The left-sided superior vena cava

Persistent Left Superior Vena Cava and Inferior Vena Cava Dual Drainage to Coronary Sinus: A Case Report

Dilation of the coronary sinus is often a result of excessive volume overload from congenital anomalies of systemic venous return to the heart. These abnormalities are often discovered incidentally later in life when a patient requires cardiac imaging, cardiac catheterization, or thoracic surgery. The most common abnormality is a persistent left superior vena cava. Inferior vena cava malformation is less common, yet several different anomalies can arise. The presence of persistent left superior vena cava or inferior vena cava anomalies requires further evaluation to rule out congenital heart disease in infants. Knowledge of technically challenging systemic venous anatomy is beneficial prior to procedures necessitating central venous access such as a central line, cardiac catheterization, and intracardiac device implantation. We present an unusual case of persistent LSVC and IVC both draining directly into a severely dilated coronary sinus that was diagnosed by fetal echocardiogram and later confirmed postnatally by transthoracic echocardiogram and computed tomography angiography. To our knowledge this is the second reported case of IVC drainage into the CS and the first case that reports this as a prenatal diagnosis.

An unusual case of dilated coronary sinus: case report and clinical implications

Background 

The presence of a dilated coronary sinus (CS) assessed by transthoracic echocardiography (TTE) is highly suggestive of inferior or superior vena cava (SVC) anomalies, in the absence of a shunt. The most frequent finding is the persistence of a left superior vena cava (LSVC): well-known feature to electrophysiologists. Abnormal inferior vena cava (IVC) drainage is another cause of CS dilatation.

Case summary 

An 83-year-old woman presented with heart failure symptoms, atrial fibrillation with rapid ventricular rate, and a dilated CS assessed by TTE. Atrioventricular (AV) node ablation was considered given the poor efficacy of a rate control strategy. Cardiac computed tomography (CT) revealed a double SVC with an LSVC draining directly into the dilated CS. Single-lead pacemaker implantation was performed using a right-sided vascular access with no technical difficulties. An aborted AV node ablation procedure was due to the impossibility of getting to the right atrium. Fluoroscopy and CT imaging at second look analysis confirmed the diagnosis of an abnormal IVC with an agenesia of its supra-hepatic segment directly drained into the CS.

Discussion 

Our clinical case illustrates an unusual and rare double venous abnormality: both LSVC and IVC directly drained into the CS and were responsible for its massive dilatation.

Developmental anomalies of the superior vena cava and its tributaries: What the radiologist needs to know?

Deviations from the normal process of embryogenesis can result in various developmental anomalies of the superior vena cava (SVC). While these anomalies are often asymptomatic, they assume clinical importance during interventions such as central venous catheterisations and pacemaker implantations and during cardiothoracic surgeries while instituting cardiopulmonary bypass and for creation of cavo-pulmonary connections. Role of imaging in identifying these anomalies is indispensable. Cross-sectional imaging techniques like CT venography and magnetic resonance (MR) venography allow direct visualisation and consequently increased detection of anomalies. CT venography plays an important role in detection of SVC anomalies as it is readily available, has excellent spatial resolution, short acquisition times and potential for reconstruction of images in multiple planes. This pictorial review focuses on the developmental anomalies of the SVC and its tributaries highlighting their embryological basis, imaging appearances on CT venography and potential clinical implications, where relevant.

Implantation of a Dual-Chamber Automatic Cardioverter Defibrillator in a Patient with Persistent Left Superior Vena Cava: Case Report and Brief Literature Review

Persistence of the left superior vena cava (PLSVC) is a congenital anomaly reported in 0.3–0.5% of patients. Due to the multiple and complex anatomical variations, transvenous lead placement can become challenging. We report the case of a 47-year-old patient diagnosed with non-ischemic dilated cardiomyopathy with reduced left ventricular ejection fraction (LVEF—27%), who was referred to our clinic for implantation of a dual-chamber cardioverter defibrillator for primary prevention of sudden cardiac death. During the procedure we encountered an abnormal guidewire trajectory and after venographic examination we established the diagnosis of persistent left superior vena cava. After difficult implantation of a 7F defibrillation lead through the coronary sinus, we managed to place the atrial lead through a narrow brachiocephalic vein into the right atrial appendage. In this paper, we aim to illustrate the medical and technical implications of implanting a cardioverter defibrillator in patients with PLSVC, highlighting the benefit of identifying and utilizing both the innominate vein, and the left superior vena cava and coronary sinus for placement of multiple leads, which would otherwise have been impossible.

Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava and Discrete Subaortic Stenosis Diagnosed in a Patient with Sick Sinus Syndrome: A Case Report and Brief Review of the Literature

A persistent left superior vena cava (PLSVC) is the most frequent anomaly of the venous drainage system. While both a right and left superior vena cava (SVC) are usually present, a unique, left-sided SVC, also known as an isolated PLSVC, accounts for only 10–20% of cases. It is frequently associated with arrhythmias and other congenital cardiac anomalies. Though it is usually an asymptomatic condition, it may pose significant problems whenever central venous access is needed. We report a case of an isolated PLSVC that was diagnosed incidentally during pacemaker implantation for sinus node dysfunction. The venous anomaly was associated with subvalvular aortic stenosis determined by a subaortic membrane; this particular association of congenital cardiovascular anomalies is a rare finding, with only a few cases reported in the literature. We aim to highlight the clinical and practical implications of this condition, as well as to discuss the embryonic development and diagnostic methods of this congenital defect.

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.

A case report: upgrade to cardiac resynchronization therapy with a blocked persistent left-sided superior vena cava

Background 

Pacemaker-induced cardiomyopathy (PICM) can occur in up to 9% of patients having a pacemaker. Pacemaker-induced cardiomyopathy can be treated by upgrade to a biventricular pacemaker with a left ventricular (LV) lead implantation. The procedure can be technically challenging in patients with persistent left-sided superior vena cava (PLSVC).

Case summary 

We report the case of a 72-year-old gentleman with a PLSVC, who had a dual-chamber pacemaker implanted 15 years ago for complete heart block. After 12 years of good health, the gentleman developed breathlessness due to PICM. At upgrade to biventricular pacemaker, his coronary sinus was found to be occluded and a collateral branch was used to successfully position an LV lead. Marked clinical improvement was seen before representation with syncope after 2 years due to simultaneous failure of both LV and right ventricular leads. Subsequently, a right-sided de novo biventricular pacemaker was implanted. In this instance, the PLSVC was beneficial because it isolated the existing leads from the new implant, thereby reducing the risk of SVC obstruction.

Discussion 

Although implantation of pacemaker leads through a PLSVC constitutes a challenging procedure due to manoeuvring difficulties of the pacing leads into the cardiac chambers, in this particular case, the presence of PLSVC was beneficial because it meant that no leads were present in the true SVC, reducing the risk of occlusion and avoiding the need for lead extraction.

Persistent left superior vena cava in patient with right atrial myxoma undergoing open heart surgery. A case report and review of literature

Persistent left superior vena cava (PLSVC) is a rare and asymptomatic congenital cardiovascular anomaly. Being asymptomatic, PLSVC was usually discovered while performing interventions (such as insertion of central lines, Swan-Ganz catheters, or placing pacemakers) through the left internal jugular vein or left subclavian veins. Commonly, PLSVC is detected not only as an isolated congenital anomaly, but also it can be associated with many other cardiac anomalies. Also, presence of a dilated coronary sinus on echocardiography should raise the suspicion of PLSVC. The diagnosis should be confirmed by contrast venography or computed tomography angiography. The present case is a female patient, 29 year old, who was undergoing elective excision of a right atrial mass, with closure of patent foramen ovale, and she had end-stage renal failure on regular hemodialysis three times weekly through a permicath inserted in the right subclavian vein.

Autopsy findings of an isolated persistent left superior vena cava in an intrauterine dead fetus

Persistent left superior vena cava (PLSVC) is one of the cardiac system abnormalities with a 0.3-0.5% incidence and caused by inadequate obliteration of the left anterior cardinal vein during embryonic development. Prognosis of PLSVC is generally assumed to be good if it is not accompanied by other cardiac system abnormalities. During the routine ultrasound control of a patient at 25th week of pregnancy at the Obstetrics and Gynecology Department of Mersin University, PLSVC anomaly was detected in an intrauterine fetus. Then, intrauterine death occurred and after removal of the deceased fetus, PLSVC diagnosis was confirmed by autopsy. According to the autopsy findings, right superior vena cava (SVC) and azygos vein were found in normal course. PLSVC opened into the right atrium via enlarged coronary sinus. There was no connection between the two SVCs. On the left side of posterior mediastinum, instead of hemiazygos or accessory hemiazygos veins, a vein symmetrical to azygos was opened into PLSVC, similar to the one on the right. No other cardiac anomaly associated with PLSVC or any other pathology in the other parts of body that could be responsible for death was discovered during autopsy. There was no evidence indicating that PLSVC played any role in intrauterine exitus of the present case. However, as mentioned in the literature, the ectopic beats in the atrium wall of patients with isolated PLSVC and enlarged coronary sinus may lead to pathologies in the conduction system of the heart. Considering the intrauterine death of an isolated PLSVC case associated with cardiac conduction pathologies, we recommend that the common assumption of 'isolated PLSVC is not associated with death' should be reviewed by studies on large series and even intrauterine cases should be closely monitored for cardiac arrhythmia.

Double superior venae cavae with absence of the coronary sinus and anomalies of the azygos venous system

The superior vena cava is formed during the fetal period by the development of anastomoses between the right and left anterior cardinal veins, and the regression of the central part of the left anterior cardinal vein. The persistence of this part of the left anterior cardinal vein causes the formation of a left superior vena cava, which is a rare anomaly in cadaver dissection. We report the case of a persistent left superior vena cava with a normal right superior vena cava in a 95-year-old male cadaver, which was discovered during anatomical dissection for medical students at Kawasaki Medical School in 2016. The left superior vena cava was formed by the confluence of the left internal jugular and left subclavian veins and terminated in the right atrium via what would normally be the coronary sinus. The right and left superior venae cavae received intercostal veins via a right and left azygos vein, respectively. However, the right azygos vein was shorter than the normal azygos vein and received only the second to fifth intercostal veins, whereas the left azygos vein received the fifth to eleventh left intercostal veins and the sixth to eleventh right intercostal veins. We consider that the anomalies of the azygos venous system were the result of regression of right supracardinal vein and the persistence of the left supracardinal vein during development. An awareness of such variations of major thoracic veins is important for the interpretation of unusual CT images.

Percutaneous closure of right coronary to superior vena cava fistula

Coronary artery to superior vena cava (SVC) fistula is a very rare congenital anomaly of the heart. It typically follows the course of sinoatrial-nodal branch. It can originate from the right coronary or circumflex artery. In the majority of cases, it terminates in the SVC close to the right atrium junction. Only five cases were treated in literature successfully through a transcatheter approach. We present a case with a symptomatic right coronary artery to SVC fistula treated with a unique percutaneous embolization using a guidewire loop/balloon occlusion technique. Controlled access and embolization of the fistula was achieved by through-and-through guidewire access across the coronary fistula from the arterial groin access to the venous groin access with balloon occlusion of the coronary artery fistula while detachable coils were positioned.

Left upper pulmonary vein connected to the persistent left superior vena cava and the left atrium

Persistent left superior vena cava (PLSVC) is the most common anomalous thoracic venous drainage. A PLSVC usually drains into the right atrium through a dilated coronary sinus. It is rare that a PLSVC flows directly into the left atrium, and even rarer that it connects to the left upper pulmonary vein (LUPV). We report a case, wherein the LUPV connected to both the PLSVC and the left atrium.

Persistent Left Superior Vena Cava in a Hemodialysis Patient

Awareness of persistent left superior vena cava (PLSVC), a rare congenital variant is helpful to a clinician to avoid the unnecessary complications. We report a case of PLSVC in a patient with chronic kidney disease which was identified following a difficult catheterization into the right internal jugular vein (IJV). The catheterization was attempted through the left IJV and the position of which could not be confirmed with check radiograph and two-dimensional echo. PLSVC was suspected in the computed tomography angiography and was confirmed following digital subtraction angiography.

Cardiac Arrhythmias in Patient with Isolated Persistent Left Superior Vena Cava

We report here the case of a 47-year-old male presented with atypical chest pain, fatigue and arrhythmias that was found to have persistent left superior vena cava. The clinical exam was normal. Twelve leads ECG showed sinus rhythm of 70 beats/min, QRS axis of 90 degree and right bundle branch block. Transthoracic echocardiography revealed left ventricular hypertrophy, a large coronary sinus and mild pulmonary hypertension. Saline contrast echocardiography was performed and micro-bubbles were visible first into the coronary sinus and then passed through the right atrium. Multislice computed tomography confirmed the presence of persistent left superior vein cava and the site of drainage into the right atrium via a large coronary sinus. Right superior vein cava was absent. In this case report, we emphasize the importance of full assessment in patient with persistent left superior vena cava.

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.

An Innovation in Pacemaker Lead Implantation via Persistent Left Superior Vena Cava: The "3D Alpha Curve" Stylet

Persistent left superior vena cava (PLSVC) draining into coronary sinus is typically detected incidentally during transcatheter interventions using left subclavian venous approach. In our experience, we have encountered this anomaly on a few occasions and in all these cases we successfully implanted leads in the right ventricle (RV) by shaping the stylet into a "U-shaped" or "pigtail-shaped" curve. Herein, we report a case of an adult male who underwent successful dual-chamber pacemaker implantation via PLSVC through left axillary venous approach. In this case, we were unable to deliver the lead into RV using aforementioned stylets. As an innovation, we used a "three-dimensional alpha curve"-shaped stylet that facilitated an easy entry of pacing lead into the RV.

Percutaneous Intervention of a Persistent Left Superior Vena Cava Draining Into Left Pulmonary Vein and Coarctation of the Aorta

We describe a 54-year-old male with history of type II DM, hypertension and dyslipidemia during admission for bronchopneumonia discovered to have coarctation of the aorta and a persistent left superior vena cava (PLSVC) draining into the left atrium through the left superior pulmonary vein. The latter was thought to contribute to a transient ischemic attack and an episode of chest pain resulting in ST-segment elevation in the inferior leads. He was treated with coarctation stenting and percutaneous exclusion of the PLSVC with a vascular plug.

Persistent Left Superior Vena Cava Draining Into the Left Atrium Found During Bypass Operation

We report the case of a 72-year-old woman who underwent urgent coronary bypass grafting (CABG). Intraoperatively a persistent left superior vena cava (PLSVC) draining into the left atrium was detected. Because of the resulting right-to-left shunt volume even after complete drainage and collapse of the right atrium, the heart was still ejecting in the absence of significant aortic insufficiency. Thorough examination revealed a PLSVC draining into the left atrium. After ligation of the PLSVC, the CABG could be performed as planned.

Percutaneous device closure of Persistent Left Superior Vena Cava Connecting to the Left Atrium with intact coronary sinus: A Rare Entity

We report a 4 year old child referred for routine cardiology evaluation as part of evaluation of murmur with scoliosis. On examination, there was mild duskiness. Echocardiography revealed bilateral superior vena cavae, a small innominate vein, a left superior vena cava to the left atrium and an intact coronary sinus. The findings were confirmed on computed tomography angiography. Percutaneous closure of the left superior vena cava by an Amplatzer vascular plug was done successfully. Although the patient was apparently asymptomatic, the procedure was done to prevent risk of cerebral emboli.

An extremely rare case report of surgery of lung cancer with the absence of azygos vein

In thoracic surgery, we occasionally encounter vessel anomalies. We herein report an extremely rare surgical case with the absence of the azygos vein. Mediastinal vascular abnormalities are said to be rare. The etiology of vascular abnormalities of the whole body, including the chest is known gene mutations, hormone abnormalities, infection, and trauma. But, many causes have been unknown. In thoracic surgery field, there is some reports and literature about pulmonary arteriovenous malformation, pulmonary sequestration, and partial anomalous pulmonary venous return. But reports about absence of azygos vein are not much. It is considered that it is less likely to become a problem in clinical. As we discussed in the paper, it will be more interesting if the association with PLSVC reveals from more cases. A 58-year-old man was admitted to our hospital in order to undergo operation for the treatment of lung cancer. We detected absence of the azygos vein by preoperative computed tomography (CT). Furthermore, three-dimensional angiography (3D-angiography) showed that the right superior intercostal vein and hemiazygos vein in the left thoracic cavity were more developed than usual. Then, we discuss the key points during surgery and suggest the potential association between the absence of the azygos vein and a persistent left superior vena cava (PLSVC).

MR Imaging of Thoracic Veins

MR imaging of thoracic veins is performed to evaluate the heart and thoracic vasculature. The protocol can be customized to the clinical question. In the embryo, systemic and pulmonary vein development is closely related to heart development. Congenital anomalies of the thoracic veins are strongly associated with other cardiac and situs abnormalities. Acquired venous abnormalities are often iatrogenic, or secondary to malignancy. This article discusses development and anatomy of the thoracic venous systems, clinical MR imaging methods for their evaluation, and illustrates the MR imaging appearance of congenital and acquired abnormalities of systemic thoracic veins, coronary sinus, and pulmonary veins.

Congenital Anomalies of Superior Vena Cava and their Implications in Central Venous Catheterization

Congenital anomalies of superior vena cava (SVC) are generally discovered incidentally during central venous catheter (CVC) insertion, pacemaker electrode placement, and cardiopulmonary bypass surgery. Persistent left SVC (PLSVC) is a rare (0.3%) anomaly in healthy subjects, usually asymptomatic, but when present and undiagnosed, it may be associated with difficulties and complications of CVC placement. In individuals with congenital heart anomalies, its prevalence may be up to 10 times higher than in the general population.

In this perspective, awareness of the importance of the incidental finding of PLSV during CVC placement is crucial. To improve knowledge of this rare but potentially dangerous condition, we describe the embryological origin of SVC, its normal anatomy, and possible congenital anomalies of the venous system and of the heart, including the presence of a right to left cardiac shunt. Diagnosis of PLSVC as well as the clinical complications and technical impact of SVC congenital anomalies for CVC placement are emphasized.

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.

[Placement of a central venous catheter in cases of persistent left superior vena cava]

This article presents a case report on the placement of a central venous catheter (CVC) in a patient with an unknown persistent left superior vena cava (PLSVC). Normally, PLSVCs remain asymptomatic but can be associated with disastrous consequences for the patient during placement of a CVC particularly due to vascular perforation and pulmonary injury. A PLSCV is particularly common in association with congenital heart defects; however, otherwise healthy patients can also be affected. As the presence of a PLSCV is normally unknown special attention must be paid in every patient during placement of a CVC.

Knowledge of the anomalies of the big central veins reduces the morbidity during the cannulation for hemodialysis: Description of a case of persistent left superior vena cava and revision of literature

The persistence of a left superior vena cava is the result of a lack of an embryological involution of the left anterior cardinal vein. This anomaly is very rare: about 0.3% of the general population. Its incidence increases remarkably from 3-10% in those patients affected with congenital heart disease. Described herein is a case of persistent left superior vena cava, discovered by chance, following the placement of a central venous catheter for hemodialysis. A chest X-ray in projection back-forward showed the central venous catheter along the left sternal margin simulating a placement in the aorta artery. This clinical picture, as described in the literature, is often accompanied by other anatomical anomalies, in our case, by the congenital agenesis of a solitary pelvic kidney. In agreement with the literature and in contrast with what has been reported recently, we sustain that a central venous catheter placed, for any reason, in the persistent left superior vena cava must be removed immediately because it can induce hyperkinetic arrhythmia and cardiac arrest as in our case. Our case report should be a warning that lack of awareness of the anomalies of the big central veins can cause a rise in morbidity.

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.

Chronic cyanosis due to persistent left superior vena cava draining into the left atrium in the absence of a coronary sinus

We report a rare case of a 5-year-old child who presented with chronic hypoxemia and a normal cardiac examination, and was found to have a persistent left superior vena cava draining directly into the left atrium. The coronary sinus was absent. This case introduces a contradiction to the generally accepted concept that this anomalous connection can only occur in the presence of a partly or completely unroofed coronary sinus. High index of suspicion is required to include this pathology in the differential diagnosis for a patient with persistent cyanosis with normal cardiac examination.

Central venous catheters in the left-sided superior vena cava: clinical implications

AIM

Left-sided superior vena cava (LSVC) is a congenital venous anomaly with an incidence of about 0.3%, and which is sometimes discovered during vascular intervention [Le Cat. Histoire de l'acadroyale des sciences .Paris 1738:62, I Steinberg, W Dubilier, D Lucas. Persistence of left superior vena cava. Dis Chest 1953;24:479-88]. There is little clear guidance on what to do in this event.

METHODS

Children with LSVC were identified from our prospectively collected database of percutaneous central venous catheter (CVC) insertions between 2004 and 2011. If a LSCV was suspected, usually a venogram was performed. All available documentation was reviewed to identify complications.

RESULTS

Eleven children with LSVC had 12 CVCs during the study period. Mean age at operation was 5.8 years (range 27 days to 15 years). Cardiovascular anomalies were already known in three cases. After CVC insertion, the line tip lay in the LSVC in eight cases and in the RA in 4. In 11 cases there was no immediate problem, but in 1 case there were postoperative bradyarrhythmias, which caused the CVC to be removed on day 1. This case was later found to have abdominal sepsis. The mean duration the CVCs were retained was 331days (range 1 day to 4 years). Other reasons for CVC removal were infection (n=1), damaged line (n=2), no longer required (n=2), and death unrelated to CVC (n=2).

CONCLUSIONS

Our experience suggests that a LSVC (i) is often first discovered during CVC insertion, (ii) can be safely used for parenteral nutrition or chemotherapy, and (iii) the best practice would be to leave the CVC tip high in the LSVC or in the RA via another route.

Imaging of the coronary sinus: normal anatomy and congenital abnormalities

Knowledge of the anatomy of the coronary sinus (CS) and cardiac venous drainage is important because of its relevance in electrophysiologic procedures and cardiac surgeries. Several procedures make use of the CS, such as left ventricular pacing, mapping and ablation of arrhythmias, retrograde cardioplegia, targeted drug delivery, and stem cell therapy. As a result, it is more important for physicians interpreting the results of computed tomographic (CT) examinations dedicated to the heart or including the heart to be able to identify normal variants and congenital anomalies and to understand their clinical importance. Abnormalities of the CS range from anatomic morphologic variations to hemodynamically significant anomalies such as an unroofed CS, anomalous pulmonary venous connection to the CS, and coronary artery-CS fistula. It can be important to identify some anatomic variations, even though they are clinically occult, to ensure appropriate preprocedural planning. Both CT and magnetic resonance imaging provide excellent noninvasive depiction of the anatomy and anomalies of the CS. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.324105220/-/DC1.

Anomalous venous circuit: a detour to the heart

We report a case of a complicated vascular access secondary to systemic venous defects, which have not been previously reported. Evaluation revealed an atypical coursing of a subclavian vein-persistent superior vena caval system into the hemizygos-azygos system and ultimately into the right (proper) superior vena cava. The clinical and surgical considerations of such an anomaly are discussed therein. We look at embryological origins of such a merger and share our experience in troubleshooting through the anomaly.

A challenging dual chamber permanent pacemaker implantation in persistent left superior vena cava with absent right superior vena cava

An isolated persistent left superior vena cava (PLSVC) with absent right superior vena cava is a rare and generally asymptomatic congenital malformation. It is usually discovered incidentally during a pacemaker implantation or electrophysiological procedures. We report an adult male who underwent successful dual chamber permanent pacemaker implantation through left subclavian approach with a 7-year follow-up showing a still appropriate function of the device. We discuss the technical issues and solutions to overcome such technical difficulties.

Bilateral absence of the superior vena cava

Bilateral absence of the superior vena cava (SVC) is a very rarely detected, mainly asymptomatic congenital vascular anomaly. Though usually innocent, this anomaly may complicate cardiothoracic surgery and certain procedures like central venous catheter insertion. This SVC anomaly is poorly known, and we assume that its incidence in the general population may be higher than detected. In this paper, we summarize current knowledge on this anomaly and its clinical implications. In addition, we present a neonatal case with bilateral absence of the SVC associated with a fetal cystic hygroma. Conclusion. Totally absent SVC can cause unexpected problems during cardiothoracic surgery. Suspicion of SVC absence should arise in basic echocardiography. Our paper suggests that, like other congenital anomalies, bilateral absent SVC may be associated with a fetal cyctic hygroma.

Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients

Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device.

Systemic venous anatomy in congenital heart disease: implications for electrophysiologic testing and catheter ablation

INTRODUCTION

Cardiac arrhythmias are a significant problem in patients with congenital heart disease. Many patients with congenital heart disease have abnormal systemic venous anatomy which can complicate electrophysiologic testing, catheter ablation and pacemaker and defibrillator implantation. We reviewed the systemic venous anatomy in a cohort of patients undergoing electrophysiologic testing and catheter ablation.

METHODS AND RESULTS

We reviewed all electrophysiologic studies performed in patients with adult congenital heart disease (n = 80) at our institution between January 1998 and October 2009. Ten patients (13%) had a congenital systemic venous anomaly. Of these, seven (9%) had a left superior vena cava and four (5%) had infrahepatic interruption of the inferior vena cava (two had both anomalies). One patient's inferior vena cava was connected to a left-sided atrium; she had right atrial isomerism. In four patients (40%), systemic venous abnormalities were discovered at the time of electrophysiologic testing.

CONCLUSIONS

Systemic venous anomalies occur frequently in the congenital heart disease population and may complicate electrophysiologic testing and catheter ablation. Pre-procedural imaging may assist in facilitating a successful procedure.