Resection and a rare type of reconstruction of the superior vena cava with the left brachiocephalic vein

Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

Persistant Left Superior Vena Cava with and Without Right Superior Vena Cava: Significance of Prenatal Diagnosis

This study aims to define the associated anomalies with PLSVC, and to compare single PLSVC and bilateral superior vena cava in terms of accompanying anomalies and pregnancy outcomes. This was a retrospective study of the fetuses diagnosed with single and/or bilateral SVC at a tertiary fetal medicine center during 8 years. We detected 16 cases of single PLSVC and 84 cases of bilateral SVC. We found an association between the PLSVC and cardiac and extracardiac anomalies. Comparison between single PLSVC and BSVC cases revealed significant differences in the occurrence of heterotaxy and right isomerism. The study highlights the importance of prenatal diagnosis in PLSVC cases. Isolated PLSVC with situs solitus may be considered a benign finding, but larger studies are needed to understand the clinical implications of PLSVC in relation to chromosomal anomalies. Routine screening protocols should include three-vessel and trachea views to detect PLSVC.

Highly accelerated, Dixon-based non-contrast MR angiography versus high-pitch CT angiography

OBJECTIVES

To compare a novel, non-contrast, flow-independent, 3D isotropic magnetic resonance angiography (MRA) sequence that combines respiration compensation, electrocardiogram (ECG)-triggering, undersampling, and Dixon water-fat separation with an ECG-triggered aortic high-pitch computed tomography angiography (CTA) of the aorta.

MATERIALS AND METHODS

Twenty-five patients with recent CTA were scheduled for non-contrast MRA on a 3 T MRI. Aortic diameters and cross-sectional areas were measured on MRA and CTA using semiautomatic measurement tools at 11 aortic levels. Image quality was assessed independently by two radiologists on predefined aortic levels, including myocardium, proximal aortic branches, pulmonary veins and arteries, and the inferior (IVC) and superior vena cava (SVC). Image quality was assessed on a 5-point Likert scale.

RESULTS

All datasets showed diagnostic image quality. Visual grading was similar for MRA and CTA regarding overall image quality (0.71), systemic arterial image quality (p = 0.07-0.91) and pulmonary artery image quality (p = 0.05). Both readers favored MRA for SVC and IVC, while CTA was preferred for pulmonary veins (all p < 0.05). No significant difference was observed in aortic diameters or cross-sectional areas between native MRA and contrast-enhanced CTA (p = 0.08-0.94).

CONCLUSION

The proposed non-contrast MRA enables robust imaging of the aorta, its proximal branches and the pulmonary arteries and great veins with image quality and aortic diameters and cross-sectional areas comparable to that of CTA. Moreover, this technique represents a suitable free-breathing alternative, without the use of contrast agents or ionizing radiation. Therefore, it is especially suitable for patients requiring repetitive imaging.

Increased Pulmonary-Aortic Interspace in Fetal Right Aortic Arch: A Matched Case-Control Study

INTRODUCTION

The prenatal detection rate of a right aortic arch (RAA) has increased with the implementation of the three-vessel view (3VV) to the second-trimester anomaly scan formed by the pulmonary artery (PA), aorta (Ao), and superior vena cava (SVC). We examined the value of measuring the distance between PA and Ao in the 3VV in cases with an RAA.

METHODS

We conducted a case-control study in which fetuses with an isolated RAA were matched to 3 healthy controls. Using 3VV images, the distances between PA, Ao, and SVC were measured and the ratio between PA to Ao (PAAo) distance and Ao to SVC (AoSVC) distance was calculated.

RESULTS

Fifty-four RAA cases and 162 matched controls were included. The mean absolute distance PAAo was 3.1 mm in cases and 1.8 mm in controls (p < 0.001), and the mean PAAo/AoSVC ratio was 2.9 and 1.4, respectively (p < 0.001). The ROC curve of PAAo/AoSVC ratio showed a cut-off point of 1.9 with sensitivity and specificity over 87% for the diagnosis of RAA.

CONCLUSIONS

The pulmonary-aortic interspace and the PAAo/AoSVC ratio were significantly larger for RAA cases as compared to controls. If an increased pulmonary-aortic interspace is observed, a PAAo/AoSVC of ≥1.9 can be helpful in the diagnosis of an RAA.

Absent Superior Vena Cava: An Uncommon Cause of Anomalous Systemic Venous Return

We report a case of a one-year-old boy with tetralogy of Fallot, who was preoperatively diagnosed to have an associated systemic venous anomaly. Computed tomography confirmed the absent superior vena cava, and the case was managed with an appropriate cannulation strategy. Preoperative diagnosis and thorough planning of this rather benign anomaly were imperative for the successful outcome of this case. Clinical and surgical implications of this anomaly are discussed in this report.

Safety and efficacy of catheter ablation of para-Hisian accessory pathway via a direct superior vena cava approach: A multicenter study

BACKGROUND

Radiofrequency (RF) catheter ablation of para-Hisian accessory pathways (APs) can be challenging due to proximity to the conduction system.

METHODS

A total of 30 consecutive patients with para-Hisian AP were enrolled for ablation in three centers, 12 (40%) of whom had previously failed attempted ablation from the inferior vena cava (IVC) approach. Ablation was preferentially performed using a superior approach from the superior vena cava (SVC) in all patients.

RESULTS

The para-Hisian AP was eliminated from the SVC approach in 28 of 30 (93.3%) patients. In the remaining two patients, additional ablation from IVC was required to successfully eliminate the AP. There were two patients experienced reversible complete atrial-ventricular block and PR prolongation during the first RF application. Long-term freedom from recurrent arrhythmia was achieved in 29 (96.7%) patients over a mean follow-up duration of 15.6 ± 4.6 months.

CONCLUSION

Catheter ablation of para-Hisian AP from above using a direct SVC approach is both safe and effective, and should be considered especially in patients who have failed conventional ablation attempts from IVC approach.

Bidirectional Glenn operation without cardiopulmonary bypass: Single center experience and results

BACKGROUND

The bidirectional Glenn (BDG) shunt operation serves as temporary surgery for the treatment of single-ventricle physiology with the eventual Fontan procedure. In some cases, the procedure can be performed without the support of a cardiopulmonary bypass (CPB) machine. In this study, we present the surgical outcomes of off-pump BDG operation with the use of a temporary veno-atrial shunt to decompress the superior vena cava (SVC) during clamping time.

METHODS

A cohort of 23 patients underwent off-pump BDG operations at Cardiovascular Center, E Hospital. All patients were operated on using a veno-atrial shunt to decompress the SVC.

RESULTS

Satisfactory results with mean oxygen saturation increased from 79.6 ± 11.2% to 87.2 ± 4.7%. The SVC clamping time was 14 ± 2.4 min (ranging from 12 to 21 min). Among 23 patients, only six patients required blood transfusion, 17 patients had BDG without blood transfusion. No neurological complications or deaths occurred after the surgery, and the post-operative period was uneventful.

CONCLUSIONS

The use of veno-atrial shunts to decompress SVC during off-pump BDG operation is safe with good surgical outcomes and can avoid the deleterious effects caused by CPB. It is easily reproducible, at low cost and economically effective.

Application of Electrocardiogram Localization during Peripherally Inserted Central Catheter Line Insertion into the Persistent Left Superior Vena Cava of Neonates

BACKGROUND

 Most neonates with persistent left superior vena cava (PLSVC) have no clinical symptoms or hemodynamic changes, and this anomaly is only found during cardiac catheterization, pacemaker implantation, or central venous catheterization. Electrocardiogram (ECG) localization is helpful for the application of the peripherally inserted central catheter (PICC) technique in neonates with PLSVC.

OBJECTIVE

 To explore the characteristic waveforms of the P wave when a PICC under ECG localization is applied in neonates with PLSVC.

STUDY DESIGN

 The observation and management strategies for the P wave changes during catheter insertion (CI) of two neonates with PLSVC admitted to our institution between January and July 2020, who underwent PICC line insertion, were summarized.

RESULTS

 The characteristic P wave changes in two children with a PICC line inserted via the PLSVC were observed. When a wide inverted P wave appeared on ECG, the catheter was immediately withdrawn by 0.5 cm, a bidirectional P wave gradually appeared and then disappeared. After that, the catheter was further withdrawn by 0.5 cm. After catheterization, the optimal position of the PICC was confirmed by X-ray photography and bedside B-ultrasound. The PICC line was removed as scheduled after indwelling for 18 and 29 days, respectively, in the two cases, and no PICC-related complications occurred during indwelling.

CONCLUSION

 The characteristic P wave changes on ECG during CI provide important clinical reference values for the application of the PICC technique under ECG localization in neonates with PLSVC.

KEY POINTS

· Electrocardiogram localization.. · Peripherally inserted central catheter.. · Persistent left superior vena cava..

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the "hyperechoic triangle" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

Diagnostic Value of Contrast-Enhanced Ultrasonography for Catheter-Related Right Brachiocephalic Vein and Superior Vena Cava Lesions in Patients Undergoing Hemodialysis-A Pilot Study

OBJECTIVES

To evaluate the diagnostic efficacy of contrast-enhanced ultrasonography (CEUS) for detecting catheter-related right brachiocephalic vein (RBV) and superior vena cava (SVC) obstructions in patients undergoing hemodialysis (HD).

METHODS

From June 1, 2021 to December 31, 2022, we enrolled 80 patients undergoing HD who had used or were using a central venous catheter as vascular access. We evaluated the diagnostic efficacy of conventional ultrasonography and CEUS for identifying RBV and SVC obstructions and compared them with that of digital subtraction angiography (DSA). In the stratified analysis, the SVC was divided into the upper and lower segments. In total, we analyzed 240 central venous segments, including the RBV.

RESULTS

Among the RBV and SVC visualized by DSA, conventional ultrasonography and CEUS could visualize 67.92 and 100% of the vein segments, respectively; however, the lengths and diameters of the RBV and SVC were smaller than those recorded with DSA (P < .001). The diagnostic efficacy of CEUS for detecting catheter-related central venous obstruction was better than that of conventional ultrasonography, with a higher sensitivity (83.95 vs 41.98%), specificity (89.94 vs 53.46%), accuracy (87.92 vs 49.58%), and F1 score (82.42 vs 49.64%). CEUS showed good agreement (κ = 0.732) with DSA. In the stratified analyses, CEUS also showed higher sensitivity (83.93, 83.33, and 84.62%, respectively) and better agreement with DSA (κ = 0.635, 0.655, and 0.673, respectively) than conventional ultrasonography for detecting the RBV and the upper and lower segments of the SVC.

CONCLUSIONS

CEUS had high sensitivity and specificity in diagnosing catheter-related RBV and SVC obstructions.

A Novel Technique of Placing Desfibrillator Leads in Patients with Persistent Left Superior Vena Cava

Persistent left superior vena cava is the most common thoracic venous anomaly. It is usually asymptomatic, but it can make implanting intracardiac devices difficult.We present a novel technique to facilitate desfibrillator lead implantation in patients with persistent left superior vena cava and the absence of the right superior vena cava. We used a fixed-curve Selectra 3D 65-42 cm sheath (Biotronik), orienting it toward the tricuspid valve (TV) by rotating it counter-clockwise. During follow-up, the electrodes remained stable.Our technique was safe, simple, and feasible for patients with this complex venous anatomy.

Transcatheter Closure of Superior Sinus Venosus Defects

Superior sinus venosus defect is a communication between the right and left atrium located above the upper margin of the oval fossa, immediately inferior to the junction of the superior vena cava and the right atrium. It is systematically associated with partial anomalous pulmonary venous drainage, especially of the right upper pulmonary vein. Surgical repair has been the gold standard approach to close that defect. Introduced in 2014, percutaneous closure has gradually become a safe and effective alternative to surgery in carefully selected patients, although worldwide experience remains limited. This article provides an appraisal of the patients' selection process and a step-by-step description of the procedure as well as a comprehensive review of its outcomes.

Evaluation of Inferior and Superior Vena Cava and the Vena Cava Ratio in Growth Restricted Fetuses

OBJECTIVE

To evaluate the changes in the diameters of superior vena cava (SVC) and inferior vena cava (IVC) and to measure the ratio between SVC and IVC in growth-restricted fetuses and compare these results with normally grown fetuses.

METHODS

Twenty-three consecutive patients with fetal growth restriction (FGR) (Group I) and 23 pregnant gestational age-matched controls (Group II) between 24 and 37 weeks of gestation were enrolled in the study between January 2018 and October 2018. The diameter of the SVC and IVC from inner wall to inner wall was measured in all patients by sonographic examination. The ratio between the diameter of the SVC and IVC was also measured in each patient to eliminate the gestational age factor. We have named this ratio the "vena cava ratio" (VCR). All parameters were compared between the two groups.

RESULTS

The diameter of the SVC was significantly greater in the fetuses with FGR (2.6-7.7 [5.4]) than in controls (3.2-5.6 [4.1]; P = .002; P < .01). The diameter of the IVC was significantly less in the fetuses with FGR (1.6-4.5 [3.2]) than in controls (2.7-5 [3.7]; P = .035; P < .05). The VCR was between 1.1 and 2.3 and the median value was 1.8 in Group I. The VCR was between 0.8 and 1.7 and the median value was 1.2. VCR was significantly higher in fetuses with FGR (P = .001 P < .01).

CONCLUSION

This study shows that VCR is higher in fetuses with growth restriction. Further studies are needed to clarify the association between VCR and antenatal prognosis and postnatal results.

Absent right superior vena cava and persistent left superior vena cava: An incidental finding

A patient with Marfan syndrome undergoing Bentall operation was found to have an absent right superior vena cava and persistent left superior vena cava. The dilation of coronary sinus raised the suspicion of persistent left superior vena cava. The diagnosis was confirmed by agitated saline contrast echocardiography and computed tomography of the chest.

Giant right atrial aneurysm associated with persistent left cranial vena cava in a cat

A 10-month-old female spayed Scottish Fold was referred to cardiology for incidental radiographic cardiomegaly. Echocardiography was suspicious for a right atrial or right auricular aneurysm. The differential diagnosis also included peritoneal-pericardial diaphragmatic hernia, mass lesion (cyst, granuloma, or neoplasia), or cardiac malformation. A giant right atrial aneurysm associated with a persistent left cranial vena cava was subsequently confirmed with computed tomography.

Persistent left superior vena cava without right superior vena cava during fetal life

Enlarged coronary sinus detected during cardiac examination in the prenatal period is the first finding that raises suspicion for persistent left superior vena cava. In this report, a patient was presented who was referred with the prediagnosis of cor triatriatum sinister in the antenatal period and diagnosed with isolated persistent left superior vena cava (SVC).