Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience

Prenatal Diagnosis and Postnatal Outcomes of Persistent Left Superior Vena Cava Associated With Mild Narrow Aorta: A Cohort Study

PURPOSE

To explore prenatal ultrasonic features and prognosis of the persistent left superior vena cava (PLSVC) complicated with mild narrow aorta.

MATERIALS AND METHODS

A retrospective study was conducted involving 1348 fetuses diagnosed with PLSVC prenatally between January 2016 and December 2019. Forty-five fetuses with PLSVC associated with mild narrow aorta were selected from the cohort as the study group and 79 fetuses with isolated PLSCV were recruited randomly as the control group. All clinical and ultrasound results, including images and parameters of cardiac structures, were reviewed retrospectively. General conditions, ultrasound (US) measurements, and fetal prognosis were compared between the groups.

RESULTS

Aorta valve diameter (AOD), Z-score of aorta valve (AODz-score), aortic isthmus diameter (AOIsD), and pulmonary diameter (PAD)/AOD were significantly different in study group than control group no matter in the second or third trimester. Thirty-eight fetuses in study group were born with favorable outcomes after long-term follow-up. A total of 13.16% (5/38) remain mild narrow aorta and 3 of them showed smaller left ventricle after 3 years follow up. Prenatal AODz-score in infants remains mild narrow aorta after 2 years aged was higher than ones' aorta return to normal (P = .01), especially when AODz-score >1.725. Moreover, when prenatal ratio of AOIsD/left subclavian artery was <1.12, it was more likely that the aorta would remain mildly narrow at age 2.

CONCLUSION

Fetuses diagnosed with PLSVC with mild narrow aorta had favorable prognosis. AODz-score and AOIsD/left subclavian artery may be two predictors that reveal the risk of a mildly narrowed aorta remaining after birth.

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).

Slittable sheath supported right ventricular pacing lead implantation in persistent left superior vena cava with absent right superior vena cava: a case report

BACKGROUND

Persistent left superior vena cava (PLSVC) is the most common variant of systemic venous drainage. In the absence of the right superior vena cava (RSVC), implantation of a right ventricular pacing lead may be challenging. Therefore specific implantation techniques and experiences in PLSVC are worth reporting.

CASE PRESENTATION

We present a case report of a 90-year-old Caucasian female patient with PLSVC during single chamber pacemaker implantation due to the third-degree atrioventricular block. With common implantation techniques, we did not even reach the right ventricle. Therefore slittable CPS Direct ™ Universal sheath was employed to overcome the acute angle from PLSVC to tricuspid valve and ensure more fixation stability for longer 100-cm right ventricular lead placement.

CONCLUSION

This case demonstrates safe implantation of 100-cm long right ventricular bipolar active fixation pacing lead using common slittable CPS Direct ™ Universal sheath after failed attempts with "C" and "J" stylet shaped electrode. This sheath provides different angle towards tricuspid valve and more fixation stability in patient with PLSVC and absent connection to right atrium.

Surgical repair of an unroofed coronary sinus in a dog

A 5-year-old, 7.9 kg castrated male Miniature Dachsund presented with heart enlargement on radiography. The dog was asymptomatic. Echocardiography revealed a tubular structure running along the posterior wall of the left atrium and connecting to the right atrium on the caudal side of the left atrium and annulus, which was presumed to be a dilated coronary sinus. After confirming a shunt between the left atrium and coronary sinus by cardiovascular catheterization, an unroofed coronary sinus was diagnosed. Open-heart surgery using cardiopulmonary bypass was performed through left atriotomy. The defect between the left atrium and the coronary sinus was closed by suturing. The cardiac enlargement improved after surgery. The dog was still alive 1227 days after surgery without clinical signs.

A black box congenital heart defect: Anomalous superior vena cava drainage into the left atrium

A 25-year-old pregnant woman with low oxygen saturation due to unclear congenital heart disease was admitted. During work-up the rare anomaly of superior vena cava drainage to the left atrium was diagnosed by transthoracic bubble test with agitated saline. The pathology was later confirmed by contrast multislice computed tomography angiography after delivery.

Pacemaker Implantation in a Patient with Isolated Persistent Left Superior Vena Cava Draining into the Left Atrium: A Case Report and Brief Literature Review

Anomalies of the thoracic venous system are rare and usually discovered incidentally, but they become clinically relevant in the case of patients requiring cardiac device implantation. Persistent left superior vena cava is considered the most common venous drainage abnormality, with several anatomical variants that generate technical difficulties during pacemaker or defibrillator lead placement. We report a case of an isolated persistent left superior vena cava with abnormal drainage into the left atrium, associated with a hypoplastic right-sided superior vena cava, in a patient scheduled for permanent pacemaker implantation. Considering the patient's anatomical characteristics, a transvenous approach proved unfeasible and the procedure was successfully accomplished via the surgical placement of a left ventricle epicardial lead. We aim to emphasize the clinical importance of such venous anomalies and to discuss the practical implications and challenges derived from these types of conditions, especially in the field of electrophysiology.

Surgical resection of a thymoma developed in a case with isolated persistent left superior vena cava

Introduction

Persistent left superior vena cava (PLSVC) is one of the most common vascular abnormalities in the chest. In approximately 10 % of cases, the right superior vena cava is missing, which is called isolated persistent left superior vena cava (IPLSVC).

Presentation of case

The case is an 85 years-old female. An anterior mediastinal tumor was accidentally revealed when the patient was admitted after a traffic accident. As the tumor became larger within four months, a thymectomy was planned. The anterior mediastinal tumor was in front of the ascending aorta, which was close to the confluence of the left and right brachiocephalic veins in normal anatomy. However, in this case, the right superior vena cava was missing, and the right brachiocephalic vein flowed into the left superior vena cava by the chest computed tomography. Preoperative examinations found no accompanying cardiac abnormality. Robot-assisted thymectomy was performed. No tumor infiltration was observed in the right brachiocephalic vein. No abnormality was found in either phrenic nerve. The tumor could be safely resected, and her postoperative course was uneventful. The pathological diagnosis was a thymoma.

Discussion

A case of thymectomy with IPLSVC is quite rare. A careful observation of the preoperative computed tomography images helps to diagnose IPLSVC. Technically, thymectomy was not much different from normal, other than the reversed location of the veins. However, it should be noted that IPLSVC cases may have cardiac malformations.

Conclusion

Thymectomy for thymoma with IPLSVC can be safely performed when the left and right veins are reversed.

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Persistent left superior vena cava (PLSVC) is the most common anatomical abnormality that occurs in the thoracic vasculature. Most PLSVCs are so-called double SVCs that coexist with the right SVC, and isolated PLSVCs (IPLSVCs) that exist only on the left are rare.

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The patient was asymptomatic and had no complications of cardiac malformations. The IPLSVC flowed into the right atrium from the dilated coronary sinus via the vein of Marshall.

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IPLSVC with thymoma is extremely rare. The tumor's location was where the confluence of the left and right brachiocephalic veins would be if the anatomy was normal. In this case, the resection was safely completed despite the anatomical abnormality.

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.

Pictorial Essay: Understanding of Persistent Left Superior Vena Cava and Its Differential Diagnosis

Persistent left superior vena cava (PLSVC) is a rare congenital, thoracic, and vascular anomaly. Although PLSVCs generally do not have a hemodynamic effect, several types of PLSVC and some cardiac anomalies may manifest with clinical symptoms. The presence of PLSVC can render catheterization via left subclavian access difficult when placing a pacemaker or central venous catheter. As such, recognizing a PLSVC that is typically incidentally discovered can prevent complications such as vascular injury. Differentiating vessels found in a similar location as PLSVC is necessary when performing thoracic vascular procedures. This pictorial essay explains the multi-detector CT findings of a PLSVC, and provides a summary of other blood vessels that require differentiation during thoracic vascular procedures.

Anatomical variations in Coronary Venous Drainage: Challenges and Solutions in Delivering Cardiac Resynchronisation Therapy

AIMS

To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties.

METHODS

From 4 implanting institutes, data of all CRT implants between October 2008-October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted 'normal' anatomy. Patient demographics, procedural detail and subsequent left ventricle (LV) lead pacing indices were collected.

RESULTS

From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2±10.6 years in age with a LV ejection fraction of 34±10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), 5 of which had coronary sinus ostium atresia (CSOA) including 2 with an 'unroofed' coronary sinus (CS); 1 patient had a unique anomalous origin of the CS and 1 patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anaesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including 1 case of endocardial LV implant. Pacing follow-up over 37.64±37.6 months demonstrated LV lead threshold between 0.62-2.9 volts (pulsewidth 0.4-1.5 milliseconds) in all cases; 5 patients died within 2.92±1.6 years of successful implant.

CONCLUSION

CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required. This article is protected by copyright. All rights reserved.

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.

Persistent left superior vena cava transvenous lead extraction: A European experience

BACKGROUND

Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare.

METHOD

Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported.

RESULTS

Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality.

CONCLUSION

TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.

Absent right superior vena cava with persistent left superior vena cava in a patient with COVID-19

Vascular injury associated with cannulation during extracorporeal membrane oxygenation (ECMO) induction is a rare but life-threatening complication. The presence of abnormal vascular anatomy increases the risk of vascular injury and should be recognized before cannulation. We report the case of a patient with coronavirus disease (COVID-19) who was expected to undergo ECMO. By performing computed tomography (CT), we identified the absence of right superior vena cava (RSVC) with a persistent left superior vena cava (PLSVC) that could have caused serious complications associated with ECMO cannulation. PLSVC is observed in less than 0.5% of the general population; however, the combination of PLSVC and an absent RSVC in visceroatrial situs solitus is extremely rare. Attempting cannulation for Veno-venous (VV)-ECMO from the right (or left) internal jugular vein to the right atrium may cause serious complications. Cannulation may fail or lead to complications even in patients with inferior vena cava malformations. Although these vascular abnormalities are rare, it is possible to avoid iatrogenic vascular injury by identifying their presence in advance. Since anatomical variations in the vessels from the deep chest and abdominal cavity cannot be visualized using chest radiography and ultrasonography, we recommend CT, if possible, for patients with severe respiratory failure, including those with COVID-19, who may be considered for VV-ECMO induction.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Transvenous lead extraction in patients with persistent left superior vena cava

PURPOSE

Predictors of difficulty and complications of transvenous lead extraction (TLE) have been investigated in several studies; however, little is known about the venous anatomical characteristics that can have an impact on procedural outcomes. Among them, the persistent left superior vena cava (PLSVC) is a common anomaly often discovered incidentally during cardiac device implantation and could raise concerns if TLE is indicated. We report technical considerations and outcomes of TLE for two patients with leads implanted via PLSVC.

METHODS AND RESULTS

Two cardiac implantable electronic device recipients with isolated PLSVC required TLE due to infective endocarditis in one case and lead failure in the other. In the first case, TLE procedure was performed in a hybrid operating room with minimally invasive video-assisted thoracoscopic monitoring due to the high procedural risk. Two active fixation 20-year-old pacing leads were removed with a relatively short fluoroscopy time. In the second case, we successfully extracted a single-coil active fixation lead without the need of a locking stylet or advanced extraction tools. There were no procedural complications or adverse events at 1-year follow-up.

CONCLUSION

TLE procedures for two patients with isolated PLSVC were successfully completed with less difficulty and tools than expected based on the characteristics of the targeted leads. If indicated, TLE in the presence of a PLSVC should be considered in experienced centers.

Anomalous atrium associated with persistent left superior vena cava

Persistent left superior vena cava (PLSVC) is the most common venous anomaly with an incidence of 0.3-0.5% in the general population. Here, we report a rare case of PLSVC with anomalous atrium in a cadaver during the student's dissection session at the University of Tsukuba. In this case, the coronary sinus had merged with the right atrium to form an enlarged sac-like structure and received systemic venous flow including inflow from the PLSVC. The roof of the coronary sinus with the right atrium was thicker than that of the control cases. We further found that the distance between the sinoatrial node and the opening of the coronary sinus was slightly more than half of that in control cases. This variant appears interesting and is worth reporting for developmental and clinical consideration.

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.

Active fixation coronary sinus lead in a patient with persistence of left superior vena cava

In patients with PLSVC, the use of an active fixation lead (like the Medtronic "Attain Stability") on the coronary sinus can lead to a successful and safe cardiac resynchronization, facilitating its positioning with a low long-term displacement rate.

Navigating Challenging Left Ventricular Lead Placements for Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) is a mainstay in the management of heart failure patients with electrical dyssynchrony. Left ventricular (LV) lead positioning remains an important variable that predicts the response to CRT. Anatomical and technical challenges can hinder optimal LV lead placement using traditional lead implantation approaches. Knowledge of normal anatomical variants and common anomalies is essential for successful LV lead implants. With advancements in tools and techniques for LV lead delivery, the implanting electrophysiologist can target the optimal LV pacing site, rather than accepting a suboptimal location that is less likely to provide clinical benefit. In this review, we discuss various challenges to achieving optimal LV lead implantation and present strategies to overcome them.

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.

Clinical and procedural implications of congenital vena cava anomalies in adults: A systematic review

BACKGROUND

Although congenital vena cava (CVC) anomalies in adults have implications for surgical and radiological interventions, the literature is scare and disparate. The aim of this systematic review was to assess cardiovascular clinical and procedural implications of CVC anomalies in adults without congenital heart disease.

METHODS AND RESULTS

We searched PubMed and EMBASE from database conception through October 2018 for English-language studies describing the epidemiology of CVC anomalies or their clinical or procedural implications in humans. Two independent reviewers screened 7093 records and identified 16 relevant studies. We found two major implications of CVC anomalies: 1) congenital inferior vena cava (CIVC) anomalies are associated with a 50-100-fold higher risk of deep venous thrombosis, particularly among younger patients, and 2) persistent left superior vena cava (PLSVC) is associated with a 2-3-fold higher risk of supraventricular arrhythmias. PLSVC also poses technical challenges to cardiovascular electronic device implantation, requiring alterations in surgical approach and lengthening procedure and X-ray exposure times. Due to the large disparity in reported prevalence rates of CIVC anomalies, we performed a meta-analysis of CIVC anomaly prevalence including 8 studies, which showed a weighted prevalence of 6.8% (95% CI, 4.5-9.2%).

CONCLUSION

These findings challenge the notion that CVC anomalies are rare and asymptomatic in adults. Rather, the literature indicates that CVC anomalies are not uncommon and have important clinical and procedural implications. To further understand the prevalence and implications of CVC anomalies, a robust US population-based study and nationwide registry is warranted in the current era of venous interventions.

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.

Orthotopic heart transplantation with reconstruction of persistent left superior vena cava

BACKGROUND

Persistent left superior vena cava is a not uncommon congenital vascular abnormality. We report a case of heart transplantation with reconstruction of persistent left superior vena cava using a prosthetic vascular graft.

CASE PRESENTATION

A 20-year-old man with idiopathic dilated cardiomyopathy and persistent left superior vena cava underwent orthotopic heart transplantation 2 years and 3 months after left ventricular assist device implantation. Because the persistent left superior vena cava had a larger diameter than the right superior vena cava, the transected persistent left superior vena cava was reconstructed with a prosthetic vascular graft anastomosed to the free wall of the right atrium. Postoperative enhanced computed tomography revealed good patency of the graft. The patient's postoperative course has been uneventful during 2 years of follow-up, despite the risk of complications.

CONCLUSIONS

Reconstruction of a persistent left superior vena cava with a prosthetic vascular graft may be one option at the time of heart transplantation.

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.

Biventricular pacemaker implantation via a persistent left superior vena cava after removal of an infected device from the right side

Persistent left superior vena cava (PLSVC) is a congenital anomaly that poses a unique challenge when implanting cardiac implantable electronic devices (CIEDs) from the left side. To date, only a few isolated case reports are available regarding biventricular pacemaker implantation via PLSVC. These reports lack procedural details and tips to overcome difficulties faced by the physician when performing this technically demanding procedure. In the present report, we describe a patient who successfully underwent biventricular pacemaker implantation via a PLSVC after transvenous extraction of an infected device from the contralateral side, and discuss the technical implications.

Direct His-bundle Pacing in a Patient with a Persistent Left Superior Vena Cava

We report a case of direct His-bundle lead placement at the time of implantable cardioverter-defibrillator insertion and atrioventricular node ablation. The patient was found to have an isolated persistent left superior vena cava, and selective His-bundle pacing was successfully achieved through the use of a steerable sheath and dedicated mapping catheter.

Prenatal diagnosis of persistent left superior vena cava: a retrospective study of associated congenital anomalies

Objective:

To evaluate persistent left superior vena cava (PLSVC) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period and to review their outcomes.

Materials and Methods:

The data of patients with a prenatal diagnosis of PLSVC between January 2013 and December 2017 were reviewed retrospectively.

Results:

Data of 32 cases were reviewed. Nineteen (60%) cases were associated with cardiac defects, 5 (15%) were associated with both cardiac and extracardiac defects, and 8 (25%) had no associated anomalies. Two fetuses had karyotype anomalies. All patients with isolated PLSVC survived. Among the cases associated with extracardiac anomalies, cardiac anomalies, and with both extracardiac and cardiac anomalies, the survival rate was 40%, 40%, and 25%, respectively. Outcome was more favorable in cases with isolated PLSVC (100% vs. 40%).

Conclusion:

Prenatally diagnosed PLSVC is associated with cardiac and extracardiac anomalies in the majority of cases. The prognosis is good in isolated cases, but worsens when accompanied by cardiac or extracardiac anomalies.

Cardiac resynchronization therapy device implantation in a patient with persistent left superior vena cava without communicating innominate vein - should we proceed from the same side? - A dilemma revisited

Persistent left superior vena cava (PLSVC) is an uncommon congenital anomaly. We report a case of implantation of cardiac resynchronization therapy - pacemaker (CRT-P) device in a 38-year-old lady with idiopathic dilated cardiomyopathy. After left axillary vein puncture, we faced an unexpected entry of left subclavian to PLSVC draining into the coronary sinus (CS). The target posterolateral vein which had been identified before, seemed to have an acute angle at its entry into the CS. Hence, at this stage we were in a dilemma, whether to switch to the right side or to continue from the same side. We continued the procedure from the left side and completed it successfully after some manipulation and improvisation.

Comparison of coronary sinus diameter Z-scores in normal fetuses and fetuses with persistent left superior vena cava (PLSVC)

To establish Z-score reference ranges for coronary sinus (CS) diameter in normal fetuses and explore the diagnostic value of CS Z-score in fetuses with persistent left superior vena cava (PLSVC). Study of 235 normal fetuses and 30 fetuses with PLSVC was involved. Noncardiac biometrical parameters included biparietal diameter (BPD), femoral length (FL), heart area (HA), gestation age (GA). The coronary sinus systolic and diastolic diameter (CSDs and CSDd ) were measured at the end of systole and diastole. CSDs and CSDd Z-score models were constructed by using linear regression analysis with Non-cardiac biometrical parameters as independent variables. Z-scores between normal fetuses and fetuses with PLSVC were compared. A simple, linear regression model was the best description and correlations between fetal CSDs and CSDd and four independent variables were excellent. Reference ranges for predicting means and SDs of the fetal CS were established. Equations for Z-score calculation were provided, CSDs and CSDd Z-scores were statistically different between normal fetuses and those with PLSVC. Development of CSDs and CSDd Z-score reference ranges in normal fetuses was realized. The CSDs and CSDd Z-scores can provide quantitative evidence in prenatal diagnosis of PLSVC.

Anatomical considerations for the management of a left-sided superior caval vein draining to the roof of the left atrium

Aims The pathophysiological entity of a persisting left-sided superior caval vein draining into the roof of the left atrium represents an extreme form of coronary sinus de-roofing. This is an uncommon, but well-documented condition associated with systemic desaturation due to a right-to-left shunt. Depending on the size of the coronary ostium, the defect may also present with right-sided volume loading. We describe two patients, both of whom presented with desaturation, and highlight the important anatomical features underscoring management. Methods and Results Both patients were managed interventionally with previous assessment of the size of the coronary sinus ostium through cross-sectional imaging. This revealed a restrictive interatrial communication at the right atrial mouth of the coronary sinus in both patients, which permitted an interventional approach, as the residual left-to-right shunt subsequent to closure of the aberrant vessel would be negligible. At intervention, test occlusion of the left superior caval vein allowed assessment of decompressing vessels before successful occlusion using an Amplatzer Vascular Plug.

CONCLUSIONS

Persistence of a left superior caval vein draining to the left atrium may be associated with an interatrial communication at the mouth of the unroofed coronary sinus. The ostium of the de-roofed coronary sinus can be atretic, restrictive, normally sized, or enlarged. Careful assessment of the size of this defect is required before treatment. In view of its importance, which has received little attention in the literature to date, we suggest an additional consideration to the classification of unroofed coronary sinus.

Ultrasound-guided catheterization of the left subclavian vein without recognition of persistent left superior vena cava: A case report

RATIONALE

A persistent left superior vena cava (PLSVC) is rare, but the most common thoracic venous anomaly. We report a case of PLSVC unrecognized during left subclavian vein catheterization using real-time ultrasound-guided supraclavicular approach.

PATIENT CONCERNS

A 79-year-old man with history of hypertension presented with traumatic subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage. Before the operation, a central venous catheter (CVC) was placed into the left subclavian vein.

DIAGNOSES

A dilated coronary sinus on echocardiogram and subsequent agitated saline test confirmed the diagnosis of PLSVC.

INTERVENTIONS

A CVC was placed into the left subclavian vein under real-time ultrasound guide, with supraclavicular approach. A postoperative chest X-ray revealed a left-sided paramediastinal course of the CVC; the CVC was removed under the impression of malposition.

OUTCOMES

The CVC functioned properly.

LESSONS

Ultrasound is used for safe and correct placement of CVC; however, the presence of PLSVC could not be detected by ultrasonography in this case. When the chest radiograph shows the central venous catheter passing along the border of the left heart and a dilated coronary sinus detected on echocardiogram, we should have suspicion of a PLSVC.

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.

What's in a Name? Utilization of the Innominate Vein for Pacemaker Lead Placement in the Setting of Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) represents the most common thoracic venous anomaly and is an important clinical entity for cardiologists and electrophysiologists, among others. In approximately 30% of cases, a bridging innominate vein connects the left superior vena cava to the right. The present report highlights the value of defining the venous anatomy with a case of dual-chamber pacemaker implantation in the PLSVC with the right ventricular lead placed via the innominate vein. Pertinent considerations for device implantation in the setting of this anomaly are discussed and relevant venography reviewed.

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.

Epicardial CRT-P- and S-ICD Implantation in a Young Patient with Persistent Left Superior Vena Cava

Persistent left superior vena cava is known to be a challenging anatomic abnormality for transvenous cardiac device implantation. In the a case of a young man presenting with dilative cardiomyopathy with severely impaired left ventricular ejection fraction (LVEF) and second-degree atrioventricular block (AV block), cardiac resynchronization therapy (CRT) with defibrillator (CRT-D) implantation was indicated. A transvenous approach was attempted, but placement of the right ventricular lead was not successful due to anatomic abnormalities. Therefore, epicardial CRT leads were implanted via a left mini-thoracotomy. For primary prevention of sudden death, the patient was also fitted with an additional subcutaneous implantable cardioverter defibrillator (S-ICD). Any cross-talk between the devices was ruled out both intraoperatively and by ergometry prior to discharge. The combination of epicardial CRT-P with S‑ICD implantation might be a safe and effective alternative in patients with cardiac anatomic abnormalities.

Intrathymic and other anomalous courses of the left brachiocephalic vein in the fetus

OBJECTIVE

The left brachiocephalic vein (LBCV), or innominate vein, connects the left jugular vein to the right superior vena cava. Its course is posterior to the thymus and directly anterior and superior to the aortic arch. Pediatric and adult cardiology studies have reported on the subaortic or retrotracheal courses of the LBCV and the presence of double LBCV. We observed recently in the fetus that the LBCV may have a course through the thymus (intrathymic) or be absent in the presence of a left superior vena cava. The aim of this study was to report the prevalence of isolated intrathymic and absent LBCV in normal fetuses undergoing second-trimester ultrasound screening, as well as the prevalence of other courses in association with cardiac anomalies.

METHODS

In the prospective part of this study, consecutive second-trimester ultrasound examinations were evaluated to assess the presence and course of the fetal LBCV. In the retrospective case-control part of this study, the databases of two fetal medicine centers were reviewed for cardiac anomalies and the pattern and prevalence of anomalous courses of the LBCV were reported.

RESULTS

One thousand four hundred and eighteen consecutive fetuses were examined prospectively. An intrathymic course of the LBCV with a typical bent shape was found in 1.76% (1 : 57) of cases and the absence of a LBCV in association with a persistent left superior vena cava (LSVC) was found in 0.28% (1 : 350). All fetuses with an isolated intrathymic course or absence of the LBCV had a normal outcome. Over a period of 4.5 years, a total of 1544 fetuses with cardiac malformations were reviewed at two centers. Among these, an anomalous course of the LBCV was noted in eight (0.5%) cases: six subaortic, one retrotracheal and one double LBCV.

CONCLUSION

An intrathymic LBCV is a common condition and appears to be a normal variant in the fetus. The prevalence of a LSVC in our screening population was similar to that reported in previous studies. Anomalous courses of the LBCV are seen occasionally in cases with cardiac malformation. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Persistent left superior vena cava (PLSVC) with anomalous left hepatic vein drainage into the right atrium: role of imaging and clinical relevance

Persistent left superior vena cava (PLSVC) is a very rare and yet the most commonly described thoracic venous anomaly in medical literature. It has a 10-fold higher incidence with congenital heart disease. PLSVC often becomes apparent when an unknown PLSVC is incidentally discovered during central venous line placement, intracardiac electrode/pacemaker placement or cardiopulmonary bypass, where it may cause technical difficulties and life-threatening complications. PLSVC is also associated with disturbances of cardiac impulse formation and conduction including varying degrees of heart blocks, supraventricular arrhythmias and Wolff Parkinson White syndrome. We describe the case of an 86-year-old male with a history of coronary artery disease and chronic atrial fibrillation who presented with worsening dyspnea and syncopal episodes. An ECG was consistent with complete heart block. During lead placement for the pacemaker, a left subclavian approach was unsuccessful. A left venogram was performed through the brachial vein that demonstrated a left superior vena cava. The diagnosis was confirmed with echocardiography using a bubble study and also a chest CT. The anatomy was unique as there was anomalous left hepatic vein drainage into the right atrium. The case provides insight into the diagnostic modalities and clinical considerations of this unusual thoracic venous anomaly.

Additional superior vena cava combined with abnormal inflow of the hepatic vein

We represent a case of successful surgical treatment of a rare congenital heart disease: abnormal inflow of an additional superior vena cava into the left atrium, combined with atrial septal defect, mitral and tricuspid valve regurgitation, and abnormal inflow of the left hepatic vein into a roofless coronary sinus.

Persistent Left Superior Vena Cava in Hematological Malignancy Requiring Central Venous Catheter Insertion for Intensive Chemotherapy

Persistent left superior vena cava is a congenital vascular anomaly, which is possibly arrhythmogenic and thrombogenic, rarely complicated with coronary sinus atresia. We treated a 42-year-old male with Hodgkin's lymphoma requiring central venous catheter placement for intensive chemotherapy. Persistent left superior vena cava was revealed after the insertion of the central venous catheter by the radiological finding of the catheter tip cannulated into the vena cava cavity. The relationship between coronary sinus atresia and persistent left superior vena cava induced by central venous catheterization remains unclear; however, the hematologist should pay attention to the malpositioning of the central venous catheter.