize as a vessel and gradually connect to the developing pulmonary veins.

• #3 What Is Partial Anomalous Pulmonary Venous Return?

  https://www.icliniq.com/articles/heart-circulatory-health/partial-anomalous-pulmonary-venous-return

  Partial anomalous pulmonary venous return (PAPVR), like other congenital cardiac anomalies, results from abnormal fetal cardiac development in the uterine. A joint pulmonary vein typically gives rise to four pulmonary veins during the early phases of gestation. These blood vessels form a link with the embryonic left atrium. However, alterations to this physiological mechanism lead to the connection in the pulmonary veins for the right atrium or adjacent veins. […] This phenomenon occurs due to the presence of one or more pulmonary veins that transport oxygenated blood to the right atrium instead of the left atrium.

• #4 Partial and Total Anomalous Pulmonary Venous Connection – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560707/

  Understanding the normal fetal heart and vasculature development is imperative to appreciate the diverse array of anatomic variations and abnormalities. […] Failure of the common pulmonary vein or atresia early in its development, while the persistent of the connections between systemic and pulmonary vasculature, leads to the development of TAPVC. If only a portion of the common pulmonary vein, either right or left, becomes atretic, persisting pulmonary-systemic venous connections form PAPVC. […] The most common form of PAPVC is where the left upper pulmonary vein drains into the left innominate vein to ultimately drain into the right atrium. Other forms of PAPVC include pulmonary veins draining into the SVC, coronary sinus, IVC, or azygos veins. […] This variant of PAPVC comprises a part of or the entire or part of the right lung being drained by right pulmonary veins that connect to the IVC.

• #5 Partial and Total Anomalous Pulmonary Venous Connection – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560707/

  They occur due to the absence of the wall separating the right-sided pulmonary vein from the superior vena cava leading to the mixing of oxygenated blood from the pulmonary vein into the systemic venous system. […] Leftward malposition of the septum primum, left to the orifices of right pulmonary veins, leads to their drainage into the right atrium, thereby leading to the anomalous pulmonary venous drainage. […] TAPVC implies that all the pulmonary veins connect to the systemic veins or right atrium, either by a common vertical vein or individually. […] In untreated patients, TAPVC is almost always fatal within the first few weeks of life.

• #6 Partial Anomalous Pulmonary Venous Connection: Background, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/897686-overview

  Partial anomalous pulmonary venous connection (PAPVC) is a congenital cardiac defect with no known cause and possibly has a multifactorial origin, including a genetic component. It is also seen with Turner syndrome. […] No causes of this condition are known. No evidence has implicated common teratogens (eg, drugs, infections) in the genesis of PAPVC. No evidence for a genetic predisposition has been reported.

• #7 Partial anomalous pulmonary venous return | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/partial-anomalous-pulmonary-venous-return

  Partial anomalous pulmonary venous return is a rare heart condition that’s present at birth. That means it is a congenital heart defect. […] The exact cause of partial anomalous pulmonary venous return (PAPVR) is not known. Most congenital heart defects happen as the unborn baby’s heart is forming before birth. An unborn baby also is called a fetus. […] Changes in the genes, some medicines or health conditions, and environmental factors may play a role. Lifestyle choices, such as smoking during pregnancy, also may increase the risk of congenital heart defects in the baby. […] What increases the risk of PAPVR is not well known. Possible risk factors for congenital heart defects may include: […] Changes in some genes have been linked to heart conditions at birth. For example, people with Down syndrome are often born with heart conditions. A child born with Turner syndrome also has an increased risk of PAPVR.

• #8 Anomalous Pulmonary Venous Return

  https://fpnotebook.com/CV/Peds/AnmlsPlmnryVnsRtrn.htm

  Partial Anomalous Pulmonary Venous Return or Connection (PAPVR) […] Turner Syndrome increases the risk of PAPVR.

• #9

  https://omim.org/entry/106700

  Total anomalous pulmonary venous return (TAPVR) is a cyanotic form of congenital heart defect in which the pulmonary veins fail to enter the left atrium and instead drain into the right atrium or one of the venous tributaries (summary by Bleyl et al., 1994). […] Chelius et al. (1962) described partial anomalous pulmonary venous return in 2 brothers whose maternal grandmother died at age 42 of congenital heart disease. […] Zhou et al. (2022) performed whole-exome sequencing in 144 Chinese patients with anomalous pulmonary venous return and 1,636 healthy Chinese controls and observed enrichment of potentially deleterious variants in genes highly expressed in the human heart at the critical time point for development of pulmonary veins draining into the left atrium. The authors suggested that PLXND1 represented a potentially important APVR-associated gene.

• #10 250. ACHD: Partial Anomalous Pulmonary Venous Return (PAPVR) with Dr. Ian Harris

  https://www.cardionerds.com/250-achd-partial-anomalous-pulmonary-venous-return-papvr-with-dr-ian-harris/

  Failure of one or more of the pulmonary veins to separate from the systemic venous systemic results in PAPVC/TAPVC. […] 80% of patients with PAPVR lesion may have an associated atrial level defect. In particular, a superior sinus venosus defect is frequently associated with right sided anomalous pulmonary venous connections. […] It is unusual for a single anomalous pulmonary venous connection of only 1 pulmonary lobe to result in a sufficient volume load to justify surgical repair. However, if a patient has symptoms referable to the shunt, there is 1 anomalous vein, and a moderate or large left-to-right shunt, then surgical repair is associated with a reduction in RV size and PA pressure. Pulmonary hypertension is a risk for adverse outcomes with surgery. […] A surgical correction is recommended for patients with PAPVR when functional capacity is impaired and RV enlargement is present, there is a net left-to-right shunt sufficiently large to cause physiological sequelae (aka: ratio of pulmonary flow (Qp) to systemic flow (Qs) is 1.5:1), PA systolic pressure is less than 50% systemic pressure and pulmonary venous resistance is less than one third of systemic venous resistance.

• #11 Partial anomalous pulmonary venous return – PubMed

  https://pubmed.ncbi.nlm.nih.gov/18595412/

  Partial anomalous pulmonary venous return (PAPVR) is an uncommon congenital abnormality that occurs in 0.4 to 0.7% of postmortem examinations. Ninety percent of these anomalies are associated with an atrial septal defect. Partial anomalous pulmonary venous return occurs more commonly on the right than the left and is manifested by abnormal return of the pulmonary veins to the central venous circulation. […] Most patients are asymptomatic, but when symptoms are present they are due to shunting of oxygenated blood to the venous circulation.

• #12 Partial anomalous pulmonary venous return | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/partial-anomalous-pulmonary-venous-return?lang=us

  Partial anomalous pulmonary venous return (PAPVR), also known as partial anomalous pulmonary venous connection (PAPVC), is a rare congenital cardiovascular condition in which some of the pulmonary veins, but not all, drain into the right heart or systemic venous system, rather than in the left atrium. […] Left-sided PAPVR has been reported to be found more often in adults, whereas right-sided PAPVR is reported more commonly in children. […] In ~40% of patients with right-sided PAPVR, an atrial septal defect is seen. […] More rarely it is seen with ostium primum defect, a subtype of atrioventricular defects.

• #13 Partial and Total Anomalous Pulmonary Venous Connections | Radiology Key

  https://radiologykey.com/partial-and-total-anomalous-pulmonary-venous-connections/

  Partial anomalous drainage of a right pulmonary vein to superior or inferior vena cava is associated with a sinus venosus atrial septal defect. […] Partial anomalous drainage of a right pulmonary vein to right atrium can also be associated with a secundum atrial septal defect. […] Partial anomalous drainage of a left pulmonary vein(s) is usually into the left innominate vein or coronary sinus and often associated with a secundum atrial septal defect. […] Partial anomalous drainage is common in left isomerism. […] Total anomalous pulmonary venous connection is associated with visceral heterotaxies, most commonly right isomerism.

• #14 Partial Anomalous Pulmonary Venous Return | Pediatric Radiology Reference Article | Pediatric Imaging | @pedsimaging

  https://pediatricimaging.org/diseases/partial-anomalous-pulmonary-venous-return/

  Etiology: Congenital Most common form is anomalous drainage of right superior pulmonary vein into superior vena cava which is often associated with superior sinus venosus atrial septal defect One form is Scimitar syndrome which is right sided with pulmonary veins (forming scimitar vein) draining typically to inferior vena cava or inferior vena cava-right atrium junction with hypoplasia of right lung and right pulmonary artery […] Clinical: Causes left to right shunt

• #15 Scimitar Syndrome: Causes, Symptoms and Treatment

  https://my.clevelandclinic.org/health/diseases/22747-scimitar-syndrome

  Scimitar syndrome is a congenital (present at birth) heart defect. Its a type of partial anomalous pulmonary venous return (PAPVR). […] Often, experts dont know exactly what causes scimitar syndrome. Some factors can increase the risks that your baby will have a congenital heart defect. These risks include: Genetics. Medications like the acne medicine isotretinoin (Accutane). Environmental factors like smoking or drinking alcohol during pregnancy. […] Many people with scimitar syndrome have other cardiovascular problems. Some are born with multiple heart conditions. Or scimitar syndrome may lead to other complications.

• #16 Partial anomalous pulmonary venous return | Beacon Health System

  https://www.beaconhealthsystem.org/library/diseases-and-conditions/partial-anomalous-pulmonary-venous-return?content_id=CON-20359714

  In partial anomalous pulmonary venous return, some of the pulmonary veins incorrectly send blood to the heart’s upper right chamber. That chamber is called the right atrium. Partial anomalous pulmonary venous return is a rare heart condition that’s present at birth. The exact cause of partial anomalous pulmonary venous return (PAPVR) is not known. Most congenital heart defects happen as the unborn baby’s heart is forming before birth. Changes in the genes, some medicines or health conditions, and environmental factors may play a role. Lifestyle choices, such as smoking during pregnancy, also may increase the risk of congenital heart defects in the baby. […] What increases the risk of PAPVR is not well known. Possible risk factors for congenital heart defects may include: Diabetes. Having type 1 or type 2 diabetes during pregnancy may change how the unborn baby’s heart forms. Genetics. Changes in some genes have been linked to heart conditions at birth. For example, people with Down syndrome are often born with heart conditions. A child born with Turner syndrome also has an increased risk of PAPVR. Rubella, also called German measles. Having rubella during pregnancy can cause changes in an unborn baby’s heart. Some medicines. Some medicines taken during pregnancy may increase the risk of some congenital heart conditions. Smoking. If you smoke, quit. Smoking during pregnancy or being around cigarette smoke increases the risk of some congenital heart conditions. Alcohol use. Drinking alcohol during pregnancy may increase the risk of heart conditions in the baby.

• #17 Partial anomalous pulmonary venous return – Augusta HealthSearchClose SearchSearch IconSearch IconClose Search IconMobile Menu IconMobile Menu Close IconInstagramFacebookTwitterYoutube

  https://www.augustahealth.com/disease/partial-anomalous-pulmonary-venous-return/

  Partial anomalous pulmonary venous return (PAPVR) is a rare heart defect that’s present at birth (congenital heart defect). This condition may also be called partial anomalous pulmonary venous connection (PAPVC). […] In PAPVR, an abnormal connection of veins sends blood into other blood vessels and into the upper right heart chamber (right atrium), where it mixes with oxygen-poor blood. […] A child born with Turner syndrome has an increased risk of PAPVR.

• #18 Partial anomalous pulmonary venous return // Middlesex Health

  https://middlesexhealth.org/learning-center/diseases-and-conditions/partial-anomalous-pulmonary-venous-return

  Partial anomalous pulmonary venous return is a rare heart problem that’s present at birth. That means it is a congenital heart defect. […] In PAPVR, blood flows from the lungs into the upper right heart chamber, called the right atrium. Extra blood flows to the right side of the heart. This may cause swelling of the right heart chambers. […] A child born with Turner syndrome has an increased risk of PAPVR. […] In partial anomalous pulmonary venous return, some of the pulmonary veins incorrectly send blood to the heart’s upper right chamber. That chamber is called the right atrium.

• #19 Partial anomalous pulmonary venous return | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/partial-anomalous-pulmonary-venous-return

  Some medicines taken during pregnancy may increase the risk of some congenital heart conditions. These include lithium (Lithobid) for bipolar disorder and isotretinoin (Claravis, Myorisan, others), which is used to treat acne. […] Smoking during pregnancy or being around cigarette smoke increases the risk of some congenital heart conditions. […] Drinking alcohol during pregnancy may increase the risk of heart conditions in the baby.

• #20 Total anomalous pulmonary venous return (TAPVR) – Overview – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/total-anomalous-pulmonary-venous-return/cdc-20385613

  Most congenital heart defects are caused by changes that happen early as the unborn baby’s heart is developing before birth. The exact cause of most congenital heart defects, including total anomalous pulmonary venous return (TAPVR), is not known. […] Changes in the genes, some medicines or health conditions, and environmental or lifestyle factors, such as smoking, may play a role. […] Possible risk factors for congenital heart defects, including total anomalous pulmonary venous return (TAPVR), may include: […] Genetics. Although TAPVR doesn’t usually run in families, changes in genes have been linked to heart conditions at birth. For example, people with Down syndrome are often born with heart conditions. […] Some medicines. Some medicines taken during pregnancy may increase the risk of congenital heart defects. These include lithium (Lithobid) for bipolar disorder and isotretinoin (Claravis, Myorisan, others), which is used to treat acne. Talk to your healthcare team about the medicines you take.

• #21 Anomalous pulmonary venous drainage: a pictorial essay with a CT focus | Journal of Congenital Cardiology | Full Text

  https://jcongenitalcardiology.biomedcentral.com/articles/10.1186/s40949-017-0008-4

  Partial anomalous pulmonary venous drainage (PAPVD) describes the connection of at least one pulmonary vein, but not all, to the systemic venous system or right atrium (RA). Drainage of all pulmonary veins outside the left atrium is termed total anomalous pulmonary venous drainage (TAPVD). […] The prevalence of PAPVD has been reported to be between 0.4-0.7%. It is more common on the right and results in the formation of a left-to-right shunt. […] Right-sided anomalous drainage may occur into any of the central veins. The most common form of PAPVD is the anomalous drainage of the RSPV into the superior vena cava (SVC). […] Up to 18.2% of PAPVD cases affect the left-sided pulmonary veins. The commonest pattern on the left is the LSPV connected to the left brachiocephalic vein. […] Careful scrutiny of the pulmonary veins is important and the identification of less than four pulmonary veins connected to the left atrium should alert the reader to a diagnosis of PAPVD.

• #22 Case Study: Partial Anomalous Pulmonary Venous Return Of The Right Upper Pulmonary Vein Into The Cephalic Portion Of The SVC Causing A Left-To-Right Shunt In 56-Year-Old Asian Female

  https://www.acquaintpublications.com/article/case_study_partial_anomalous_pulmonary_venous_return_of_the_right_upper_pulmonary_vein_into_the_cephalic_portion_of_the_svc_causing_a_left_to_right_shunt_in_56_year_old_asian_female

  Partial Anomalous Pulmonary Venous Return (PAPVR) is a disease that is often asymptomatic in children and may not present until later in adulthood either symptomatically, or as an incidental finding on radiology or autopsy. […] The most common presentation of PAPVR involves the right upper pulmonary vein as it drains into the junction of the superior vena cava (SVC) and right atrium creating a left-to-right shunt which results in freshly oxygenated blood from the lungs being returned to, and mixed with, deoxygenated systemic blood in the right atrium. […] In most cases of PAPVR, the right upper pulmonary vein abnormally drains into the junction of the superior vena cava (SVC) and right atrium, creating a left-to-right shunt. […] There is almost always an associated Atrial Septal Defect (ASD) present in PAPVR.

• #23 Partial anomalous pulmonary venous return, the neglected congeni

  https://www.openaccessjournals.com/articles/partial-anomalous-pulmonary-venous-return-the–neglected-congenital-malformation-catheterization–assisted-echocardiography-16598.html

  Partial Anomalous Pulmonary Venous Return (PAPVR) is a rare congenital heart disease that can lead to major complications in adulthood, such as Pulmonary Arterial Hypertension (PAH). […] This cardiac defect causes a left-to-right shunt at the pre-tricuspid level, resulting in volume overload in the right ventricle and pulmonary vasculature. […] Over time, this can lead to endothelial remodeling of the pulmonary arteries and increased pulmonary vascular resistance, characteristic of Pulmonary Arterial Hypertension (PAH). […] If the defect is not corrected, the consequences can be dramatic, such as right heart failure, equalization of left and right pressures, or even reversal of the shunt characteristic of Eisenmenger syndrome. […] PAPVR is therefore a disease that seems to be poorly known by the medical professionals even though its prevalence is similar to the atrial septal defects (0.2%) and the consequences can be dramatic, particularly if patients develop PAH, or even its extreme form: Eisenmenger syndrome.

• #24 Unusual presentation of a patient with partial anomalous pulmonary venous connections without a septal defect: a case report and literature review | International Journal of Emergency Medicine | Full Text

  https://intjem.biomedcentral.com/articles/10.1186/s12245-025-00809-3

  The presentation of PAPVC is considerably nonspecific and depends on the magnitude of the intracardiac shunt and the anomalous drainage of the PV. Therefore, diagnosis is not straightforward and requires a thorough evaluation using multimodal imaging. […] However, regardless of the type of PAPVC, it causes left-to-right shunts in pre-tricuspid level, which result in recirculation of the oxygenated blood into the pulmonary circulation, increased pulmonary blood flow, and increased volume load on the right heart. […] The management of PAPVC depends on clinical findings, hemodynamic characteristics, and anatomical features. Therapeutic options include (1) follow-up, (2) medical management, (3) surgical treatment, and (4) transcatheter interventional procedures. […] Corrective intervention is indicated in the following situations: the presence of significant symptoms related to this anomaly, a significant left-to-right shunt indicated by a Qp/Qs ratio greater than 2, or imaging evidence showing right ventricular (RV) dilation or RV volume overload.

• #25 Anomalous pulmonary venous drainage: a pictorial essay with a CT focus | Journal of Congenital Cardiology | Full Text

  https://jcongenitalcardiology.biomedcentral.com/articles/10.1186/s40949-017-0008-4

  The magnitude of the left-to-right shunt is dependent on the number of PAPVD. In a series looking at single PAPVD, the shunt is modest (Qp:Qs ~ 1.3-1.6) associated with mild dilatation of the right ventricle. […] APVD is one of the treatable causes of pulmonary hypertension in adults. […] Congenital cardiac and thoracic anomalies, for example thoracic hypoplasia and cardiac dextro/levoversion may also occur, the presence of which should prompt examination of the pulmonary venous anatomy. […] This rare condition refers to failure of incorporation of normal pulmonary veins into the left atrium and accounts for up to 0.1% of congenital heart disease.

• #26 Case Study: Partial Anomalous Pulmonary Venous Return Of The Right Upper Pulmonary Vein Into The Cephalic Portion Of The SVC Causing A Left-To-Right Shunt In 56-Year-Old Asian Female

  https://acquaintpublications.com/article/case_study_partial_anomalous_pulmonary_venous_return_of_the_right_upper_pulmonary_vein_into_the_cephalic_portion_of_the_svc_causing_a_left_to_right_shunt_in_56_year_old_asian_female

  The estimated overall incidence of PAPVR is 0.5 % while a slightly higher incidence of 0.7 % is reported by autopsies. […] To further understand the etiology of PAPVR, the embryological development of the SVC must also be understood. […] The SVC is derived from the proximal portion of the right anterior cardinal vein and the right common cardinal vein at a point that is caudal to the transverse anastomosis within the embryo. […] Because of the left-to-right shunt that is established by PAPVR, a significant enough unrepaired shunt can result in pulmonary vascular remodelling that leads to the development of Pulmonary Artery Hypertension (PAH). […] The cause of PAH and right ventricular hypertrophy is the result of an increase in blood volume being introduced to the right side of the heart, resulting in right-sided volume overload and leading to PAH and ventricular hypertrophy.

• #27 Partial anomalous pulmonary venous return, the neglected congeni

  https://www.openaccessjournals.com/articles/partial-anomalous-pulmonary-venous-return-the–neglected-congenital-malformation-catheterization–assisted-echocardiography-16598.html

  There is therefore a real need to raise awareness of this congenital malformation and its consequences. […] In our recent study, we showed that the Qp/Qs ratio was the only predictor of PAH in PAPVR population. […] Therefore, an assessment of the shunt by an accurate measurement of the Qp/Qs ratio is essential. […] Currently, the gold standard method for PAH diagnosis and Qp/Qs measurement is RHC. […] The underestimation of the Qp/Qs ratio by echocardiography and the lack of correlation and concordance with the reference method, especially for the largest shunts, limit the clinician in his therapeutic decision making, i.e. the surgical correction of the patient. […] PAPVR is a rare congenital heart disease that unfortunately remains neglected and poorly managed to date, both in terms of medical follow-up after diagnosis and screening for complications Pulmonary Arterial Hypertension (PAH) and risk factors for developing PAH.

• #28 Congenital Defects Tutorial – Congenital Heart Defects | Atlas of Human Cardiac Anatomy

  https://www.vhlab.umn.edu/atlas/congenital-defects-tutorial/anomalies-of-arteries-and-veins/anomalous-pulmonary-venous-connection.shtml

  Partial anomalous pulmonary venous return is characterized by at least one but not all pulmonary veins connecting anomalously to the right heart, commonly into the superior vena cava. This defect often occurs together with an ASD and lung abnormalities. […] Patients with partial anomalous pulmonary venous return are usually asymptomatic. The greater the number of pulmonary veins successfully returning to the right side, the more severe are the presenting symptoms. […] The anomalous pulmonary venous system may have varying levels of obstruction due to compression by adjacent structures, which leads to pulmonary hypertension. Obstruction is typically severe in Type III, as the diaphragm can significantly compress the pulmonary venous structures.

• #29 Partners in Care | Atrial Septal Defect With Partial Anomalous…

  https://partnersincare.health/conditions/atrial-septal-defect-with-partial-anomalous-pulmonary-venous-return

  An atrial septal defect (ASD) and partial anomalous pulmonary venous return (PAPVR) are two congenital heart defects that commonly occur together. […] Partial anomalous pulmonary venous return (PAPVR) occurs when one or more of the veins drain to an abnormal location on the right side of the heart. […] Treatment of ASD with PAPVR requires open-heart surgery to close the hole inside the heart and to reroute the anomalous pulmonary vein connection over to the left atrium.

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