Orthotopic heart transplantation for congenital heart defects: anomalies of the systemic venous return

Persistent Left Superior Vena Cava: Implications of Surgical Management

Persistent left superior vena cava is the most common congenital anomaly of thoracic venous return, which results when the left anterior cardinal vein fails to regress. A 41-year-old African American male with a history of an unspecified childhood cardiac murmur presented to the emergency department with congestive heart failure exacerbation revealing an incidental finding of a persistent left superior vena cava. Ultimately, he required implantable cardioverter defibrillator placement and cardiac transplantation assessment. In the setting of advanced device placement or cardiac transplantation, a persistent left superior vena cava warrants several important clinical considerations at a center capable of addressing the possibility of a right-sided approach and transplantation irregularities.

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.

Heart transplantation in a patient with persistent left superior vena cava

A 56-year-old male presented with severe exertional dyspnea and pitting edema in the lower extremities. The pre-operative evaluation demonstrated biventricular dysfunction associated with severe tricuspid valve regurgitation and a persistent left superior vena cava. He was registered as a transplantation candidate, and orthotopic heart transplantation was performed using the standard bicaval technique. The left superior vena cava was connected to the right atrial appendage after the construction of a conduit using the recipient’s autologous coronary sinus tissue. One-month postoperatively, computed tomography imagery demonstrated a patent conduit between the left superior vena cava and right atrial appendage.

Reconstructive methods for anomalous systemic venous return: surgical management of persistent left superior vena cava

Persistent left superior vena cava can present as a benign anatomic finding or as a pathologic entity, causing significant hemodynamic manifestations. Its presence can also promote modifications in the surgical techniques used for treatment of other cardiac pathologies. When persistent left superior vena cava constitutes a pathologic entity that needs to be surgically addressed, this can be approached either by intracardiac or extracardiac procedures. Extracardiac procedures appear simpler and reproducible. A previously reported technique for extracardiac approach of left superior vena cava using an enlarged left superior vena cava-right atrial appendage anatomosis is reviewed.