Left superior vena cava in pediatric cardiology associated with extra-cardiac anomalies

Congenital Heart Defects in Patients with Anorectal Malformations: A Retrospective Cohort Study of 281 Patients

In patients born with anorectal malformations (ARM), additional congenital heart defects (CHD) can occur. We aimed to provide an overview on disease and treatment details of CHD identified in patients born with ARM, from a unique large cohort of a very rare disease. We performed a retrospective single-center cohort study between January 2000 and July 2023. All consecutive patients with ARM were included. Outcomes were the number of patients with CHD, and screening percentage and percentage of patients diagnosed with CHD over 3 time periods (2000-2006, 2007-2014, 2015-2023). We used uni- and multi-variable logistic regression analyses to search for associations between CHD present and baseline characteristics. In total, 281 patients were included. Some 241 (85.8%) underwent echocardiography, of whom 80 (33.2%) had CHD. Screening percentage with echocardiography increased (74.1% vs. 85.7% vs. 95.9%, p < 0.001) and percentage of patients diagnosed with CHD remained similar over time (30.2% vs. 34.5% vs. 34.0%, p = 0.836). Atrial and ventricular septal defects (n = 36, n = 29), and persistent left superior vena cava (n = 17) were most identified. The presence of VACTERL-association or a genetic syndrome was independently associated with the presence of CHD. CHD were present in 33% of patients with ARM that underwent echocardiography. Over time, the number of CHD identified through screening remained similar. Patients with the presence of VACTERL-association or a genetic syndrome had a higher risk of having CHD. Therefore, acknowledging the potential presence of CHD in patients with ARM remains important.

Association of Prenatally Diagnosed Isolated Single Left Superior Vena Cava and Postnatal Development of Coarctation of the Aorta

To report the prevalence of coarctation of the aorta (CoA) in fetuses with single left superior vena cava (SL-SVC) and to evaluate changes in echocardiographic measurements. Additionally, to report the prevalence of associated malformations. Retrospective observational study of fetuses diagnosed with SL-SVC between 2012 and 2021 at a tertiary fetal cardiology unit. In fetuses without intracardiac abnormalities, Z-scores of the ventricles, great arteries, and Doppler flow patterns are reported. We identified 47 fetuses with SL-SVC of which 8/47 (17%) had abnormal intracardiac anatomy. One fetus was lost to follow-up. Of those with normal intracardiac anatomy and postnatal follow-up (38), karyotype abnormalities were confirmed in 2/38 (5%) and ECA in 8/38 (21%). 33/38 were live-born. None developed CoA postnatally. Paired analysis of Z-scores between early and late scans of 24 fetuses showed that diameters of the right heart structures and Doppler flows of tricuspid valve increased significantly during pregnancy, while the left heart structures and flow patterns did not change. The median risk of CoA did not change between the early and the late scan. We did not observe CoA in this cohort. A degree of ventricular asymmetry was present, but this was due to right heart dominance rather than hypoplasia of left heart structures. This likely reflects redistribution of blood and does not appear to confer increased risk of CoA. Predictive models of the postnatal development of CoA which set the dimensions of right and left heart structures in relation might not be applicable in this situation.

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.

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).

Morphologic classification of tracheobronchial arborization in children with congenital tracheobronchial stenosis and the associated cardiovascular defects

Background

We sought to classify patients with congenital tracheal stenosis (CTS) according to tracheobronchial morphology and determine anatomic features associated with tracheobronchial anomalies (TBAs) and concurrent cardiovascular defects (CVDs).

Methods

We enrolled 254 patients who underwent tracheoplasty between November 1, 2009 and December 30, 2018. The anatomic features of the tracheobronchial tree and cardiovascular system were abstracted from bronchoscopy, echocardiography, computerized tomography, and operative reports.

Results

Four types of tracheobronchial morphology were identified: Type-1, which included normal tracheobronchial arborization (Type-1A, n = 29) and tracheal bronchus (Type-1B, n = 22); Type-2 (tracheal trifurcation; n = 49), and Type-3 (typical bridging bronchus; n = 47). Type-4 (bronchus with an untypical bridging pattern) was divided into Type-4A (involving bronchial diverticulum; n = 52) and Type-4B (absent bronchus; n = 55). Carinal compression and tracheomalacia were significantly more frequent in Type-4 patients than in the other patients (P < 0.01). CVDs were common in patients with CTS, especially in patients with Type-3 and Type-4 (P < 0.01). Persistent left superior vena cava was most common among patients with Type-3 (P < 0.01), and pulmonary artery sling was most frequent among those with Type-4 (P < 0.01). Outflow tract defects were most likely to occur in Type-1B. Early mortality was detected in 12.2% of all patients, and young age (P = 0.02), operation in the early era (P < 0.01), and bronchial stenosis (P = 0.03) were proven to be risk factors.

Conclusions

We demonstrated a useful morphological classification for CTS. Bridging bronchus was most closely linked with vascular anomalies, while tracheal bronchus was frequently associated with outflow tract defects. These results may provide a clue to CTS pathogenesis.

Diagnostic Value of Chromosomal Microarray Analysis for Fetal Congenital Heart Defects with Different Cardiac Phenotypes and Extracardiac Abnormalities

(1) Background: The objective of this study was to investigate the diagnostic value of chromosomal microarray analysis (CMA) for congenital heart defects (CHDs) with different cardiac phenotypes and extracardiac abnormalities (ECAs) and to explore the pathogenic genetic factors of CHDs. (2) Methods: We collected fetuses diagnosed with CHDs by echocardiography at our hospital from January 2012 to December 2021. We analyzed the CMA results of 427 fetuses with CHDs. We then categorized the CHD into different groups according to two dimensions: different cardiac phenotypes and whether it was combined with ECAs. The correlation between the numerical chromosomal abnormalities (NCAs) and copy number variations (CNVs) with CHDs was analyzed. Statistical analyses, including Chi-square tests and t-tests, were performed on the data using IBM SPSS and GraphPad Prism. (3) Results: In general, CHDs with ECAs increased the detection rate for CA, especially the conotruncal defects. CHD combined with the thoracic and abdominal walls and skeletal, thymic and multiple ECAs, were more likely to exhibit CA. Among the CHD phenotypes, VSD and AVSD were associated with NCA, while DORV may be associated with NCA. The cardiac phenotypes associated with pCNVs were IAA (type A and B), RAA, TAPVC, CoA and TOF. In addition, IAA, B, RAA, PS, CoA and TOF were also associated with 22q11.2DS. The length distribution of the CNV was not significantly different between each CHD phenotype. We detected twelve CNV syndromes, of which six syndromes may be related to CHDs. The pregnancy outcome in this study suggests that termination of pregnancy with fetal VSD and vascular abnormality is more dependent on genetic diagnosis, whereas the outcome in other phenotypes of CHDs may be associated with other additional factors. (4) Conclusions: CMA examination for CHDs is still necessary. We should identify the existence of fetal ECAs and specific cardiac phenotypes, which are helpful for genetic counseling and prenatal diagnosis.

Single left superior vena cava: antenatal diagnosis, associated anomalies and outcomes

OBJECTIVES

To describe the associated cardiac and extracardiac findings and estimate the prevalence of single left superior vena cava (LSVC) among fetuses referred for fetal echocardiography.

METHODS

This was a retrospective case series of fetuses diagnosed with situs solitus and single LSVC at the Brompton Centre for Fetal Cardiology, London, UK, from October 2006 to December 2020. Prenatal and postnatal outcome data were collected. Prenatal diagnosis was based on abnormal vessel alignment at the three-vessel view and/or three-vessel-and-trachea view, showing a vessel to the left of the pulmonary artery (i.e. the LSVC) and absence of the usual vessel to the right of the ascending aorta (i.e. the right superior vena cava), and further visualization of the LSVC draining into the coronary sinus.

RESULTS

Of 19 968 fetal echocardiograms performed during the study period, 34 cases of single LSVC were identified (a prevalence of 0.17%). Of these, 32 pregnancies had a live birth, one was lost to follow-up and one resulted in intrauterine demise. Single LSVC was isolated in 79.4% of cases. No major congenital heart disease was identified. One fetus showed mild isthmus hypoplasia, with no aortic coarctation postnatally. Two fetuses had umbilical vessel abnormalities. A genetic abnormality was found in one case (15q24.1-q24.2 deletion).

CONCLUSIONS

Antenatal diagnosis of single LSVC in the setting of situs solitus is usually a benign isolated finding. Nevertheless, investigation of other cardiac, extracardiac and genetic disorders should be considered. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Persistent Left Superior Vena Cava: Why is Prenatal Diagnosis Important?

ObjectiveTo investigate fetal anomalies and pregnancy outcomes in pregnancies with persistent left superior vena cava (PLSVC) to provide assistance in prenatal counseling.MethodsCases diagnosed with PLSVC between January 2015 and January 2020 were obtained from the hospital's electronic system and were analyzed retrospectively.ResultsTwenty-seven cases were analyzed. The prevalence of PLSVC among congenital heart diseases (CHD) was 6.9%. Conotruncal anomalies and renal anomalies were the most common accompanying cardiac and extracardiac anomalies, respectively. Chromosomal abnormality was detected in one fetus.In the postpartum period coarctation of aorta (CoA) was found in one fetus.ConclusionsWhen PLSVC is detected during prenatal ultrasonography, fetal anatomy should be carefully examined because of the anomalies that may accompany it. Prenatal genetic counseling should be given especially to cases with additional anomalies. In isolated cases, cardiac anatomy should be evaluated with repeated echocardiography because of the risk of CoA.

Clinical significance of prenatally diagnosed persistent left superior vena cava

AIMS

The aim of our study was to investigate the persistent left superior vena cava (PLSVC) cases diagnosed in the prenatal period in our clinic and to compare the obstetric and genetic outcomes of isolated PLSVC cases with cases accompanied by other cardiac or extracardiac anomalies.

METHODS

The cases diagnosed as PLSVC between January 2015 and January 2019 in our perinatology clinic were evaluated retrospectively. Patients were divided into two subgroups as isolated PLSVC and PLSVC accompanied by another anomaly. Furthermore, patients with extra anomalies were divided into three groups which are cardiac anomaly, extracardiac anomaly and those with both. The groups were compared in terms of genetic results and obstetric outcomes.

RESULTS

89 patients were included in our study. Cases with positive pregnancy outcomes were significantly higher in the isolated PLSVC group than with extra anomaly group (p<0.001). No karyotype anomaly was observed in the isolated group. Pregnancy results were significantly worse (postpartum demise, termination of pregnancy, in utero demise) in with both cardiac and extracardiac anomalies group (p<0.001). There was no significant difference between the groups in terms of karyotype results (p=0.535).

CONCLUSION

The diagnosis of PLSVC has gained importance and it can be made easier due to the fact that anatomic imaging can be performed in more detail. The isolated PLSVC cases have a very good prognosis. Obstetric outcomes vary according to the accompanying anomaly.

Genetic Evidence for Congenital Vascular Disorders in Patients with VACTERL Association

INTRODUCTION

 The VACTERL association is a rare malformation complex, showing at least three anomalies of the following organ systems: vertebra, anorectum, heart and vessels, trachea and esophagus, genitourinary tract, and limbs. In addition to a multifactorial event, congenital vascular disorders are also discussed as triggers for the VACTERL association. The aim of this study was to determine whether there is a genetic background for vascular disorders triggering VACTERL association.

MATERIALS AND METHODS

 We performed a functional analysis on whole exome sequencing data of 21 patients with VACTERL or VACTERL-like phenotype using the online analysis tool "Database for Annotation, Visualization and Integrated Discovery (DAVID) v6.8." The study was approved by the institutional ethics committee (approval no. 026-13). Written informed consent was obtained from all patients or their parents.

RESULTS

 We identified a total of 86 genetic variants (in 75 genes) classified as damaging (including probably damaging missense, nonsense, and frameshift variants), which are associated to cardiovascular development. Each investigated patient showed at least one damaging variant in genes associated to cardiovascular development. These variants were further reduced by significance in cardiovascular development to 39 genetic variants (in 33 genes). Of note, a pair of siblings, both presenting with cardiac and renal defects, had the same damaging variant in two different genes.

CONCLUSION

 Our results indicate a genetic background for congenital vascular disorders in patients with VACTERL association. In line with the literature, our data suggest that genetic mutation led to vascular diseases, which in turn may cause malformations similar to the VACTERL association.

Isolated left side superior vena cava in a dialysis patient: Right direction, wrong turn!

Tunneled catheter insertion is a routine procedure undertaken by nephrologists world over. However, the presence of a venous anomaly can always test one's skills and can give them anxious moments. Persistent left superior vena cava (SVC) is the most common venous anomaly. We share our experience of successfully placing a hemodialysis central venous catheter in a very rare congenital anomaly wherein patient had persistent left SVC with agenesis of the right SVC.

Impact of concomitant complex cardiac anatomy in nonsyndromic patients with complete atrioventricular septal defect

OBJECTIVE

We studied a cohort of patients with nonsyndromic complete atrioventricular septal defect with and without concomitant complex cardiac anatomy and compared the outcomes after surgical repair.

METHODS

Between 1993 and 2018, 62 nonsyndromic patients underwent complete atrioventricular septal defect repair. Sixteen patients (26%) had complex complete atrioventricular septal defect with variables representing concomitant cardiac anatomic complexity: tetralogy of Fallot, double outlet right ventricle, total anomalous pulmonary venous return, concomitant aortic arch reconstruction, multiple ventricular septal defects, staged repair of coarctation of the aorta, and a persisting left superior vena cava. The mean follow-up was 12.7 ± 7.9 years. Baseline variables were retrospectively evaluated and analyzed using univariable logistic regression. Survival was studied using Kaplan-Meier estimates, and group comparisons were performed using the log-rank test. A competing-risk analysis estimated the risk of reoperation with death as the competing event. A Gray's test was used to test equality of the cumulative incidence curves between groups.

RESULTS

The perioperative mortality was 3.2% (2/62). Actuarial survival was 100% versus 66.7% ± 14.9% at 10 years in the noncomplex and complex groups, respectively (P < .01). There was no significant difference in the overall reoperation rate between the noncomplex group (7/46; 15%) and the complex group (4/16; 25%) (odds ratio, 1.86; 95% confidence interval, 0.46-7.45; P = .30). The competing-risk analysis demonstrated no significant difference in reoperation between the groups (P = .28).

CONCLUSIONS

Our data show that nonsyndromic patients without complex cardiac anatomy have a good long-term survival and an acceptable risk of reoperation similar to contemporary outcomes for patients with complete atrioventricular septal defect with trisomy 21. However, the corresponding group of nonsyndromic patients with concomitant complex cardiac lesions are still a high-risk population, especially regarding mortality.

Prenatal diagnosis of persistent left superior vena cava, polyhydramnios and a small gastric bubble in a fetus with VACTERL association

OBJECTIVE

We reported a fetus that presenting with persistent left superior vena cava (PLSVC), polyhydramnios, and a small gastric bubble during prenatal examination and identified VACTERL association after birth.

CASE REPORT

A 34-year-old woman underwent amniocentesis at 18 weeks of gestation because of advanced maternal age and the result was normal. Subsequently, an ultrasound revealed single umbilical artery (SUA) at 21 weeks of gestation. She received a detailed fetal anatomy survey that presented the same findings and PLSVC. A small visible gastric bubble was noted at that time, and the other organs were unremarkable. Polyhydramnios was identified at 30 weeks of gestation and amnioreduction was subsequently performed at 32 weeks of gestation. However, polyhydramnios was persisted despite amnioreduction and intrauterine growth restriction was also detected. A cesarean section was performed because of fetal distress at 36 + 2 weeks, and a 1832-g female baby was delivered. Pre-axial polydactyly at left thumb, SUA and esophageal atresia with distal tracheoesophageal fistula (TEF) were identified after birth. The neonate died at age of 4 days because of surgical complication following esophageal anastomosis.

CONCLUSION

Prenatal diagnosis of PLSVC associated with polyhydramnios and a small gastric bubble may indicate esophageal atresia with TEF, and further examination for associated syndromes such as VACTERL association is warranted.

Two Cases of Cardiac Implantable Electronic Device Placement via Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is the most common variation of anomalous venous return to the heart and present in 0.1–0.5% of the general population. The left anterior cardinal veins typically obliterate during early cardiac development but failure of involution results in PLSVC. It is an asymptomatic congenital anomaly, usually discovered while performing interventions through the left subclavian vein or during cardiovascular imaging. PLSVC can be associated with cardiac arrhythmias and congenital heart disease. We present two cases of PLSVC: first, a 68-year-old male who presented with complete heart block, for which a temporary pacemaker was initially inserted followed by a permanent pacemaker; second, a 53-year-old female with a history of hypertension and ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, and a survivor of sudden cardiac death, who underwent an implantable cardioverter-defibrillator (ICD) for secondary prevention.

Both cases of PLSVC were detected incidentally during the transvenous approach to the heart. PLSVC was suspected by the unusually left medial position of the lead, while cineflouroscopy showed the venous trajectory toward the coronary sinus and drainage into the right atrium. It is technically difficult to cross the wire through the tricuspid valve when coming from the PLSVC and coronary sinus without making a loop in the right atrium, which is known as a wide loop technique.

PLSVC is an uncommon anomalous anatomical variant and should be recognized appropriately by specialists who frequently carry out procedures through the left subclavian vein, such as implantation of permanent pacemaker, ICD and cardiac resynchronization therapy. It should also be recognized that wide loop formation of the right ventricular lead in the right atrium is helpful to cross the tricuspid valve and to affix the lead in the right ventricle.

Left Superior Vena Cava in the Fetus: A Rarely Isolated Anomaly

The frequency of chromosomal anomalies among fetuses with isolated persistent left superior vena cava (PLSVC) is still debated. The objective of the present study was to assess the prevalence of genetic and morphological anomalies identified in fetuses with PLSVC. We conducted a single-center retrospective study including all fetuses diagnosed with a PLSVC between 2010 and 2017. PLSVC was categorized as isolated or associated according to antenatal diagnosis of associated congenital heart defects, hypoplastic aortic isthmus, abnormal venous/arterial connections, and extracardiac anomalies. Among 229 fetuses diagnosed with PLSVC, 39 cases (17%) were strictly isolated and no syndromic/genetic anomaly or aortic coarctation was diagnosed. Seventy-two fetuses had a cardiovascular defect with a rate of genetic anomalies of 22%, 29 had an extracardiac malformation, and 89 had both an extracardiac and a cardiovascular defect. Among fetuses with abnormal development of the arterial/venous system as the only associated anomaly such as aberrant right subclavian artery or absent ductus venosus, 22% had a genetic anomaly. Overall, sixty-five fetuses or infants had a genetic concern, including 23 aneuploidies, 15 pathogenic micro-deletions/duplications, and 5 variants of unknown significance; 12 patients had VACTERL association, and 12 heterotaxy syndrome. Seven infants had an aortic coarctation diagnosed at birth.In conclusion, a thorough prenatal ultrasound examination is paramount, and the identification of variants of the venous/arterial system in addition to PLSVC should raise suspicion for genetic or morphologic abnormalities. Invasive prenatal diagnosis with array-CGH should be offered when PLSVC is non-isolated, after a detailed ultrasound evaluation in a tertiary center.

Left superior vena cava: cross-sectional imaging overview

Persistent left-sided superior vena cava (PLSVC) is the commonest systemic venous anomaly in the thorax with a reported prevalence of up to 0.5% in otherwise normal population and up to 10% in patients with congenital heart disease (CHD). In the absence of associated CHD, it is usually asymptomatic, discovered incidentally. It may complicate catheter or pacemaker lead placement. PLSVC typically drains into the right atrium through the coronary sinus. In children with CHD, the presence of a PLSVC may affect the choice of certain surgical procedures. PLSVC is significantly more common in association with situs ambiguous than with situs solitus or inversus, up to 60-70%. In patients with situs ambiguous, the drainage of LSVC is variable, more commonly directly into the atria rather than through the coronary sinus (CS). Rarely, there is a PLSVC draining into the CS with absent right SVC. PLSVC draining into the right atrium via the CS will not usually cause blood shunting between the right and the left sides. However, shunting occurs when PLSVC is associated with unroofed CS, or when it directly drains into the left atrium. With an increased use of CT and MRI for chest and cardiac imaging, PLSVC is being more encountered by radiologists than before. In this article, we will discuss the embryology of PLSVC, its anatomic course and drainage pathways, as well as its clinical relevance and relation to congenital heart disease and viscero-atrial situs.

Aberrant Left Brachiocephalic Vein versus Persistent Left Superior Vena Cava without Bridging Vein in Adults: Evaluation on Computed Tomography

Objective: Persistent left superior vena cava without bringing vein (PLSVC w/o BV) is a common thoracic venous anomaly, while aberrant left brachiocephalic vein (ALBCV) is an uncommon condition. We compared the incidences of the two venous anomalies and assessed congenital cardiovascular diseases (CCDs) in adults using computed tomography (CT).

Materials and Methods: We reviewed the recorded reports or CT images of 49,494 adults for PLSVC w/o BV and ALBCV in two hospitals. We determined incidences of two venous anomalies and the rate of associated CCDs.

Results: 76 PLSVCs w/o BV and 27 ALBCVs were found. The incidence of PLSVC w/o BV was 0.15% and the incidence of ALBCV was 0.055%. PLSVC w/o BV had higher incidence than ALBCV (p<0.001). Four PLSVCs w/o BV and one ALBCV were associated with congenital heart diseases. Two PLSVCs w/o BV and four ALBCVs were associated with congenital aortic arch anomaly (CAAA). ALBCV had higher incidence of associated CAAA than PLSVC w/o BV (P=0.02).

Conclusion: The incidence of ALBCV was <50% that of PLSVC w/o BV. The two venous anomalies found on CT during adulthood were rarely associated with CCDs.

Isolated Persistent Left Superior Vena Cava, Sick Sinus Syndrome, and Challenging Pacemaker Implantation

Persistent left superior vena cava with absent right superior vena cava is a very rare venous anomaly and is known as isolated PLSVC. It is usually an asymptomatic anomaly and is mostly detected during difficult central venous access or pacemaker implantation, though it could also be associated with an increased incidence of congenital heart disease, arrhythmias, and conduction disturbances. Herein, we describe a dual-chamber pacemaker implantation in a patient with isolated PLSVC and sick sinus syndrome.

Pacemaker Placement in Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is a rare disorder which is asymptomatic and hence is usually discovered while performing interventions through the left subclavian vein. We present a case of a 78-year-old male who was undergoing elective placement of a permanent pacemaker for tachycardia – bradycardia syndrome with post-conversion pauses of up to nine seconds. After achieving access through the left subclavian vein the wire kept on going on the left side of the chest instead of crossing the midline to the right side. The wire was removed and contrast venography was done, PLSVC with dilated coronary sinus emptying into the right atrium was confirmed. There was some difficulty in passing the lead to the right ventricle even with the acute curve in the stylet. The sheath size was increased and a longer deflectable sheath was used and with the tip of the lead anteriorly the right ventricle was cannulated and the lead was affixed. There were good sensing and pacing parameters. Post procedure chest x-ray was done and the patient was discharged without any complications.

Isolated persistent left superior vena cava: A case report and its clinical implications

The venous anomaly of a persistent left superior vena cava (PLSVC) affects 0.3%-0.5% of the general population. PLSVC with absent right superior vena cava, also termed as "isolated PLSVC," is an extremely rare venous anomaly. Almost half of the patients with isolated PLSVC have cardiac anomalies in the form of atrial septal defect, endocardial cushion defects, or tetralogy of Fallot. Isolated PLSVC is usually innocuous. Its discovery, however, has important clinical implications. It can pose clinical difficulties with central venous access, cardiothoracic surgeries, and pacemaker implantation. When it drains to the left atrium, it may create a right to left shunt. In this case report, we present the incidental finding of isolated PLSVC in a patient who underwent aortic valve replacement. Awareness about this condition and its variations is important to avoid complications.

Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is a common cardiac anomaly associated with congenital heart diseases. A diagnosis of PLSVC usually warrants a detailed fetal echocardiography. Lesser known associations are the extra cardiac anomalies notably the upper airway and the gastrointestinal tract anomalies. We highlight here the importance of detailed fetal assessment for extra cardiac anomalies in addition to fetal echocardiography in fetuses diagnosed with PLSVC. We hereby present a preterm infant who presented with a triad of PLSVC, laryngeal atresia, and esophageal atresia.

Persistent left superior vena cava accompanying congenital heart disease in children: Experience of a tertiary care center

BACKGROUND

This study focuses on determining concomitant persistent left superior vena cava (SVC) in patients with congenital heart disease (CHD).

METHODS

Between 2005 and 2012, a total of 2.663 patients with CHD, 88 (3.3%) of whom were diagnosed with persistent left SVC, were evaluated retrospectively. The demographic characteristics of patients, clinical and radiographic findings, echocardiography, cardiac catheterization, and angiography results obtained from the patients' records were reviewed.

RESULTS

The median age of the patients was 9.5 months, and 46 of the 88 (52.3%) patients were female. The most common concomitant CHD were ventricular septal defect, double outlet right ventricle (DORV), and tetralogy of Fallot (TOF). When the patients were compared according to their CHD, persistent left SVC frequency was significantly higher in those with DORV (P<.001), TOF (P=.04), patent ductus arteriosus (P=.01), and atrial septal defect (P=.03). Eighty-three of the 88 (94.3%) patients with persistent left SVC had right SVC, and 5 (5.7%) had absence of the right SVC. Twenty-seven of the 83 (32.5%) patients with double SVC had connected normal innominate vein. In all cases, right aortic arch association was seen in 14 (15.9%) patients. Eighty-four (95.4%) of the patients were diagnosed by echocardiography prior to catheter angiography. Persistent left SVC drained to the coronary sinus in all cases.

CONCLUSION

Increased awareness about the association of certain CHD with persistent left SVC and a careful echocardiographic examination can facilitate the diagnosis of persistent left SVC. In addition, precise prior diagnosis of persistent left SVC can prevent complications during surgery.

Systematic review and meta-analysis of persistent left superior vena cava on prenatal ultrasound: associated anomalies, diagnostic accuracy and postnatal outcome

OBJECTIVES

To quantify the prevalence of chromosomal anomalies in fetuses with persistent left superior vena cava (PLSVC), assess the strength of the association between PLSVC and coarctation of the aorta and ascertain the diagnostic accuracy of antenatal ultrasound in correctly identifying isolated cases of PLSVC.

METHODS

MEDLINE, EMBASE, CINHAL and the Cochrane databases were searched from the year 2000 onwards using combinations of keywords 'left superior vena cava' and 'outcome'. Two authors reviewed all abstracts independently. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. The rates of the following outcomes were analyzed: chromosomal abnormalities; associated intracardiac anomalies (ICAs) and extracardiac anomalies (ECAs) diagnosed prenatally; additional ICAs and ECAs detected only at postnatal imaging or clinical evaluation but missed at prenatal imaging; and association of PLSVC and coarctation of the aorta. Meta-analyses of proportions were used to combine data.

RESULTS

In total, 2708 articles were identified and 13 (n = 501) were included in the systematic review. Associated ICAs and ECAs were detected at the prenatal ultrasound examination or at a follow-up assessment in 60.7% (95% CI, 44.2-75.9%) and 37.8% (95% CI, 31.0-44.8%) of cases, respectively. Chromosomal anomalies occurred in 12.5% (95% CI, 9.0-16.4%) of cases in the overall population of fetuses with PLSVC and in 7.0% (95% CI, 2.7-13.0%) of isolated cases. Additional ICAs and ECAs were detected only after birth and missed at ultrasound in 2.4% (95% CI, 0.5-5.8%) and 6.7% (95% CI, 2.2-13.2%) of cases, respectively. Coarctation of the aorta was associated with isolated PLSVC in 21.3% (95% CI, 13.6-30.3%) of cases.

CONCLUSIONS

PLSVC is commonly associated with ICAs, ECAs and chromosomal anomalies. Fetuses with isolated PLSVC should be followed up throughout pregnancy in order to rule out coarctation of the aorta. As most of the data in this review were derived from high-risk pregnancies, the rate of associated abnormalities is likely to be higher than that in the general population of fetuses with PLSVC, for which more data are needed. Revisión sistemática y metaanálisis de la persistencia de la vena cava superior izquierda en la ecografía prenatal: anomalías asociadas, precisión del diagnóstico y resultado postnatal RESUMEN OBJETIVOS: Cuantificar la prevalencia de anomalías cromosómicas en fetos con vena cava superior izquierda persistente (VCSIP), evaluar la solidez de la asociación entre la VCSIP y la coartación aórtica, y determinar la precisión del diagnóstico de la ecografía prenatal como método para identificar correctamente casos aislados de VCSIP. MÉTODOS: Se buscó en las bases de datos de MEDLINE, EMBASE, CINHAL y Cochrane artículos publicados desde el año 2000 en adelante, usando combinaciones de las palabras clave "vena cava superior izquierda" y "resultado". Dos de los autores revisaron de forma independiente todos los resúmenes encontrados. La evaluación de calidad de los estudios incluidos se realizó mediante la escala Newcastle-Ottawa para estudios de cohortes. Se analizaron las tasas de los siguientes resultados: anomalías cromosómicas; anomalías intracardíacas (AIC) y anomalías extracardíacas (AEC) asociadas diagnosticadas prenatalmente; AIC y AEC adicionales detectadas sólo en ecografías postnatales o mediante evaluación clínica, pero no observadas en ecografías prenatales; y la asociación entre la VCSIP y la coartación aórtica. Se utilizó un meta-análisis de proporciones para combinar los datos.

RESULTADOS

En total, se identificaron 2708 artículos y se incluyeron 13 (n = 501) en la revisión sistemática. En la ecografía prenatal o en una revisión de seguimiento se detectaron AIC y AEC asociadas en el 60,7% (IC 95%, 44,2-75,9%) y el 37,8% (IC 95%, 31,0-44,8%) de los casos, respectivamente. Se produjeron anomalías cromosómicas en el 12,5% (IC 95%, 9,0-16,4%) de los casos en la población general de fetos con VCSIP y en el 7,0% (IC 95%, 2,7-13,0%) de casos aislados. Las AIC y AEC adicionales sólo se detectaron después del nacimiento y en el 6,7% (IC 95%, 2,2-13,2%) de los casos, respectivamente. La coartación aórtica se encontró asociada con la VCSIP aislada en un 21,3% (IC 95%, 13,6-30,3%) de los casos.

CONCLUSIONES

La VCSIP está comúnmente asociada a AIC, AEC y anomalías cromosómicas. Los fetos con VCSIP aislada deben ser objeto de seguimiento durante todo el embarazo, con el fin de descartar la coartación aórtica. Como la mayoría de los datos de esta revisión proceden de embarazos de alto riesgo, es probable que la tasa de anomalías asociadas sea más alta que la de la población general de fetos con VCSIP, por lo que se necesitan más datos.

Right Heart Catheterization Through Persistent Left Superior Vena Cava, an Extremely Rare Procedure and Review of Current Literature

Persistent left superior vena cava (PLSVC) is encountered occasionally during angiographic procedures. It usually coexists with right superior vena cava and drains to the right atrium through the coronary sinus, but multiple variations are described. Although PLSVC is extensively reported in the literature, there are very few articles addressing right heart catheterization in patients with isolated PLSVC. We present a patient with absent right superior vena cava and PLSVC draining to a dilated coronary sinus diagnosed during right heart catheterization in the setting of pulmonary hypertension. We were able to safely complete the procedure through the right internal jugular vein. Transthoracic echocardiography and chest CT scan were consistent with this finding. Although clinically silent most of the time, undiagnosed PLSVC can lead to catastrophic consequences when the patient undergoes invasive procedures. If PLSVC is suspected, the anatomy of the thoracic venous system must be identi-fied before invasive cardiac procedures.

Absent right superior caval vein in situs solitus

Introduction In up to 0.07% of the general population, the right anterior cardinal vein obliterates and the left remains open, creating an absent right superior caval vein and a persistent left superior caval vein. Absent right superior caval vein is associated with additional congenital heart disease in about half the patients. We wished to study the consequences of absent right superior caval vein as an incidental finding on prenatal ultrasonic malformation screening. Material and methods This is a retrospective case series study of all foetuses diagnosed with absent right superior caval vein at the national referral hospital, Rigshospitalet, Denmark, from 2009 to 2012.

RESULTS

In total, five cases of absent right superior caval vein were reviewed. No significant associated cardiac, extra-cardiac, or genetic anomalies were found. Postnatal echocardiographies confirmed the diagnosis and there were no postnatal complications. All children were found to have healthy hearts at follow-up.

CONCLUSIONS

In all cases, the findings proved to be a benign condition with no clinical manifestations or complications. Although isolated absent right superior caval vein does not seem to affect the outcome, associated anomalies may be serious. Absent right superior caval vein should, therefore, prompt a search for additional malformations. Furthermore, the diagnosis of an isolated absent right superior caval vein is important, because knowledge of the anomaly can prevent future problems when invasive procedures are necessary.

Left-sided superior vena cava and venous hyperoxia masquerading as inadvertent carotid artery catheterization

BACKGROUND

A persistent left-sided superior vena cava (PLSVC) is a rare, often asymptomatic, venous anomaly that may be first diagnosed during central venous catheterization. During chest radiograph interpretation, a PLSVC can be confused with inadvertent arterial catheterization.

CASE REPORT

We describe the presentation of a 45-year-old man with end-stage liver disease who required central venous catheterization for treatment of septic shock. An aberrantly placed catheter noted on chest radiograph and an elevated central venous oxygen saturation gave the appearance of inadvertent carotid artery catheterization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A persistent left-sided superior vena cava can masquerade as an inadvertent cannulation of the carotid artery during central line placement. It is important for emergency physicians to be aware of this possibility when evaluating a chest radiograph with an aberrantly placed catheter. Venous hyperoxia may further complicate attempts to differentiate between arterial and venous catheterization in patients with septic shock. After confirmatory tests, the emergency physician should consider removal of the catheter due to potential complications.

Prevalence of persistent superior vena cava and association with congenital heart anomalies

A contralateral persistent superior vena cava (PSVC) can occur in a normal child or in association with congenital heart defects (CHDs). Its prevalence has been demonstrated in relatively small cohorts. We aim to assess the frequency of a PSVC in a large cohort of children with and without CHDs. To estimate its significance, we have searched for a PSVC in all children referred for echocardiography in our institution during a 16.5-year period. A group of 17,219 children comprised 8,140 children with a structural heart anomaly and 9,079 children with a structurally normal heart. Association between a PSVC and specific classes of CHD were looked for. A total of 288 children (1.7%) had a PSVC; 0.56% (51 of 9,079) in the normal heart group and 2.9% (237 of 8,140) in the congenital heart anomalies group. Odds ratio for having heart anomaly in the presence of PSVC was 5.2 (95% confidence interval 3.7 to 7.0). A PSVC was above all associated with atrioventricular septal defects, conotruncal malformations, and left-sided defects. The odds ratio of having PSVC in the aforementioned malformations compared with the normal heart group was 23.8, 13.6, and 11.0, respectively. In conclusion, although present in normal subjects, PSVC was more often associated with congenital heart and other anomalies, especially with atrioventricular septal defects, conotruncal malformations, and left-sided defects.

High prevalence rate of left superior vena cava determined by echocardiography in patients with congenital heart disease in Saudi Arabia

BACKGROUND

Persistent left superior vena cava (LSVC) is one of the common anomalies of the systemic veins. Its prevalence is 0.1-0.3% in the general population and is more common with congenital heart disease (CHD). The importance of detecting persistent LSVC prior to cardiac surgery is paramount for systemic veins cannulations.

AIM

The aim was to evaluate the prevalence of persistent LSVC in patients with CHD in Saudi Arabia.

METHODS

All patients referred to our institution had echocardiography. All complete studies were reviewed for the presence of persistent LSVC. A computerized database was created including the demographic data, CHD diagnoses, and the presence of persistent LSVC.

RESULTS

A total of 2,042 were examined with an age range of 1 day to 16 years. The complete echocardiographic studies were 1,832 (90%) of whom 738 (40%) patients had CHD. The prevalence of persistent LSVC in patients with CHD was 7.8% (OR 9.26, 95% CI 4.7-18.2, p<0.001). The most common cardiac defect associated with persistent LSVC was complete atrioventricular septal defect (AVSD); all patients with AVSD had Down syndrome. The total number of patients with AVSD was 41, and persistent LSVC was found in 11 (26%) of them (odds ratio 5.1, 95% CI 2.4-10.8, p<0.001).

CONCLUSIONS

The prevalence of persistent LSVC in the current population is almost double the reported prevalence obtained using the same echocardiographic screening tool.

Cyanosis when head turned to left in an infant with primary ciliary dyskinesia

A 19-month-old boy with primary ciliary dyskinesia (PCD), mirror-image dextrocardia, situs inversus (SI) totalis suffered from persistent hypoxia. Cyanosis became clinically evident when the child turned the head to the left and resolved after turning the head to the right. Echocardiography demonstrated two superior caval veins; the left sided superior vena cava (SVC) entering the left sided right atrium (RA) and the right sided into the right sided left atrium (LA). Surgical redirection of the right sided caval vein into RA was performed.

Small atrial septal defect associated with heart failure in an infant with a marginal left ventricle

Atrial septal defect (ASD) is usually asymptomatic in infancy, unless pulmonary hypertension or severe co-morbidity is present. We report a case of a 4-week-old infant with moderate-sized ASD, small patent ductus arteriosus (PDA), and a borderline sized left ventricle that developed heart failure. Despite the relatively small diameter of the ASD, this defect influenced the mechanism of heart failure significantly. After surgical closure of both PDA and ASD, the signs of pulmonary hypertension resolved and the patient developed a normal sized left ventricle. This report illustrates that the presence of a small ASD in combination with a marginal left ventricle may result in inadequate left ventricular filling, pulmonary hypertension and heart failure.

Persistent left superior vena cava - considerations in fetal, pediatric and adult populations

Persistent left superior vena cava (LSVC) is the commonest congenital anomaly of the thoracic venous system. It is within the group of anomalous systemic venous return (ASVR) and the group is subdivided in cephalic, involving the superior vena cava (SVC) and caudal, involving the inferior vena cava (IVC) types. It is also important to recognise that there can be a persistent LSVC with or without a normal right superior vena cava (RSVC). In most cases, a persistent LSVC drains into the right atrium via the coronary sinus without any clinical symptoms. In this article we discuss embryology, diagnostic and further management approaches and a review of the literature related to persistent LSVC.

Persistent left superior vena cava: experience of a tertiary health-care center

BACKGROUND

The aim of this study was to assess the prevalence of persistent left superior vena cava (PLSVC) in patients with all types of congenital heart defects and to determine the congenital heart anomalies accompanying PLSVC.

METHODS

The present study is based on a retrospective review of 1205 children who consecutively underwent cardiac catheterization from 2000 to 2007. In order to determine the existence of PLSVC, all the subjects routinely underwent superior vena cava (SVC) injection during angiography at the catheter laboratory of the study center.

RESULTS

The prevalence of PLSVC was computed to be 6.1% for the present study population. Transthoracic echocardiography was able to detect PLSVC in 32 children (2.6%) whereas angiography diagnosed PLSVC in 74 children (6.1%). The mean age of the patients with PLSVC was 40.09 ± 50.21 months. A communication between the right and left SVC was determined in 27% of the children who were diagnosed with PLSVC after angiography was performed (20 out of 74). A statistically significant association was present between PLSVC and other congenital cardiac anomalies, including ventricular septal defect (n= 42, 56.8%), atrial septal defect (n= 31, 41.9%), pulmonary stenosis (n= 19, 25.7%), atrioventricular septal defect (n= 10, 13.5%), patent ductus arteriosus (n= 6, 8.1%) and cor triatriatum (n= 3, 4.1%).

CONCLUSION

Transthoracic echocardiography usually visualizes dilated coronary sinus in association with PLSVC. However, SVC injection should be performed in patients undergoing angiography so that morbidity and mortality related with persistent left superior vena cava can be avoided during cardiovascular surgery.

Recognition of persistent left superior vena cava in non-congenital patients undergoing cardiac surgery

Persistent left superior vena cava (PLSVC) represents the most frequent congenital malformation of the thoracic venous drainage system. In adults referred to surgery for an acquired cardiac disease, abnormal venous drainage may be missed if not carefully researched. Discovering a previously undiagnosed PLSVC during cardiopulmonary bypass (CPB) may present some inconvenience for both the perfusionist and the surgeon, especially during a minimally invasive approach. The authors believe PLSVC probably may represent an under-reported condition. A careful screening of patients undergoing cardiac surgery may prove helpful. In particular, a complete echocardiographic study may help to better diagnose this condition before surgery. Different signs may raise the suspicion of PLSVC and should be carefully researched during preoperative patient work-up.

Persistent left superior vena cava: does it have a role in the pathogenesis of hypoplastic left heart syndrome?

The coexistence of a persistent left superior vena cava (PLSVC) and congenital anomalies, both cardiac and noncardiac, is well documented, but whether PLSVC contributes to the development of cardiac malformations is controversial. We conducted a retrospective review of perinatal and pediatric autopsies to determine the association between PLSVC and other congenital anomalies. Of 362 patients, 91 (25%) had congenital heart disease and 19 (5.2%) had PLSVC. Eight cases (47%) were associated with specific syndromes, including heterotaxy syndrome, trisomy 18, trisomy 13, and Jacobsen syndrome. Seventeen cases of PLSVC (89%) were associated with congenital heart disease, most of which were complex. Isolated PLSVC was found in 2 cases (11%). Eight of the 19 PLSVC cases (47%) were associated with hypoplastic left heart syndrome (HLHS), a result that was statistically significant (P  =  0.041). Left ventricle inflow/outflow obstruction is believed to be a critical pathogenic factor in the development of HLHS. Whereas 5 of 8 cases of HLHS had additional obstructive cardiac outflow tract lesions, 3 of 8 cases did not. PLSVC is known to be able to compromise left ventricle inflow via a dilated coronary sinus, and we speculate that PLSVC may have played a contributing role in the pathogenesis of HLHS in these three cases. As an isolated lesion, PLSVC would not be sufficient to cause HLHS, but it might contribute in combination with other obstructive lesions, or in the setting of other genetic and/or environmental factors still to be defined for HLHS. A larger series will be needed to confirm this hypothesis.

Prenatal diagnosis of abnormal cardinal systemic venous return without other heart defects: a case series

OBJECTIVES

To describe fetal spectrum and echocardiographic characteristics of anomalous systemic venous return (ASVR, cardinal veins) without other structural heart defects (isolated ASVR), evaluate associated extracardiac and genetic anomalies and review neonatal outcome.

METHODS

From 2003 to 2009, 369 consecutive fetuses were diagnosed with cardiac malformation, including 27 cases with an isolated ASVR. The following variables were collected: type of ASVR, extracardiac anomalies, karyotype and short-term outcome.

RESULTS

The most common forms of ASVR were persistent left superior vena cava (SVC) (n = 15) and interrupted inferior vena cava (IVC) (n = 6). The other ASVR types were a persistent left SVC without a right SVC (n = 4), bilateral agenesis of the SVC with cephalic venous drainage toward the IVC through the azygos system (n = 1) and total ASVR to the coronary sinus (n = 1). Genetic disorders were confirmed in five cases, all with a persistent left SVC, with extracardiac anomalies present in four of them. Ten other patients had extracardiac anomalies detected prenatally or postnatally. When available, ASVR diagnosis was confirmed postnatally in all cases.

CONCLUSION

Isolated ASVRs can be accurately diagnosed prenatally and are frequently associated with extracardiac and genetic anomalies. A detailed morphological ultrasound and fetal karyotype should be suggested. Neonatal outcome was mainly related to the associated anomalies.

Cardiac findings in fetal and pediatric autopsies: a five-year retrospective review

This review aims to determine the spectrum of cardiac findings in our fetal and pediatric postmortem population and provide an analysis of associated extracardiac malformations and genetic abnormalities. Pediatric autopsy reports from 2003 to 2007 inclusive were reviewed and cases with cardiac pathology selected for analysis. Over the 5-year period, 119 cases (10.8%) with abnormal cardiac findings were identified from a total of 1102 postmortem examinations. Of these cardiac cases, 42% were after termination of pregnancy for fetal anomaly, 29% after fetal demise, 14% after neonatal unit death, 3% after hospital inpatient death, and 11% after sudden unexpected death. Structural abnormality cases numbered 107 (90%), with ventricular septal defect as the most common individual defect. Nonstructural abnormality cases, such as myocarditis, numbered 12 (10%). Extracardiac malformations were identified in 78%. Chromosome or gene aberrations were detected in 37%. This review highlights the potential benefit of introducing routine fetal anomaly scanning, the need for cardiac pathology training for pediatric pathologists, and the importance of examination of the heart and associated vessels in all cases to provide parents with as much information as possible and aid identification of the etiology and associations of cardiac pathology.

Search for the azygos: a lesson learnt from a case with left superior vena cava, esophageal atresia and tracheo-esophageal fistula

The azygos vein is of superior importance during the operation for esophageal atresia with tracheo-esophageal fistula (EA; TEF). Its location helps the surgeon to locate the fistula. Newborns with persistent left superior vena cava (LSVC) may have alterations in the location of the azygos, and since LSVC is not uncommon in EAs with fistulae, it is important to locate the azygos during a pre-operative echocardiogram. Foreknowledge of a possible absent azygos may avoid morbidity while trying to locate the fistula. We present a case of a newborn with EA, TEF, and LSVC in which the azygos vein was absent.

Morphological and Physiological Predictors of Fetal Aortic Coarctation

Background— Prenatal diagnosis of aortic coarctation suffers from high false-negative rates at screening and poor specificity.

Methods and Results— This retrospective study tested the applicability of published aortic arch and ductal Z scores (measured just before the descending aorta in the 3-vessel and tracheal view) and their ratio on 200 consecutive normal controls at a median of 22±0 gestational weeks (range, 15±4 to 38±4 weeks). Second, this study tested the ability of serial Z scores to distinguish fetuses with coarctation within a cohort with ventricular and/or great arterial disproportion detected at screening or fetal echocardiography. Third, it evaluated the diagnostic significance of associated cardiac lesions, coarctation shelf, and isthmal flow disturbance. We studied 44 fetuses with suspected coarctation at 24±0 weeks (range, 17±3 to 37±4 weeks). Receiver-operating characteristic curves were created. Logistic regression tested the association between z scores, additional cardiac diagnoses, and coarctation. Good separation was found of isthmal Z scores for cases requiring surgery from controls and false-positive cases, and receiver-operating characteristic curves showed an excellent area under the curve for isthmal Z score (0.963) and isthmal-to-ductal ratio (0.969). Serial isthmal Z scores improved to >−2 in suspected cases with normal outcomes; those requiring surveillance or surgery remained <−2. Minor lesions did not increase the diagnostic specificity of coarctation, but isthmal flow disturbance increased the odds ratio of true coarctation versus arch hypoplasia 16-fold.

Conclusions— Isthmal Z scores and isthmal-to-ductal ratio are sensitive indicators of fetal coarctation. Serial measurements and abnormal isthmal flow patterns improve diagnostic specificity and may reduce false positives.