Accuracy of two-dimensional echocardiography in diagnosing left superior vena cava

Association of autoimmune pancreatitis with Raghib syndrome

Key Clinical Message

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis scarcely found in children. Raghib syndrome is a rare congenital heart defect known as persistent left superior vena cava (LSVC) draining into the left atrium. Total signs of Raghib syndrome in AIP case accompanied by an IgG4-related disease were described.

Abstract

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis scarcely found in children. Raghib syndrome is a rare congenital heart defect known as persistent left superior vena cava (LSVC) draining into the left atrium. Here, we describe Raghib syndrome in AIP case accompanied by an IgG4-related disease (AIP/IgG4RD). A 13-year-old boy presented with a 3-month history of fever and abdominal pain. The laboratory findings showed SGOT and SGPT, ALP was increased, while amylase and γ-GT were normal. Immunoglobulins were normal, except for IgG. Endosonography, spiral CT of the abdomen, and cholangiopancreatography showed an enlargement of the pancreas. Contrast echocardiography discovered opacification of the coronary sinus and left atrium. Transesophageal echocardiography for LSVC revealed a dilatation in the coronary sinus, indicating persistent LSVC. Following the injection of agitated saline into the left antecubital vein, bubbles entered both left and right atria in LSVC. It is reasonable to exclude some of these rare disorders as Raghib syndrome, in cases that will be started on medications like corticosteroids, which increases the susceptibility to thromboembolic events.

The value of cardiac CT in the diagnosis of unroofed coronary sinus syndrome

BACKGROUND

Unroofed coronary sinus syndrome (UCSS) is a rare cardiovascular malformation with nonspecific clinical manifestations that easily causes misdiagnosis and missed diagnosis. The aim of this study is to present the different features of UCSS by various CCT (cardiac CT) postprocessing techniques and evaluate the diagnostic advantages of CCT.

METHODS

9 UCSS patients who were diagnosed by imaging and undergone both CCT and transthoracic echocardiography (TTE) were included in this study, and their CCT images were reviewed. The UCSS images were classified by multiplanar reformations, maximum intensity projection, volume rendering and cinematic rendering. The size of CS roof defect was also measured.

RESULTS

Only 4 of 9 CCT confirmed UCSS patients were detected by TTE (4/9, 44.4%), the sensitivity of TTE was lower compared to CCT by Fisher's exact test (P < 0.05). UCSS was classified according to the Kirklin and Barratt Boyes's method, including 1 case was classified as type I, 4 cases as type II, 1 case as type III, 2 cases as type IV, 1 case as type V (variant type), and TTE was undiagnosed in all type III-V patients. Additionally, CCT showed 12 extra malformations in these patients, only 5 of them were found by TTE (5/12, 41.7%), and TTE missed all extracardiac malformations. The mean size of CS roof defect was 3.04 ± 1.57 cm.

CONCLUSIONS

CCT with various postprocessing technologies has excellent value in diagnosing and differentiating subtypes of UCSS, measuring size of coronary sinus defect, describing accompanying cardiovascular abnormalities.

Mitral Inflow Obstruction Resulting From a Dilated Coronary Sinus: Role of Intraoperative Transesophageal Echocardiography in Diagnosis and Surgical Repair: A Case Report

Mitral inflow obstruction caused by dilated coronary sinus is a rare congenital cardiac anomaly that must be differentiated from other causes of left ventricular inflow obstruction such as cor triatriatum, supramitral membrane, and supramitral ridge, because their surgical repair is different. Although preoperative transthoracic echocardiography is the primary imaging modality for diagnosis, intraoperative transesophageal echocardiography has a higher sensitivity and specificity over transthoracic echocardiography in differentiating these lesions. We report 2 cases of supramitral obstruction where the intraoperative transesophageal echocardiography has refined the preoperative diagnosis and changed the course of surgical repair.

Imaging characteristics of persistent left cranial vena cava incidentally diagnosed with computed tomography in dogs

Persistent left cranial vena cava (PLCVC) is an uncommon congenital thoracic venous anomaly in dogs. This study examines the clinical and CT findings of dogs diagnosed with PLCVC incidentally. In this study, complete type of PLCVC was diagnosed in 26 dogs with CT angiography. Shih tzu (17 cases) and Pekingese dogs (3 cases) were overrepresented. There was no gender predisposition, and the average age at presentation was 10.3 years. Of 26 dogs, one dog had a bridging vein connecting right and left cranial vena cavae, and another dog showed azygos vein terminating PLCVC. On the thoracic CT images in the third dog, the right cranial vena cava was absent so that right brachiocephalic vein ended to PLCVC. However, the right costocervical vein drained another vein coursing caudally to the right atrium with azygos vein. In conclusion, CT angiography is a very useful method to diagnose PLCVC and variations of related thoracic vein anomalies in dogs.

A novel method of placing right ventricular leads in patients with persistent left superior vena cava using a conventional j stylet

BACKGROUND

Locating pacemaker electrodes can become complicated by congenital abnormalities such as persistent left superior vena cava (LSVC).

OBJECTIVE

To evaluate a technique for the implanting of ventricular electrode in patients with persistent LSVC.

MATERIALS AND METHODS

The study was carried out from June 2001 to June 2010 involving all patients who were admitted to the Hospital Universitario Mayor, Instituto de Corazon de Bogota and Hospital Universitario Clinica San Rafael (Bogota-Colombia) for implanting pacemakers or cardiac defibrillators. LSVC was diagnosed by fluoroscopic observation (anterior-posterior view) of the course of the stylet. Four steps were followed: 1) Move the electrode with a straight stylet to the right atrium. 2) Change the straight stylet by a conventional J stylet and push the electrode to the lateral or anterolateral wall of the right atrium. 3) Remove the guide 3-5 cm and 4) Push the electrode which crosses the tricuspid valve into the right ventricle and finally deploy the active fixation mechanism.

RESULTS

A total of 1198 patients were admitted for pacemaker or cardiac defibrillator implant during the 9-year study period, 1114 received a left subclavian venous approach. There were 573 males and 541 females. Persistent LSVC was found in five patients (0.45%) Fluoroscopy time for implanting the ventricular electrode ranged from 60 to 250 seconds, 40 to 92 minutes being taken to complete the whole procedure.

CONCLUSION

We present a simple and rapid technique for electrode placement in patients with LSVC using usual J guide and active fixation electrodes with high success.

Persistent Left Superior Vena Cava With Absent Right Superior Vena Cava and Bicuspid Aortic Valve: A Case Report and Review of Literature

Persistent left superior vena cava with absent right superior vena cava is a rare congenital anomaly with few cases reported to date. To the best of our knowledge, the current case is the first one to be reported from New Zealand. The condition may present difficulties in central venous catheterization, pacemaker electrode insertion and cannulation during cardiopulmonary bypass. We describe a case of persistent left superior vena cava with absent right superior vena cava, who presented with aortic stenosis (bicuspid aortic valve) and rhythm disturbances.

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.

Unusual combination of holt-oram syndrome and persistent left superior vena cava

Holt-Oram (HO) is a syndrome characterized by congenital cardiovascular malformations, specifically atrial and ventricular septal defects, and skeletal abnormalities of the upper limbs bones. Associations of HO cardiac disorders with other congenital cardiac malformations, specifically persistent left superior vena cava (PLSVC) are rarely reported and its real incidence is unknown. We present a case of this unusual combination in a patient undergoing cardiac resynchronization therapy (CRT) device implant.

METHODS AND RESULTS

A 63-year-old male with HO and a history of repaired atrial septal defect was presented for implantable cardioverter defibrillator (ICD) upgrade to CRT. The old implant was located in the right prepectoral area. The old device pocket in the right was accessed and a venous access to the right subclavian vein was obtained. The coronary sinus (CS) was easily cannulated and a long sheath advanced into the CS. A contrast injection revealed an unusually big-sized CS, with a diameter 2.5 times the fully deployed balloon. A 0.035 wire was advanced retrograde reaching the confluence of the innominate and left subclavian veins. The outer sheath was advanced to this location and contrast venography through the sheath allowed visualization of the left jugular and subclavian veins and visualization of the PLSVC draining into the CS. No target veins for lead implant were identified. The patient was referred for surgical implant of an epicardial lead. Transesophageal echocardiogram showed a CS identified as an unusually big vascular structure located between the left atrium and the left atrial appendage.

CONCLUSION

We report an uncommon association of HO and PLSVC. This association was only reported twice in the past and this is the first one that constitutes a casual finding during the attempt of CRT device implant. This is a combination that may complicate a device implant and recognition of it in advance may avoid performing potentially unsuccessful procedures.

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-sided superior vena cava: integrated noninvasive diagnosis

Persistent left superior vena cava (PLSVC) is a rare finding. We describe 5 patients with PLSVC diagnosed by a noninvasive approach, including two-dimensional (2D) echocardiogram, nuclear magnetic resonance and multislice computed tomography (MCT). In 4 cases the PLSVC was isolated ("alone PLSVC"), and in 1 case associated with a right superior vena cava.

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

BACKGROUND

In case reports and small series, the coexistence of a persistent left superior vena cava (LSVC) and extra-cardiac anomalies has been noted. However, an association between LSVC and extra-cardiac anomalies has not been documented. We investigated the association between LSVC and extra-cardiac anomalies in patients referred to our tertiary pediatric cardiology department between 1998 and 2005.

METHODS

Trans-thoracic echocardiograms were performed on 4426 consecutive patients. Cardiac and extra-cardiac anomalies were registered prospectively in a computerized database. In a retrospective observational design, characteristics of patients with LSVC were collected.

RESULTS

In 4426 patients, 1825 (41%) were diagnosed with congenital heart disease (CHD) and 295 patients (7%) with extra-cardiac anomalies. LSVC was present in 102 patients, of which 89 (87%) with CHD (OR 10.2, 95% CI 5.7 to 18.3, p<0.001) and 61 (60%) with extra-cardiac anomalies (OR 26.0, 95% CI 17.1 to 39.5, p<0.001). Confirmed syndromes were present in 43 LSVC patients (42%), including VACTERL association (vertebral defects, anal atresia, cardiac malformations, tracheo-esophageal fistula with esophageal atresia, radial and renal dysplasia, and limb anomalies, 9%), trisomy 21 (7%), 22q11 (6%) and CHARGE association (coloboma, heart defects, atresia of choanae, retardation, genital and ear anomalies, 5%). In 17 LSVC patients (17%) with multiple anomalies in different organ systems, a syndrome diagnosis was not confirmed.

CONCLUSIONS

The LSVC appears to be indicative for both cardiac and extra-cardiac anomalies (e.g. septal defects, tetralogy of Fallot, VACTERL and CHARGE association). Disorders in the development of the secondary heart field may be causal to this combination of anomalies.

Implantation of a biventricular pacing and defibrillator device via a persistent left superior vena cava

A persistent left superior vena cava was discovered in a 66-year-old man with heart failure undergoing implantation of a biventricular pacing and defibrillator device. An active fixation right ventricular defibrillator lead was placed through a curved guiding catheter. A sub-selection catheter and a guidewire allowed the engagement of a posterior-lateral branch of the coronary sinus, performance of an angiogram without an occlusive balloon, and optimal lead placement. The right atrial lead was positioned using a standard stylet. Despite the technical challenges, implantation of a biventricular pacing and defibrillator device via a persistent left superior vena cava is safe and feasible.

A case of absent right and persistent left superior vena cava

BACKGROUND AND PURPOSE

Our case report deals with the importance of detailed echocardiographic examination for differential diagnosis of coronary sinus dilation and development of abnormalities of great thoracic veins.

CASE PRESENTATION

A 49-year-old man underwent transthoracic echocardiography for atypical chest pain. A dilated coronary sinus was found and venous contrast echocardiography raised the suspicion of absent right and persistent left superior vena cava. Transesophageal echocardiography showed absence of right superior vena cava. The echocardiographic findings were confirmed by upper venous digital subtraction cavography.

CONCLUSION

combination of agenesia of right SVC and isolated persistent left SVC in adult patients is a very rare abnormality. Both clinicians and sonographers should be alerted to the possible presence of this combined venous anomaly. Transthoracic echocardiograpy - including agitated saline infusion to the antecubital vein - is an important diagnostic tool for accurate diagnosis of this congenital thoracic venous malformation.

Echocardiographic evaluation of left superior vena cava to the left atrium

We report two cases of left superior vena cava draining directly to the left atrium in the absence of complex congenital heart disease. This is a rare finding causing a decrease in patient oxygen saturations. The location and diagnosis of this systemic venous anomaly requires diligence on the part of the cardiac sonographer, who should be able to identify the structure during the course of a thorough echocardiographic examination. Both adult and pediatric cardiac sonographers should be alerted to the possible presence of this vessel. Once the vessel has been successfully identified, repair and follow-up are relatively simple with positive patient prognosis.

Biventricular pacing via a persistent left superior vena cava: report of four cases

Persistence of left superior vena cava (LSVC) is an uncommon finding during pacemaker implantation, which may be particularly relevant in performing LV transvenous pacing. Rarely, it is further complicated by the presence of atresia of the coronary sinus ostium (CSO). This article reports the authors experience with biventricular pacing (Biv-P) in this unusual clinical setting. From October 1999 to April 2002, 158 patients underwent biventricular pacing. In four of them (mean age 62.2 years), the presence of a persistent LSVC draining into the coronary sinus (CS) was detected at implantation, associated with atresia of the CSO in two patients. A common characteristic was the angiographic finding of a large CS with few tributaries. The LV leads were successfully positioned in the middle cardiac vein in three patients and in a posterolateral vein in one patient. All vessels were large and their cannulation via downstream CS catheterization required the lead to be manipulated through sharp angles. Mean fluoroscopic exposure and procedural times were not significantly different from the overall Biv-P population. In all patients, at a mean follow-up of 11 months, sensing and capture threshold remained stable and a significant decrease in NYHA functional class and increase in LVEF were noted. The direct lead placement in large CS tributaries in the presence of persistent LSVC was feasible and safe. The leads remained stable up to a mean follow-up of nearly 1 year.

Implantation of a cardiac resynchronization system for idiopathic dilated cardiomyopathy in a patient with persistent left superior vena cava using an experimental lead for left ventricular stimulation

A persistent left superior vena cava (PLSVC) was discovered at the implantation of a cardiac resynchronization system in a woman with an idiopathic dilated cardiomyopathy. Standard leads were used to obtain right ventricular and right atrial (RA) stimulation according to a formerly described technique. The left ventricle was stimulated through the posterolateral vein of the heart by a novel lead design to be used over a guidewire for placement. Despite expected difficulties in this anatomic situation, the research lead was positioned in 23 minutes.

Right ventricular electrode lead implantation via a persistent left superior vena cava. An improved technique

Persistent left superior vena cava occurs in approximately 0.5% of the population. This may complicate pacemaker implantation by making lead insertion difficult and causing lead instability through the left cephalic vein and the subclavian vein approach. We used a wide loop technique in the right atrium and successfully advanced the lead in the right ventricle apex. A persistent left superior vena cava does not preclude successful lead placement.

Prospective angiographic study of the abnormalities of systemic venous connections in congenital and acquired heart disease

Angiographic definition of systemic venous connections was obtained prospectively in 780 consecutive patients with congenital heart disease and 102 patients with acquired valvular heart disease undergoing cardiac catheterization. Attempts were made to enter the innominate vein and perform a balloon occlusion angiogram in each patient. In patients with congenital heart disease, bilateral superior vena cava were present in 32/771 patients (approximately 4%) with levocardia and 3/9 patients with dextrocardia. Among patients with bilateral superior vena cava (n = 35), an innominate vein of variable size that could be entered was present in six patients. Small tributaries connecting the right and left superior vena cava were found and entered in six patients. The superior vena cava was entered via its connection to morphologic left atrium in five patients and via the coronary sinus in 17 patients. Abnormalities of the inferior vena cava were seen in 7/780 patients. The following abnormalities of the inferior vena cava were noted: azygous continuation of rightsided inferior vena cava in levocardia -- 3 patients, hemiazygos continuation of the leftsided inferior vena cava in levocardia -- 1 patient, azygos continuation of the leftsided inferior vena cava in dextrocardia -- 1 patient, interruption of inferior vena cava below the liver with a plexus of veins joining the azygos vein -- 1 patient, and an inferior vena cava draining into the leftward aspect of the common atrium -- 1 patient. Abnormalities of the systemic venous connections were seen in 2/102 patients with acquired heart disease: bilateral superior vena cava in 1 patient and bilateral inferior vena cava in 1 patient.

CONCLUSIONS

Abnormalities of systemic venous connections were seen in approximately 5% patients with congenital heart disease and approximately 2% patients with acquired heart disease. Small tributaries or an innominate vein of variable size often connect left and right superior vena. Contrast material can be injected into these connections to document the presence of bilateral superior vena cava.

Echocardiographic imaging of coronary sinus diverticula and middle cardiac veins in patients with preexcitation syndrome: impact on radiofrequency catheter ablation of posteroseptal accessory pathways

To determine the value of echocardiography for identifying coronary sinus (CS) diverticula and middle cardiac veins (MCVs) in patients with posteroseptal accessory pathways (PAPs), transthoracic (TTE) and transesophageal echocardiography (TEE) were performed in 18 consecutive patients with PAP and in 15 control subjects with left lateral accessory pathway before CS angiography. The size, shape, and location of CS diverticula and MCV were described and compared to angiography. TEE and angiography were concordant for the identification of diverticula (n = 5) and agreed for depicting MCV in 22 of the 27 cases. TTE revealed 4 of 5 diverticula and identified 4 of 27 MCV (P < 0.001). Fourteen MCV but no diverticula were found in the control subject. There was no significant difference between transesophageal and angiographic measurements for the width (23.5 +/- 4.9 vs 26.8 +/- 6.6 mm) and height (13.5 +/- 3.8 vs 15.7 +/- 3.4 mm) of the diverticula, and the width (3.5 +/- 0.7 vs 3.7 +/- 0.6 mm) of MCV. TEE underestimated the length of the MCV (12.0 +/- 1.8 vs 27.2 +/- 6.0, P < 0.001). Delivery of radiofrequency energy within the neck of a diverticulum or within an MCV was successful in 5 of 5, and 6 of 13 cases in patients with PAPs, respectively. In conclusion, echocardiography was as reliable as angiography for detecting and describing CS diverticula and MCV in patients with preexcitation syndrome. Echocardiography is recommended prior to electrophysiological study because it may simplify radiofrequency catheter ablation.

Can a dilated coronary sinus produce left ventricular inflow obstruction? An unrecognized entity

Drainage of a persistent left superior vena cava to the coronary sinus is a common congenital lesion associated with dilatation of the coronary sinus. We report on 4 cases in which marked enlargement of the coronary sinus was present, immediately superior to and partially occluding the mitral valve, with consequent obstruction to left ventricular inflow. In 1 patient, presenting with cardiac failure in early infancy, this abnormality was the major defect, mimicking the features of cor triatriatum, and surgical correction led to significant symptomatic improvement. In 3 other patients this abnormality was associated with other congenital lesions, and it is postulated that in these cases impairment of flow into the left ventricle in the presence of an atrial septal defect elevated the left atrial pressure and increased the shunt across the atrial septum, thereby increasing the symptoms and clinical findings. Surgical reduction of the enlarged coronary sinus was performed in each case through the interatrial septum, and the technique is described.

Usefulness of magnetic resonance imaging in the assessment of venoatrial connections, atrial morphology, bronchial situs, and other anomalies in right atrial isomerism

Multiple complex venous and intracardiac anomalies are frequently seen in patients with right atrial isomerism, and complete anatomic information may not always be obtained from combined echocardiography and angiography. Twenty patients with right atrial isomerism were prospectively studied with use of magnetic resonance imaging (MRI); satisfactory imaging was obtained in 18 patients, aged 6 days to 12 years (median 3 months). All patients had undergone echocardiography, cardiac catheterization, and angiocardiography. The purpose of this study was to assess the usefulness of MRI in the evaluation of venoatrial connections, atrial morphology, bronchial situs, and additional anomalies. Bilateral superior venae cavae were documented in 12 patients and anomalous hepatic venous drainage in 11. The pulmonary venous system was imaged in all 18 patients, of whom 12 had total anomalous pulmonary venous connection: 9 supracardiac, 2 infracardiac, and 1 mixed type. Some obstruction to pulmonary venous return was present in 9 of the 12 patients, and the site of obstruction was demonstrated by MRI in 6. Bilateral morphologic right atrial appendages were imaged in 7 patients. Bilateral morphologic right bronchi were identified in 17 patients, asplenia was confirmed in 17 of 18 patients by the absence of splenic tissue on imaging, and hiatal hernia was imaged in 4. Compared with angiography and echocardiography, MRI more clearly defined the pulmonary venous connections in 10 patients with pulmonary venous obstruction. Anomalous hepatic venous connections were better defined by MRI in 2. Therefore, MRI provided valuable supplementary information on the cardiovascular and visceral anomalies in these patients.

Contrast Two-Dimensional Echocardiography Provides Clinical Information Not Available with Color Flow Imaging

Contrast two-dimensional (2D) echocardiography using peripheral venous injections of agitated saline provides useful clinical information not available with standard 2D Doppler and color flow imaging techniques. Intraor extracardiac right-to-left shunting in patients with atrial or ventricular septal defects and patent ductus arteriosus can be identified in this manner, and the relative degree of shunt can be assessed. Other conditions, such as left superior vena cava to the coronary sinus or pulmonary arteriovenous malformation, are accurately detected only when contrast 2D echo is incorporated during the noninvasive examination. Recent work has also demonstrated that venous injections of agitated saline can be used to enhance continuous wave Doppler recordings of tricuspid regurgitant jet envelopes when poorly defined, or with color flow imaging to characterize the jet area. Twodimensional visualization of the needle placed in the pericardial sac for drainage of pericardial effusion may be difficult. Injection of agitated saline through the needle may be used to verify proper location in the pericardial sac and not in the ventricular chambers. The role of contrast 2D echocardiography with new agents has been used to assess myocardial perfusion. All of these applications of contrast echo contribute to standard echocardiographic techniques to provide a better characterization of flow dynamics not seen with color flow imaging.