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).