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.

Bilateral inferior venae cava combined with the persistent left superior vena cava and hemiazygos continuation of left inferior vena cava with drainage into right atrium: A case report

The persistent left superior vena cava (PLSVC) is a common venous abnormality. However, malformation of the bilateral inferior venae cava (IVC) is extremely rare, with an incidence rate of .3%. IVC malformation is associated most frequently with heart defects and isomerism and often has a poor prognosis. We presented a case of vascular malformations in the fetus of bilateral caval veins with the interruption of the left-sided venous return with hemiazygos continuation in presence of a right-sided inferior caval vein. Also noted were the PLSVC and a dilated right heart with a widened pulmonary trunk. In this case, there were no heart defects or chromosomal abnormalities, and the newborn postpartum was in a good condition.

Complex connections: A young man presenting with shortness of breath, hypoxemia, right lumbar pain and left limb swelling

A 43‐year‐old Caucasian man was admitted to hospital due to shortness of breath, right lumbar pain and lower left limb swelling. Arterial blood gas sample showed mild hypoxemia and respiratory alkalosis. CT scan confirmed pulmonary embolism, splenic and bilateral renal ischemic lesions. Echocardiography showed right ventricular and coronary sinus (CS) dilatation. Using contrast echocardiography, a superior sinus venous atrial septal defect and persistent left superior vena cava (PLSVC) draining in CS were suspected. Cardiac CT confirmed the diagnosis and showed overriding right superior vena cava (RSVC) draining in both atria. The patient underwent successful surgical correction.

Four-Dimensional Echocardiography Is an Accurate Tool for Coronary Sinus Evaluation in Patients with Persistent Left Superior Vena Cava Diagnosis

Persistent left superior vena cava (PLSVC) is a rare vascular congenital anomaly yet the most common for the thoracic venous system. Usually asymptomatic, PLSVC is commonly diagnosed when echocardiography or other cardiovascular imaging is performed. Due to venous drainage abnormality, PLSVC is frequently associated with other anomalies of the intrinsic heart's conduction system, leading to tachy- or brady- arrhythmias. We present the case of a patient with 20 years history of supraventricular rhythm disorders diagnosed with isolated PLSVC. Furthermore, we discuss the diagnostic approach providing insights into four-dimensional echocardiography (4DE) evaluation for PLSVC diagnosis, assuming that there is a direct correlation between coronary sinus dilatation caused by abnormal venous return and supraventricular rhythm disorders. We highlight that correct understanding of the pathophysiology of PLSVC will lead to a reduction in unnecessary and potentially harmful testing, to a shorter diagnostic time and to a financial resource saving, as a whole.

Persistent Left Superior Vena Cava Identified After Hemodialysis Catheter Insertion: A Case Report

Introduction

Central venous catheter (CVC) insertion is the most commonly performed clinical procedure when a patient initiates hemodialysis. Despite its clinical benefits, CVC insertion has several risks of complications. Thrombosis, venous stenosis, infection, arrhythmia, pneumothorax, and bleeding are among these complications. Malposition of the tip of the CVC can also occur with an incidence of up to 7%. One of several factors that could contribute to malposition is venous anatomy variation. Persistent left superior vena cava (PLSVC) is an extremely rare venous anatomical disorder but might have a significant clinical impact.

Case Presentation

Here we report a PLSVC case that was identified in chest radiography after the insertion of a CVC catheter in a patient with end-stage renal disease (ESRD). A 40-year-old woman with a history of type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity was presented in the emergency room with dyspnea for 1 week. Acute hemodialysis was required because of the ESRD and pulmonary edema. The PLSVC condition accompanied by various complications that occurred in this patient became a dilemma for the nephrologist in determining the diagnosis and proper CVC management.

Discussion

PLSVC is the most common congenital abnormality of the vena cava, even though it has a very small incidence. PLSVC occurs in about 0.1–0.5% of the total population and reaches 10% in individuals with congenital heart abnormalities. Most PLSVC presents along with normal superior vena cava and drains into the right atrium, which makes it very difficult to see the clinical signs and symptoms. Almost all PLSVC conditions are found incidentally during or after invasive procedures such as CVC insertion. CVC insertion in the PLSVC condition needs proper management to minimize the risk of complications.

Conclusion

This case shows the importance of understanding the PLSVC condition, which, although very rare, is expected to increase the awareness of the nephrologist in making the diagnosis, determining appropriate management, and preventing complications, thereby improving patient safety.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

BACKGROUND

Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure.

CASE PRESENTATION

This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days.

CONCLUSIONS

TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

Persistent Left Superior Vena Cava in a Heart Transplant Recipient's Native Heart: A Rare Case Diagnosed by Transesophageal Echocardiogram

Persistent left superior vena cava (PLSVC) is a rare abnormality with incidence reported as 0.3% to 0.5% in the general population and about 10 times higher in patients with congenital heart disease. The diagnosis of PLSVC in native or donor hearts of patients undergoing heart transplants has been reported in surgical journals. However, this rare finding has not been described in similar heart transplant settings in anesthesia literature. This case describes a 44-year-old male orthotopic heart transplant recipient who was incidentally diagnosed with PLSVC in his native heart on transesophageal echocardiogram after a central venous catheter placement. The particular position of the central venous catheter, in our case, raised the suspicion of PLSVC but needed further verification. With the help of images and videos, we demonstrate that transesophageal echocardiogram can be instrumental in diagnosing PLSVC. Furthermore, the case highlights the importance of effectively communicating with the surgeon about such a finding so that the surgical plan can be modified in a timely manner.

Vena cava anomalies in thoracic surgery

BACKGROUND

Vena cava anomalies are a rare group of anatomical variations due to an incorrect development of the superior or inferior vena cava during fetal life. They generally show no clinical relevance and the diagnosis is done due to the association with congenital heart diseases in most of cases. However, preoperative identification of these anomalies is mandatory for surgeons to proper surgical planning. If not recognized, lethal complications may occur, as already reported in literature.

CASE PRESENTATION

We report a case series of three different unidentified vena cava anomalies in patients undergoing lung resection. These unrecognized anomalies led to minor complications in two cases and required an accurate intraoperative evaluation in another. A careful retrospective evaluation of preoperative radiological images showed the anomalies.

CONCLUSIONS

A careful evaluation of the vena cava anatomy at pre-operative imaging is mandatory for thoracic surgeons to properly plan the surgery and avoid complications.

Catheter ablation of persistent atrial fibrillation solely guided by complex fractionated atrial electrograms in a patient with persistent left superior vena cava

Catheter ablation in patients with persistent atrial fibrillation (AF) is challenging. There are few reports of catheter ablation for persistent AF with persistent left superior vena cava (PLSVC). We report an ablation case of persistent AF with PLSVC solely guided by complex fractionated atrial electrogram (CFAE). The subject was a 65-year-old man. Electroanatomic mapping system was used to integrate computed tomography data with 3D mapping data. We identified the CFAE sites on the electroanatomic mapping. Radiofrequency ablation was applied to the CFAE sites; the posterior aspect of left superior pulmonary vein (LSPV), the anterior ridge of left atrial appendage, and the roof at the anterior to the LSPV. After those ablations, AF was finally terminated by ablation in the middle of the PLSVC. Previous investigators have reported that pulmonary vein antrum isolation (PVAI) is effective for the management of patients with either paroxysmal or persistent AF. However, some patients experience episodes of AF despite successful PVAI, which implies that important triggers and perpetuators remain in the posterior left atrium, crista terminalis, superior vena cava, coronary sinus ostium, interatrial septum, and the ligament of Marshall/PLSVC. In conclusion, CFAE ablation was useful in a patient with persistent AF with PLSVC.