Catheter ablation of the left-sided variant of right top pulmonary vein in a case with persistent left superior vena cava

A 50-year-old woman underwent catheter ablation for atrial fibrillation. Preoperative computed tomography revealed a left-sided variant of the right top pulmonary vein (PV) and a persistent left superior vena cava. The right top PV was successfully isolated through a wide antral circumferential ablation line simultaneously with the right PVs.

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.

Catheter ablation of atrial fibrillation in a patient with interruption of the inferior vena cava complicated with persistent left superior vena cava

A 55-year-old woman of I-IVC complicated with PLSVC underwent catheter ablation for atrial fibrillation through right jugular vein access. TSP was achieved by electrocautery and the J-tip guidewire with the help of deflectable sheath and ICE. After PVI, the CS-PLSVC and LA-PLSVC connections were ablated within PLSVC.

Complete free wall isolation of arrhythmogenic persistent left superior vena cava

INTRODUCTION

Persistent left superior vena cava (PLSVC) is one of the major sources of triggers and drivers of atrial fibrillation (AF). There has been no established PLSVC ablation procedure to eliminate the arrhythmogenicity along the entire length of PLSVC.

METHODS AND RESULTS

A 70-year-old woman with a history of two previous catheter ablations for AF, mitral valvuloplasty, and an unroofed coronary sinus-type atrial septal defect closure underwent the redo AF ablations. The AF trigger and driver were identified within the patient's enlarged PLSVC. The AF was treated by complete PLSVC free wall isolation.

CONCLUSION

Complete PLSVC free wall isolation may be an effective ablation method to eliminate the arrhythmogenicity along the entire length of the PLSVC.

Case Report: Persistent left superior vena cava: an incidental finding during peripherally inserted central catheter placement

Background

A peripherally inserted central catheter (PICC) is a specialized type of long-term intravenous catheter commonly employed for administering chemotherapy. The operation and management of PICC should exclusively be carried out by trained healthcare professionals equipped with the requisite knowledge of anatomy, procedural technique and patient care. Persistent left superior vena cava (PLSVC) is a vascular malformation which is typically asymptomatic in clinical presentation, almost always identified during invasive surgery or imaging examinations.

Case presentation

Herein, we detailed a case involving a breast cancer patient whose PLSVC was identified during the placement of PICC because of the negative P-wave in electrocardiogram (ECG). Subsequent examination, including chest x-ray imaging, postoperative enhanced CT of the chest, ECG, and consultation with an experienced imaging physician confirmed that the patient's variant type was PLSVC type I. 2160. Removal of the catheter was deemed unnecessary, as the catheter tip was appropriately positioned and no other concomitant cardiovascular malformations were detected.

Conclusion

The PLSVC is a vascular anomaly and is relatively uncommon within the general population. The operator should possess a thorough familiarity with the potential anatomical variations of left superior vena cava, and specialized case profile should be established for patients diagnosed with PLSVC.

Right sided approach for left bundle branch pacing using lumen-less lead: Technical considerations and follow-up outcome

INTRODUCTION

Left bundle branch pacing has gained significant momentum in the last few years. The procedure involves deploying the lead deep inside the interventricular septum through left subclavian vein. We aimed at analyzing the feasibility, efficacy and long-term outcome of left bundle branch pacing (LBBP) using lumen-less lead through the right subclavian vein.

METHODS

This was a retrospective-institutional, single center observational study done in consecutive patients who underwent LBBP using 3830 selectsecuretm lead. Left subclavian venous access was the primary strategy for lead implantation. Patients requiring right sided approach due to venous obstruction or persistent left superior-vena-cava (PLSVC) for LBBP were included in the study.

RESULTS

Right sided approach was successful in 16 out of 19 (84%) attempted patients. C315-His catheter was used in all patients without modifying its curvature. PLSVC (n = 7), left venous obstruction (n = 7), right sided device upgradation (n = 1) and left pocket infection (n = 1) were the reasons for right sided approach. Mean follow-up duration was 17 ± 12 months. LBBP resulted in reduction in QRS duration from 137.3 ± 37.8 ms to 122.3 ± 9.5 ms (p -.13) and increase in LV ejection fraction from 46.2 ± 16.3% to 54.4 ± 11.6% (p -.11). The mean fluoroscopy duration and radiation dose were significantly high in right sided approach (n = 16) as compared to left sided approach (n = 293). In patients requiring cardiac-resynchronization therapy (CRT), right sided LBBP resulted in reduction in QRS duration from 171.8 ± 18.5 to 125.5 ± 11.9 ms (p -.0001) and increase in LVEF from 29.1 ± 3.8 to 45.1 ± 11.9% (p -.005).

CONCLUSION

Right sided LBBP is feasible, safe and effective in patients requiring pacing for symptomatic bradyarrhythmia and CRT. Further development in dedicated tools for right-sided approach would help in reducing the fluoroscopy-duration and radiation-dose.

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

BACKGROUND

Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF).

METHODS AND RESULTS

Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4 ± 8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow-up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%).

CONCLUSION

Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC.

Accidental Detection of Persistent Left Superior Vena Cava During Central Venous Port Placement

Persistent left superior vena cava (PLSVC) is a rare abnormality of the thoracic vein that is often detected incidentally during central venous catheter insertion. We present the case of an 85-year-old female with PLSVC that was accidentally detected during central venous port placement. The left subclavian vein was punctured using the supraclavicular approach. Intraoperative fluoroscopy showed that the guidewire had descended through the left chest, suggesting PLSVC. Intraoperative computed tomography and venography confirmed that the PLSVC drained into the coronary sinus. In this case, the PLSVC and right superior vena cava (RSVC) coexisted, with no bridging veins. The diameter of the PLSVC was extremely small compared to that of the RSVC; therefore, catheter placement in the PLSVC was avoided considering the risk of venous thromboembolism, and a catheter was placed in the RSVC. When clinicians encounter cases where the PLSVC and RSVC coexist during central venous catheter insertion, the diameter of the PLSVC should be considered when deciding whether to place the catheter in the PLSVC. If the diameter of the PLSVC is narrow, it may be safer to avoid catheter placement in the PLSVC and instead place the catheter in the RSVC, considering the risk of venous thromboembolism after catheterization.

Absent right superior vena cava and persistent left superior vena cava: An incidental finding

A patient with Marfan syndrome undergoing Bentall operation was found to have an absent right superior vena cava and persistent left superior vena cava. The dilation of coronary sinus raised the suspicion of persistent left superior vena cava. The diagnosis was confirmed by agitated saline contrast echocardiography and computed tomography of the chest.

Misdiagnosis of persistent left superior vena cava with unroofed coronary sinus as a coronary sinus-type atrial septal defect

Key Clinical Message

Awareness of persistent left superior vena cava (PLSVC) with unroofed coronary sinus is crucial. Pre- and perioperative evaluation of this association is necessary for surgical plan. Creating an intra-atrial tunnel to divert LSVC to right atrium without obstructing the mitral valve or the pulmonary veins is the safe surgical approach.

Abstract

Unroofed coronary sinus syndrome is a rare congenital heart defect representing less than 1% of all atrial septal defect (ASD) types, and may be associated with persistent left superior vena cava (PLSVC) which may be missed during preoperative diagnosis. Herein, we present a case of a 2-year-old patient who underwent an operation for repair of a coronary sinus-type ASD; however, PLSVC was detected intraoperatively. An antra-atrial tunnel has created to divert the flow of PLSVC into the right atrium along with the repair of the ASD.

Pre-procedural imaging and atrial tachycardia ablation in a patient with complex congenital heart disease

Atrial tachycardias (AT) are common cardiac arrhythmia disorder for congenital heart disease (CHD). The anatomic substrate that surgical suture lines, scar tissue, or prosthetic material may cause pre-existing atrial conduction abnormalities which leads to the underlying mechanism of reentrant ATs. Radiofrequency Catheter ablation (RFCA) is used in the treatment of atrial tachycardia in CHD patients. However venous system abnormalities may complicate the procedure. We report that ablation of a case with atrial tachycardia with challenging anatomy (persistent left superior vena cava draining into the left atrium, coronary sinus agenesis, inferior vena cava (IVC) agenesis, azygos system drained to the superior vena cava, and repaired ventricular septal defect). This case report discusses the key points of access to cardiac chambers and mapping in very rare challenging anatomy.

The Challenges of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Persistent Left Superior Vena Cava: A Case Report and Concise Literature Review

Heart failure with reduced ejection fraction (HFrEF) is a chronic and debilitating disease, which requires extensive diagnostic and treatment resources in order to achieve an acceptable quality of life for the patient. While optimal medical treatment remains at the core of the disease's management, interventional cardiology also plays a very important role. However, in very rare situations, interventionists might find cases especially challenging due to the presence of venous anomalies, such as persistent left superior vena cava (PLSVC), anomalies that may go undiscovered during the patient's lifetime until venous cannulation is necessary. While these types of malformations also pose challenges in regards to standard pacemaker implantation, cardiac resynchronization (CRT) devices pose several additional challenges due to the complexity of the device and the necessity of finding an optimal position for the coronary sinus (CS) lead. We present the case of a 55-year-old male patient with advanced heart failure due to dilated cardiomyopathy (DCM) and LBBB who was a candidate for CRT-D therapy, describing the investigations that led to the discovery of the PLSVC as well as the technique and results of the intervention, while comparing our case to similar cases found in recent literature.

High-density electro-anatomical activation mapping to guide slow pathway modification in patients with persistent left superior vena cava

BACKGROUND

Slow pathway (SP) mapping and modification can be challenging in patients with persistent left superior vena cava (PLSVC) due to anatomical variance of Koch's triangle (KT) and coronary sinus (CS) dilatation. There is a lack of studies using detailed 3-dimensional (3D) electro-anatomical mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition.

OBJECTIVES

To describe a novel technique of slow pathway mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal coronary sinus anatomy.

METHODS

Seven patients with PLSVC and dual AV node physiology who underwent slow pathway modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal re-entrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing (LAT) mapping of the right atrial septum and proximal coronary sinus in sinus rhythm was performed.

RESULTS

SP ablation targets were consistently identified by an area in the right atrial septum with the latest activation time and multi-component atrial electrogram (EGM) adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the mid anterior CS ostium. Ablation in this area led to successful SP modification reaching standard clinical endpoints with a median of 43 sec of radio frequency energy or 14 mins of cryoablation without complications.

CONCLUSION

High-resolution activation mapping of Koch's triangle in sinus rhythm can facilitate localisation and safe slow pathway ablation in patients with PLSVC.

Coronary Sinus Defect, Premature Restriction of Foramen Ovale and Cysto-Colic Peritoneal Band

Background: Unroofed coronary sinus is a congenital cardiac anomaly usually associated with persistent left superior vena cava. Premature restriction or closure of foramen ovale is described in association with hypoplastic left heart syndrome. Abdominal peritoneal bands when present manifest clinically. Case report: A 27 years, gravida 2, presented with intrauterine fetal death at 24 weeks gestation due to fetal congestive cardiac failure, cardiomegaly and hydrops. Perinatal autopsy showed absent coronary sinus with cardiac veins draining directly into the heart. There was no persistent left superior vena cava. The foramen ovale was restricted prematurely. The ductus arteriosus was present and non-restrictive. Abdomen showed a cysto-colic peritoneal band. Conclusion: This is the first report showing a triad of (1) complete absence of coronary sinus without left superior vena cava (type-II); (2) premature restriction of foramen ovale without hypoplastic left heart; and (3) a cysto-colic peritoneal band between the gall bladder and colon.

Pulsed-Field-Ablation for the Treatment of Atrial Fibrillation in Patients with Congenital Anomalies of Cardiac Veins

INTRODUCTION

Anomalous cardiac veins are not rare and pulmonary vein (PV) isolation for atrial fibrillation (AF) treatment should include these veins. Pulsed-field ablation (PFA) is a novel technology for AF ablation with excellent efficacy and safety profile. In this case series, we describe our first experience of isolation of anomalous cardiac veins using PFA in patients with AF.

METHODS

We report a series of patients with congenital anomalies of the cardiac veins and AF, treated with PFA. All patients underwent cardiac computed tomography for procedural planning.

RESULTS

We included five patients (4 males). Anomalous cardiac veins included a connection of a left common ostium to the coronary sinus, a partial and a complete drainage of the right superior PV into the superior vena cava (SVC) with and without additional atrial septal defect, a persistent left SVC and an anomalous posterior PV. All anomalous PVs were isolated using PFA. No phrenic nerve palsy or other complications occurred. PFA of an abnormal right superior PV draining into the distal SVC was possible without affecting the sinus node. After a median of four months, four patients were free of recurrence. One patient had recurrent AF and perimitral reentry tachycardia, probably facilitated by PFA in the mitral isthmus region during isolation of an anomalous connection of the left common ostium to the coronary sinus.

CONCLUSIONS

Using systematic pre-procedural imaging and 3D-electroanatomic mapping, the currently available PFA system seems well suited, efficient and versatile for the treatment of AF in patients with anomalous cardiac veins. This article is protected by copyright. All rights reserved.

Approaches for Successful Implantation of Cardiac Implantable Devices in Patients with Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly, with 0.47% of patients undergoing pacemaker or cardiac implantable device placement found to have PLSVC. This review article describes challenges and interventions to successfully insert cardiac implantable electronic device leads into patients with PLSVC by providing multiple unique case examples.

Provocation and Localization of Arrhythmogenic Triggers from Persistent Left Superior Vena Cava in Patients with Atrial Fibrillation

BACKGROUND

Although pulmonary vein isolation (PVI) is an established procedure for atrial fibrillation (AF), non-PV foci play a crucial role in AF recurrence. Persistent left superior vena cava (PLSVC) has been reported as critical non-PV foci. However, the effectiveness of provocation of AF triggers from PLSVC remains unclear. This study was designed to validate the usefulness of provoking AF triggers from PLSVC.

METHODS

This multicenter retrospective study included 37 patients with AF and PLSVC. To provoke triggers, AF was cardioverted, and re-initiation of AF was monitored under high-dose isoproterenol infusion. The patients were divided into two groups: those whose PLSVC had arrhythmogenic triggers initiating AF (Group A) and those whose PLSVC did not have triggers (Group B). Group A underwent isolation of PLSVC after PVI. Group B received PVI only.

RESULTS

Group A had 14 patients, whereas Group B had 23 patients. After a 3-year follow-up, no difference in the success rate for maintaining sinus rhythm was observed between the two groups. Group A was significantly younger and had lower CHADS2-VASc scores than Group B.

CONCLUSIONS

The provocation of arrhythmogenic triggers from PLSVC was effective for the ablation strategy. PLSVC electrical isolation would not be necessary if arrhythmogenic triggers are not provoked.

Retrograde fast pathway cryoablation inside the coronary sinus for slow-fast atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava

INTRODUCTION

Persistent left superior vena cava (PLSVC) is accompanied by enlarged coronary sinus (CS) and deformation of the triangle of Koch. This makes anatomical evaluation of the atrioventricular (AV) nodal pathways difficult.

METHODS

We attempted cryoablation of retrograde fast pathway located in the enlarged CS roof of PLSVC for slow-fast AV nodal reentrant tachycardia (AVNRT) induced by inadvertent antegrade fast pathway elimination during ablation of left atrial tachycardia.

RESULTS

Slow-fast AVNRT was successfully eliminated without AV block progression.

CONCLUSIONS

This is the first case of successful retrograde fast pathway ablation of the CS ostial roof for slow-fast AVNRT with PLSVC.

Persistent Left Superior Vena Cava Draining Directly Into the Left Atrium With Occluded Coronary Sinus

Combined persistent left superior vena cava entering the left atrium with a congenitally atretic coronary sinus is a rare imaging finding. In the absence of a significant right-to-left shunt, it is generally asymptomatic and can be an incidental discovery. Assessing the anatomy of the cardiac vasculature is crucial before transcutaneous cardiac procedures. (Level of Difficulty: Intermediate.).

A rare complication of double prosthetic valve endocarditis; reconstructive surgical treatment of mitral-aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula

Mitral aortic intervalvular fibrosa or aorto-mitral curtain is a fibrous avascular skeletal structure located between the anterior leaflet of the mitral valve and the non-coronary and left coronary cusps of the aortic valve. Mitral and aortic valve endocarditis are rarely accompanied by mitral aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula of the aorta. Pseudoaneurysm of mitral aortic intervalvular fibrosa is a fatal complication that can occur after valvular surgery, valvular endocarditis, or blunt trauma. In this article, reconstructive surgical management with the Commando technique of a case who developed mitral-aortic intervalvular fibrosa pseudoaneurysm to left atrial fistula after aortic and mitral prosthetic valve endocarditis is described. The important feature of this article is that it is a first in the literature as it is accompanied by persistent left superior vena cava.

Double Superior Vena Cava Due to Persistent Left Superior Vena Cava Incidentally Identified on Central Venous Catheterization: A Case Report

BACKGROUND Persistent left superior vena cava (PLSVC) results in a double superior vena cava (SVC), and although it is rare, this is the most common venous anomaly of the thorax. PSLVC arises from the junction of the left subclavian and internal jugular veins. It is identified on the left side of the mediastinum adjacent to the aortic arch, and it usually drains into the right atrium through the coronary sinus. This report presents the case of a 40-year-old man with an incidental finding of double SVC due to PSLVC identified on hospital admission following a motor vehicle collision. CASE REPORT A 40-year-old man was found to have a double SVC due to PLSVC upon chest radiography during hospital admission for injuries related to motor vehicle trauma. The discovery was made following placement of a central venous catheter (CVC) down the left-sided SVC and into the coronary sinus. The patient suffered no harm as a result. The diagnosis was made by chest radiography and confirmed by computed tomography angiography. CONCLUSIONS PSLVC is an uncommon condition that can complicate common procedures and therefore must be well-understood by physicians across many medical and surgical specialties. Although PLSVC may be asymptomatic, as in this case, in some patients PLSVC presents as atrial fibrillation or with nonspecific cardiac symptoms. Therefore, all patients identified with PLSVC should be investigated to exclude associated cardiac abnormalities and arrythmias, and before the placement of central venous access devices.

Incidental Vascular Findings in Computed Tomography Performed in the Qualification for the TAVI Procedure

Transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR) is now a very widespread treatment method for symptomatic and severe aortic stenosis as an alternative for patients at intermediate or high risk of surgery or contraindications to surgery. The key role of imaging examinations before TAVI is to assess the morphology of the aortic valve, the routes of surgical access, and non-cardiac and extravascular structures. The objective of this article is to present and discuss the importance of selected accidental vascular findings in computed tomography examinations of the heart and large vessels performed in the TAVI qualification procedure: persistent left superior vena cava (SVC) with absent right SVC, right aortic arch, ectopic right coronary artery ostium, and left superior pulmonary vein draining into left brachiocephalic vein.

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.

Single left superior vena cava: antenatal diagnosis, associated anomalies and outcomes

OBJECTIVES

To describe the associated cardiac and extracardiac findings and estimate the prevalence of single left superior vena cava (LSVC) among fetuses referred for fetal echocardiography.

METHODS

This was a retrospective case series of fetuses diagnosed with situs solitus and single LSVC at the Brompton Centre for Fetal Cardiology, London, UK, from October 2006 to December 2020. Prenatal and postnatal outcome data were collected. Prenatal diagnosis was based on abnormal vessel alignment at the three-vessel view and/or three-vessel-and-trachea view, showing a vessel to the left of the pulmonary artery (i.e. the LSVC) and absence of the usual vessel to the right of the ascending aorta (i.e. the right superior vena cava), and further visualization of the LSVC draining into the coronary sinus.

RESULTS

Of 19 968 fetal echocardiograms performed during the study period, 34 cases of single LSVC were identified (a prevalence of 0.17%). Of these, 32 pregnancies had a live birth, one was lost to follow-up and one resulted in intrauterine demise. Single LSVC was isolated in 79.4% of cases. No major congenital heart disease was identified. One fetus showed mild isthmus hypoplasia, with no aortic coarctation postnatally. Two fetuses had umbilical vessel abnormalities. A genetic abnormality was found in one case (15q24.1-q24.2 deletion).

CONCLUSIONS

Antenatal diagnosis of single LSVC in the setting of situs solitus is usually a benign isolated finding. Nevertheless, investigation of other cardiac, extracardiac and genetic disorders should be considered. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Cardiac Implantable Electronic Devices in Different Anatomical Types of Persistent Left Superior Vena Cava: Case Series and Brief Review of the Literature

Persistent left superior vena cava (PLSVC) is the most common congenital malformation of the thoracic venous system, being present in 0.3% to 0.5% of the general population. In the majority of the cases, PLSVC is asymptomatic, but in certain patients, it can manifest through several symptoms, such as arrhythmias and cyanosis, especially when it is associated with complex cardiac pathologies. The clinical significance of this venous anomaly depends on the anatomical variant of the drainage site. In this article, we will present the experience of our clinic, with patients with PLSVC that were diagnosed intraprocedurally, during cardiac pacemaker (CP) or cardioverter defibrillator (ICD) implantation, highlighting the technical difficulties that this anomaly poses for cardiac device implantation. Out of 4000 patients who were admitted to our clinic for CP or ICD implantation, we encountered six cases of PLSVC (four reported in this article and two previously published) corresponding to different anatomical types of this congenital anomaly. In all of these situations, we had to adapt our technique to the patient's anatomy in order to avoid certain complications, the most serious being the improper placement of the right ventricle lead at the level of the coronary sinus.

Case report of double superior vena cava and double odd vein with hypoplastic left brachiocephalic vein

Persistent left superior vena cava (PLSVC) is a common venous variation that is usually accompanied by an absence of the left brachiocephalic vein, and displays a higher incidence in patients with congenital heart disease. Here, the case of a 57-year-old male patient who was found to have PLSVC on chest computed tomography (CT) during screening for gastric cancer metastasis at the Affiliated Hospital of Qinghai University, is described. Further coronal CT and three-dimensional reconstruction of the chest revealed the patient's double superior vena cava (DSVC), double odd veins, and left brachiocephalic vein dysplasia. The patient did not have congenital heart disease and the case was associated with dysplasia of the left brachiocephalic vein, indicating an unusual and rare venous abnormality. At the time of writing, the patient was receiving antitumour therapy.

Redirection of Persistent Left Superior Vena Cava Using a Turned-In Left Atrial Appendage

Persistent left superior cava mostly drains into the right atrium via the coronary sinus. It rarely drains into the left atrium. Extracardiac and intracardiac repair techniques have been described for the repair of persistent left superior vena cava draining into the left atrium. Herein, we report the successful application of a new intracardiac repair technique by using a turned-in left atrial appendage in a 3-year-old male patient with a persistent left superior vena cava draining into the left atrium.

A rare case of giant left circumflex coronary artery fistula to coronary sinus in patient with persistent left superior vena cava and bicuspid aortic valve

A 61-year-old male presented with symptoms of decompensated heart failure and cardiogenic shock. Transthoracic and transesophageal echocardiography showed severely impaired left ventricular (LV) systolic function (LVEF of 20-25%), bicuspid aortic valve with moderate aortic insufficiency and no significant stenosis, dilated coronary sinus and a tortuous vascular structure in the left-sided atrioventricular groove. Cardiac computed tomography confirmed the diagnosis of persistent left superior vena cava and a giant coronary artery fistula to the coronary sinus. Cardiac magnetic resonance illustrated non-specific late gadolinium enhancement in the mid-wall of the septum. The patient was treated medically and with cardiac re-synchronization therapy.

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.

Successful transvenous lead extraction of abandoned lead implanted through persistent left superior vena cava

Persistent left superior vena cava, the most common thoracic venous anomaly, may complicate transvenous lead extraction (TLE). We report a successful case of TLE in a patient with persistent left superior vena cava, despite a long dwelling time and several pocket revisions due to pocket infection. The lead was removed via a hand-powered mechanical extraction sheath, and postoperative complications did not occur. Complicated TLE cases may have a better outcome if performed in a high-volume center with experienced specialists.

Case report: Thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava

Persistent left superior vena cava (PLSVC) is a relatively rare congenital anomaly in the general population. It plays an important role in initiating and maintaining atrial fibrillation (AF) in some patients. Radiofrequency catheter ablation is the major treatment for patients with AF and PLSVC in most publications. Here, we reported a case of thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava. After preprocedural simulation using virtual reality, we successfully completed box-lesion, ablation line from superior vena cava to inferior vena cava, left atrial appendage (LAA) excision, and PLSVC ablation. It provides a new perspective on surgical treatment for patients with AF and PLSVC.

An Ectopic Primary Pacemaker in Association with Isolated Persistent Left Superior Vena Cava

We are reporting a case of a young Nepalese man, who was not known to have any past medical history, and who presented with palpitations. An electrocardiogram showed negative P-waves atrial rhythm in II, III, arteriovenous fistula, and V3-V6 with a variable block at 90-130 bpm. No positive "normal" P-waves were demonstrated in any tracing. He was found to have a congenital absence of the right superior vena cava (RSVC) along with persistent left superior vena cava (PLSVC) a condition also called isolated PLSVC (IPLSC). He underwent a treadmill stress test for further evaluation which showed a normal chronotropic response and the same persistent negative P-waves morphology. An invasive electroanatomical and activation mapping showed an absence of RSVC, the earliest atrial activation site in the anterior side of the inferior vena cava (IVC), and the absence of normal (positive) P-waves/normal sinus node (SN) activation. Considering all the available clinical data together, we believe that the patient was living with an ectopic pacemaker node that acts as a primary node and originated in the IVC/right atrium instead of the normal expected SN position. Given the high risk of complete sinoatrial nodal block in case of radiofrequency ablation, the patient was kept on medical treatment with a beta-blocker which was effective in controlling his symptoms and atrial arrhythmia.

Isolated left side superior vena cava in a dialysis patient: Right direction, wrong turn!

Tunneled catheter insertion is a routine procedure undertaken by nephrologists world over. However, the presence of a venous anomaly can always test one's skills and can give them anxious moments. Persistent left superior vena cava (SVC) is the most common venous anomaly. We share our experience of successfully placing a hemodialysis central venous catheter in a very rare congenital anomaly wherein patient had persistent left SVC with agenesis of the right SVC.

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.

Permanent pacemaker implantation in a challenging anatomy: Persistent left superior vena cava

The persistence of the left superior vena cava is one of the most common abnormalities that could affect the thoracic venous return, despite its rare occurrence. It can usually be found as the only or in combination with other congenital cardiac abnormalities. Even though it is usually asymptomatic and it rarely has important consequences on the hemodynamics, it could sometimes represent a serious threat. In this regard, PLSVC often represents an incidental finding during an invasive procedure or imaging. We present an interesting case of a 66-year-old patient, with permanent atrial fibrillation and chronic kidney disease who presented to our clinic for a syncope due to complete atrioventricular block. The implant procedure was marked by the incidental intraprocedural finding of unusual venous anatomy. This anomaly included the absence of the superior vena cava, with the communication of the right brachiocephalic trunk and right subclavian vein with a persistent left superior vena cava which drainage directly into the coronary sinus. The right-side approach, as well as the limitation of using contrast-based venography, due to the kidney disease, made the procedure more difficult, but the final position of an active fixation ventricular lead was successfully achieved with optimal and stable pacing parameters through the formation of a particular curve of the lead stylet. Persistence of the left superior vena cava is a venous anomaly, which is frequently suspicioned at transthoracic echocardiography examination when the examiner found a dilated coronary sinus but diagnosed on the implant table of a cardiac device. These anomalies can pose problems and exponentially increase the procedural time even in experienced hands.

Double superior vena cava and left brachiocephalic vein agenesis: a rare systemic vein anomaly and potential source of cardiac implantable electronic device and central venous catheter placement complications

Abnormal systemic vein development produces anomalous veins, which - in the case of persistent left superior vena cava and/or left brachiocephalic vein - exhibit considerable topographic and morphometric differences in comparison with their usual anatomy. The nature and extent of those developmental anomalies - detected during intravenous procedures, such as cardiac implantable electronic device (CIED) lead insertion or central venous catheter placement - may hinder the procedure itself and/or adversely affect its outcome, both at the stage of cardiac lead advancement through an abnormally shaped vessel and lead positioning within the heart. This may lead to problems in achieving optimal sensing and pacing parameters and in ensuring that the patient cannot feel the pacing impulses. These events accompanied a de novo CIED implantation procedure in the patient with a double superior vena cava and left brachiocephalic vein agenesis, who ultimately required reoperation.

Case Report: Candidate Genes Associated With Prenatal Ultrasound Anomalies in a Fetus With Prenatally Detected 1q23.3q31.2 Deletion

Background: Patients with deletions involving the long arm of chromosome 1 are rare, and the main aim of this study was to refine the genotype-phenotype correlation.

Case Report: In this report, a 28-year-old pregnant woman, gravida 2 para 1, at 25⁺⁴ weeks of gestation underwent ultrasound examination in our institute. The ultrasonographic findings of the fetus were as follows: (1) fetal growth restriction; (2) cleft lip and palate; (3) bilateral renal hypoplasia; (4) lateral ventriculomegaly; (5) single umbilical artery; (6) absent stomach; (7) coronary sinus dilatation with persistent left superior vena cava, ventricular septal defect and unroofed coronary sinus syndrome. Chromosomal microarray analysis of amniotic fluid from the fetus revealed a 28.025 Mb deletion in 1q23.3q31.2, spanning from position 164,559,675 to 192,584,768 (hg19).

Conclusion: Genotype-phenotype correlation might improve prenatal diagnosis of fetuses with chromosome 1q deletion. PBX1 could be a candidate gene for fetal growth restriction, renal hypoplasia and congenital heart disease. Fetal growth restriction was accompanied by decreased renal volume in the fetus. Combined with ultrasonic examination, the application of chromosomal microarray analysis will provide accurate prenatal diagnosis.

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.

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 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.