Incidence of Persistent Left Superior Vena Cava in the Normal Population and in Patients with Congenital Heart Diseases Detected Using Echocardiography

Mini-Sternotomy for Aortic Valve Replacement with Concomitant Ablation of the Pulmonary Vein and Persistent Left Superior Vena Cava: A Case Report

A 79-year-old man with severe aortic valve stenosis and atrial fibrillation was referred to our department for surgery. Computed tomography revealed persistent left superior vena cava. Lower mini-sternotomy was performed. The left atrial appendage was amputated before ablation of the persistent left superior vena cava. The jaw of the ablation device was passed behind the pulmonary veins using a tip-lighted articulating dissector. Finally, aortic valve replacement was completed. Aortic valve replacement with concomitant pulmonary vein and persistent left superior vena cava ablation via lower mini-sternotomy is a safe and less invasive alternative.

Transjugular Intrahepatic Portosystemic Shunt Creation in Isolated Persistent Left Superior Vena Cava and Portal Vein Thrombosis

Isolated persistent left superior vena cava is a rare congenital venous anomaly. It imposes technical challenges and increased risks in patients requiring a transjugular intrahepatic portosystemic shunt. The patient was a 67-year-old man with cirrhosis, recurrent large-volume ascites, hepatic hydrothorax, and portal vein thrombosis. The patient had a history of failed transjugular intrahepatic portosystemic shunt creation using a conventional CO2 portal venography technique via a left jugular vein access. The patient underwent successful transjugular intrahepatic portosystemic shunt creation under fluoroscopy and intravascular ultrasound guidance. The patient required transjugular intrahepatic portosystemic shunt revision with mechanical thrombectomy in 2 months. Intravascular ultrasound can provide additional live information to assist transjugular intrahepatic portosystemic shunt creation in patients with complex congenital venous anatomy, including those with isolated persistent left superior vena cava.

Association of Prenatally Diagnosed Isolated Single Left Superior Vena Cava and Postnatal Development of Coarctation of the Aorta

To report the prevalence of coarctation of the aorta (CoA) in fetuses with single left superior vena cava (SL-SVC) and to evaluate changes in echocardiographic measurements. Additionally, to report the prevalence of associated malformations. Retrospective observational study of fetuses diagnosed with SL-SVC between 2012 and 2021 at a tertiary fetal cardiology unit. In fetuses without intracardiac abnormalities, Z-scores of the ventricles, great arteries, and Doppler flow patterns are reported. We identified 47 fetuses with SL-SVC of which 8/47 (17%) had abnormal intracardiac anatomy. One fetus was lost to follow-up. Of those with normal intracardiac anatomy and postnatal follow-up (38), karyotype abnormalities were confirmed in 2/38 (5%) and ECA in 8/38 (21%). 33/38 were live-born. None developed CoA postnatally. Paired analysis of Z-scores between early and late scans of 24 fetuses showed that diameters of the right heart structures and Doppler flows of tricuspid valve increased significantly during pregnancy, while the left heart structures and flow patterns did not change. The median risk of CoA did not change between the early and the late scan. We did not observe CoA in this cohort. A degree of ventricular asymmetry was present, but this was due to right heart dominance rather than hypoplasia of left heart structures. This likely reflects redistribution of blood and does not appear to confer increased risk of CoA. Predictive models of the postnatal development of CoA which set the dimensions of right and left heart structures in relation might not be applicable in this situation.

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.

Complete Duplication of Inferior Vena Cava Coexisting with Double Superior Vena Cava In Situ Solitus: Hitherto Unreported Pattern

Congenital anomalies of inferior vena cava are increasingly being recognized with the technical advancements and increased utilization of cross-sectional imaging techniques. Duplication of inferior vena cava classically involves duplication of the infrarenal segment, where both inferior vena cava ascend on either side of the abdominal aorta until they form a confluence at the level of the renal veins. It has been extensively described in literature with few reports of more complex variation in the form of duplicated infrarenal inferior vena cava with azygos or hemiazygos continuation. This article describes extremely rare complete duplication of inferior vena cava involving both suprarenal and infrarenal segments. Moreover, the complete duplication of inferior vena cava is seen in association with concomitant double superior vena cava, in a patient with visceroatrial situs solitus and associated congenital heart disease, which to the best of our knowledge, has not been reported so far in literature. This study also highlights the utility of multidetector computed tomography in accurate identification of such anomalies.

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.

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.

Accidental Diagnosis of Isolated Persistent Left Superior Vena Cava After an Elective Central Venous Access Procedure for Chronic Hemodialysis: Clinical Implications and Precautions From a Case Report

Persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anatomical variant in the general population. Isolated PLSVC, without formation of the right superior vena cava, is described in 10% of cases of PLSVC only. While it can be associated with congenital heart disease, arrhythmias, and premature death, adult patients with PLSVC are mostly asymptomatic, and the diagnosis is usually accidental. We present the case of a 72-year-old male with end-stage renal disease who was started on urgent hemodialysis through a temporary non-tunneled femoral central venous catheter (CVC) in the SLED (slow low-efficiency dialysis) modality and later remained dependent on hemodialysis. At this stage, placement of a tunneled CVC in the right internal jugular vein was necessary and fluoroscopy guidance was not available. There were no complications during the procedure, but postoperative conventional chest radiography revealed an inadequate positioning of the CVC tip in the left hemithorax, crossing the midline. Subsequently, the diagnosis of PLSVC was obtained by performing a thoracic angio-CT scan, confirming CVC tip positioning inside the PLSVC, and also excluded the presence of cardiac defects or additional anatomical variations of the great vessels of the thorax. Early evaluation for the creation of autologous vascular access was started under our care, and there were no mechanical or other complications associated with hemodialysis sessions during early follow-up after discharge.

High-density electroanatomic 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 anatomic variance of the Koch triangle (KT) and coronary sinus (CS) dilation. Studies using detailed 3-dimensional (3D) electroanatomic mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition are lacking.

OBJECTIVES

The purpose of this study was to describe a novel technique of SP mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal CS anatomy.

METHODS

Seven patients with PLSVC and dual atrioventricular (AV) nodal physiology who underwent SP modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal reentrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing mapping of the right atrial septum and proximal CS 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 multicomponent atrial electrogram adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the midanterior CS ostium. Ablation in this area led to successful SP modification, reaching standard clinical endpoints with a median of 43 seconds of radiofrequency energy or 14 minutes of cryoablation without complications.

CONCLUSION

High-resolution activation mapping of the KT in sinus rhythm can facilitate localization and safe SP ablation in patients with PLSVC.

Analysis of six cancer patients with persistent left superior vena cava identified during central venous access device placement via an intracavitary electrocardiogram

Persistent left superior vena cava (PLSVC) is a rare congenital anomaly. PLSVC can be associated with clinically significant atrial septal defect (ASD) or ventricular septal defect (VSD). It is usually asymptomatic and accidentally detected during invasive procedures or imaging examinations. However, whether central venous access device (CVAD) can be placed and used in patients with PLSVC is controversial. A total of six patients were diagnosed with PLSVC and confirmed by chest CT among 3391 cancer patients who underwent CVAD placement via intracavitary electrocardiogram (IC-EKG) at the Venous Access Center (VAC) from May 2019 to December 2020. The CVADs (peripherally inserted central catheter in four patients and Ports in two patients) of these six patients were left in PLSVC. We analyzed changes in the P-wave in the IC-EKG during CVAD placement and the characteristics of the body surface electrocardiogram in these patients and discussed the catheter tip position in PLSVC. All six patients showed negative P-waves in lead II via IC-EKG from the beginning of catheterization: four patients showed negative P-waves and two showed biphasic P-waves in the body surface electrocardiogram (lead III) before catheterization. CVAD function was normal and no obvious complications were observed during the treatment of these patients. The total retention time of CVADs was 1537 days. For patients with a negative P-wave in lead II via IC-EKG during catheterization, especially in those with a negative or biphasic P-wave in lead III of the body surface electrocardiogram, PLSVC should be considered. CVAD insertion in patients with type I PLSVC is safe under certain conditions, with the proper tip position in the middle to lower part of PLSVC.

Morphologic classification of tracheobronchial arborization in children with congenital tracheobronchial stenosis and the associated cardiovascular defects

Background

We sought to classify patients with congenital tracheal stenosis (CTS) according to tracheobronchial morphology and determine anatomic features associated with tracheobronchial anomalies (TBAs) and concurrent cardiovascular defects (CVDs).

Methods

We enrolled 254 patients who underwent tracheoplasty between November 1, 2009 and December 30, 2018. The anatomic features of the tracheobronchial tree and cardiovascular system were abstracted from bronchoscopy, echocardiography, computerized tomography, and operative reports.

Results

Four types of tracheobronchial morphology were identified: Type-1, which included normal tracheobronchial arborization (Type-1A, n = 29) and tracheal bronchus (Type-1B, n = 22); Type-2 (tracheal trifurcation; n = 49), and Type-3 (typical bridging bronchus; n = 47). Type-4 (bronchus with an untypical bridging pattern) was divided into Type-4A (involving bronchial diverticulum; n = 52) and Type-4B (absent bronchus; n = 55). Carinal compression and tracheomalacia were significantly more frequent in Type-4 patients than in the other patients (P < 0.01). CVDs were common in patients with CTS, especially in patients with Type-3 and Type-4 (P < 0.01). Persistent left superior vena cava was most common among patients with Type-3 (P < 0.01), and pulmonary artery sling was most frequent among those with Type-4 (P < 0.01). Outflow tract defects were most likely to occur in Type-1B. Early mortality was detected in 12.2% of all patients, and young age (P = 0.02), operation in the early era (P < 0.01), and bronchial stenosis (P = 0.03) were proven to be risk factors.

Conclusions

We demonstrated a useful morphological classification for CTS. Bridging bronchus was most closely linked with vascular anomalies, while tracheal bronchus was frequently associated with outflow tract defects. These results may provide a clue to CTS pathogenesis.

Concomitant Coronary Artery Disease and Persistent Left Superior Vena Cava in a Patient Presenting With Symptomatic Sinus Bradycardia: A Case Report

Persistent left superior vena cava (PLSVC) is a congenital venous anomaly. It is frequently associated with other cardiac anomalies. The presence of dual superior vena cava is due to the lack of development of the left cardinal vein in utero. The coronary sinus gets dilated as a result of increased blood flow to the right heart and may be seen on echocardiography. This case describes a 50-year-old lady who presented to the emergency department with lightheadedness, nausea, and vomiting for one day, and her electrocardiogram showed a heart rate of 30 beats per minute. A temporary pacemaker was placed. She had a history of asymptomatic PLSVC diagnosed six months ago through percutaneous coronary intervention. A permanent pacemaker was passed through PLSVC to access the right ventricle and she was discharged home after five days of an uneventful hospital course. Clinicians should be aware of this rare congenital anomaly and its potential complications, particularly in patients with unexplained syncope or bradycardia. Further research is needed to better comprehend the clinical presentation, diagnostic evaluation, and management of PLSVC-related cardiac abnormalities.

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

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

Persistent left superior vena cava: Case report

Persistent left superior vena cava (PLSVC) is a rare anomaly of the systemic venous circulation. We report the case of a 22-year-old female that had history of multiple repair surgeries for her esophageal atresia, as well as a right lobectomy for bronchiectasis 15 years prior. She was admitted to the surgical ward for complete resection of the right lung. A trans-thoracic echocardiography was performed as part of the pre-surgical work-up and it revealed a dilated coronary sinus which led us to suspect the presence of a PLSVC. The latter was confirmed by a simple “Bubble study” and confirmed by CT angiogram. We will discuss throughout this paper, the clinical and radiological features, as well as the embryology of this anomaly, so that the knowledge of the existence of this anatomical variant, especially if surgery or catheterization is at reach of the medical team, may lead to avoid serious complications.

Catheter ablation for atrial fibrillation in patients with persistent left superior vena cava: Case series and systematic review

Introduction

Persistent left superior vena cava (PLSVC) is the most common form of thoracic venous abnormality. Catheter ablation (CA) for atrial fibrillation (AF) can be complicated by the existence of PLSVC, which could act as an important arrhythmogenic mechanism in AF.

Methods and results

We reported a case series of patients with PLSVC who underwent CA for AF at our center between 2018 and 2021. A systematic search was also performed on PubMed, EMBASE, and Web of Science for research reporting CA for AF in patients with PLSVC. Sixteen patients with PLSVC were identified at our center. Ablation targeting PLSVC was performed in 5 patients in the index procedures and in four patients receiving redo procedures. One patient experienced acute procedure failure. After a median follow-up period of 15 months, only 6 (37.5%) patients remained free from AF/atrial tachycardia (AT) after a single procedure. In the systematic review, 11 studies with 167 patients were identified. Based on the included studies, the estimated prevalence of PLSVC in patients undergoing CA for AF was 0.7%. Ablation targeting PLSVC was performed in 121 (74.7%) patients. Major complications in patients with PLSVC receiving AF ablation procedure included four cases of cardiac tamponades (2%), three cases of cardiac effusion (1.5%), one case of ischemic stroke, and three cases of phrenic nerve injury (1.5%) (one left phrenic nerve and two right phrenic nerve). Pooled analysis revealed that after a median follow-up period of 15.6 months (IQR 12.0–74.0 months), the long-term AF/AT-free rate was 70.6% (95% CI 62.8–78.4%, I² = 0.0%) (Central illustration). Different ablation strategies for PLSVC were summarized and discussed in the systematic review.

Conclusion

In patients with PLSVC, recurrence of atrial arrhythmia after CA for AF is relatively common. Ablation aiming for PLSVC isolation is necessitated in most patients. The overall risk of procedural complications was within an acceptable range.

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.

•

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.

•

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.

•

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.

Pediatric Left Posteroseptal Accessory Pathway Ablation from Giant Coronary Sinus with Persistent Left Superior Cava

We report a pediatric patient with persistent left superior vena cava and a D-transposition of great arteries, which is an uncommon relation. It is crucial to know the anatomy of the persistent left superior vena cava and the dilated coronary sinus to plan the mapping techniques in cases of posterior accessory pathways.

Feasibility and safety of left atrial access for ablation of atrial fibrillation in patients with persistent left superior vena cava

BACKGROUND

In patients with persistent left superior vena cava (PLSVC) ablation procedures can be challenging. We sought to determine the feasibility and safety of left atrial ablations in patients with PLSVC, especially when PLSVC is unknown prior to the ablation procedure.

METHODS AND RESULTS

In this retrospective analysis 15 adult patients (mean age 64.6 ± 14.5 years, 53.3% male) with PLSVC undergoing 27 ablation procedures for atrial fibrillation or left atrial flutter were included. In 5 (33,3%) patients PLSVC was only discovered during the procedure. Transseptal puncture (TSP) was declared "difficult" by the ablating physician in 13 of 27 (48,2%) procedures and was not successfully completed in the first attempt in two patients with known PLSVC. Once TSP was successfully completed, all relevant structures were reached both during mapping and ablation in all procedures independent of whether PLSVC was known prior to the procedure. One major complication (3,7%) occurred in 27 procedures in a patient with known PLSVC. In the patients with unknown PLSVC no complication occurred.

CONCLUSION

In experienced hands, left atrial access and ablation in patients with PLSVC is feasible and safe, particularly with regard to patients in whom the PLSVC is unknown prior to the ablation procedure. This article is protected by copyright. All rights reserved.

Endoscopic Mitral Valve Repair in a Patient With Persistent Left Superior Vena Cava Draining Into the Coronary Sinus - Cannulation Technique and Surgical Management

Persistence of the left superior vena cava is often an incidental finding during cardiac surgical procedures. In minimally invasive valvular surgery, it may jeopardise venous drainage and myocardial protection. This How-To-Do-It paper describes the cannulation strategy in a case of minimally invasive mitral surgery in a patient with persistence of the left superior vena cava and absence of the anonymous vein detected with preoperative multimodality imaging.

CT of cardiac and extracardiac vascular anomalies: embryological implications

Background

Congenital heart disease (CHD) is the most common neonatal anomaly. Extracardiac findings are commonly associated with CHD. It is mandatory to evaluate extracardiac structures for potential associated abnormalities that might impact the surgical planning for these patients. The purpose of this study was to determine the extracardiac abnormalities that could associate cardiac anomalies and to give insights into their embryological aberrations.

Results

Thirty-two pediatric patients (22 males and 10 females) underwent CT angiography to assess CHD. Diagnosis of the CHD and associated extracardiac findings were recorded and tabulated by organ system and type of CHD. Retrospective ECG-gated low-peak kilovoltage (80Kvp) technique was used on 128MDCT GE machine. Patients were diagnosed according to their CHD into four groups: chamber anomalies 90%, septal anomalies 81.3%, conotruncal anomalies 59.4%, and valvular anomalies 59.4%. Extracardiac findings were found in 28 patients (87.5%) with a total of 76 findings. Vascular findings were the most prevalent as 50 vascular findings were observed in 28 patients. Aortic anomalies were the commonest vascular anomalies. Fourteen thoracic findings were observed in 12 patients; of them lung consolidation patches were the most common and 12 abdominal findings were found in seven patients, most of findings were related to situs abnormalities.

Conclusion

Extracardiac abnormalities especially vascular anomalies are commonly associating CHD. Along with genetic basis, aberrations in dynamics of blood flow could represent possible causes of this association.

Three steps approach for preoperative evaluation of tetralogy of Fallot patients: role of 128 MDCT

Background

Tetralogy of Fallot is the most common congenital cyanotic heart disease. Advances in surgical repair recently facilitate survival of the affected patients into adulthood with good quality of life. Despite imaging plays crucial role in diagnosis of TOF patients, no single diagnostic modality suffices for complete evaluation of TOF. Thus, different diagnostic tools should be used alone or in combination according to patient’s clinical question. This study aims to find out the agreement between the echocardiography and MDCT in evaluation of TOF patients prior to surgical repair.

Results

Three-step approach used in scanning TOF patients. Firstly, classic TOF findings, MDCT was comparable to echocardiography in overriding aorta (k = 0.6), VSD (k = 0.8), RVH (k = 0.4), and sub valvular pulmonary stenosis (k = 0.6). Echocardiography is superior to MDCT in evaluation of valvular stenosis (k = 0.4). MDCT was superior to echocardiography in supravalvular pulmonary stenosis. Secondary, surgical relevant findings, McGoon ratio calculated in 94.2%, small and major APCs in 45.5% and 28.5% respectively, PDA in 35% and anomalous coronary artery in 5.1%. Thirdly, other TOF-associated anomalies, common: ASD (34.3%) and RAA (28.3%), and persistent LSVC (10.3%). Uncommon: situs ambiguous (2.5 %), PAPVR (1.2%), and IVC anomalies (3.8%). MDCT was superior to echocardiography in surgical relevant findings and other TOF-associated anomalies.

Conclusion

MDCT is a crucial imaging tool for extra cardiac evaluation of TOF patients prior to surgical repair.

Cryoablation for atrioventricular nodal re-entrant tachycardia associated with persistent left superior vena cava

Catheter ablation for atrioventricular nodal re-entrant tachycardia (AVNRT) in patients with persistent left superior vena cava (PLSVC) is challenging because of anatomical abnormalities of Koch's triangle associated with the enlarged coronary sinus ostium. We present the Case of successful ablation in a patient with PLSVC using the cryoablation technique. The ablation was successfully performed without damaging the conduction system by virtue of “cryomapping” and “cryoadhesion.” Cryoablation is a safe and efficacious alternative to radiofrequency catheter ablation for the treatment of AVNRT associated with PLSVC.

•

Catheter ablation for AVNRT in patients with PLSVC is challenging

•

We performed successful ablation in a PLSVC patient with the cryoablation technique

•

Ablation was successfully performed without damaging the conduction system

The combination of coronary sinus ostial atresia/abnormalities and a small persistent left superior vena cava-Opportunity for left ventricular lead implantation and unrecognized source of thromboembolic stroke

BACKGROUND

Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC).

OBJECTIVE

The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke.

METHODS

Twenty patients with CS ostial abnormalities and sPLSVC were identified. Clinical information, imaging methods, LV lead implantation techniques, and complications were summarized.

RESULTS

Forty percent had at least 1 previously unsuccessful LV lead placement. In 70%, sPLSVC was identified by catheter manipulation and contrast injection in the left brachiocephalic vein, and in 30% by levophase CS venography. In 30%, sPLSVC was associated with drainage from the CS into the left atrium (LA). When associated with CS ostial abnormalities, the sPLSVC diameter averaged 5.6 ± 3 mm. sPLSVC was used for successful LV lead implantation in 90% of cases. In 80%, the LV lead was implanted down sPLSVC, and in 20%, sPLSVC was used to access the CS from the RA. Presumably because of unrecognized drainage from the CS to the LA, 1 patient had a stroke during implantation via sPLSVC.

CONCLUSION

When CS ostial abnormalities prevent access to the CS from the RA, sPLSVC can be used to successfully implant LV leads. In some, the CS partially drains into the LA and stroke can occur spontaneously or during lead intervention. It is important to distinguish sPLSVC associated with CS ostial abnormalities from isolated PLSVC.

Rare case of right ventricular dilatation associated with anomalous pulmonary venous drainage, sinus venosus atrial septal defect and persistent left superior vena cava

A 34-year-old woman was seen in the emergency department for shortness of breath and chest pain. During a pandemic, it is easy to 'think horses and not zebras', and with a patient presenting with the classic coronavirus symptoms it would have been easy to jump to that as her diagnosis. After a careful history and examination, it became clear that there was another underlying diagnosis. Chest X-ray, echocardiogram and CT scan revealed marked right ventricular dilatation and pulmonary hypertension, alongside a persistent left superior vena cava (PLSVC). Further investigation with cardiac MRI and coronary angiography at a tertiary centre demonstrated that she not only have a PLSVC but also a partial anomalous pulmonary venous drainage and sinus venosus atrial septal defect. This case highlights the importance of considering all differentials and approaching investigations in a logical manner.

Persistent left superior vena cava: clinical importance and differential diagnoses

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and may be a component of the complex cardiac pathologies. While it is often asymptomatic, it can lead to significant problems such as arrhythmias and cyanosis. Besides, it can cause serious complications during vascular interventional procedures or the surgical treatment of cardiac anomalies (CA). The clinical significance of PLSVC depends on the drainage site and the accompanying CA. In this article, we will describe the epidemiology, embryology, and anatomic variations of PLSVC. Possible accompanying CA and heterotaxy spectrum will be reviewed with the help of multidetector computed tomography (MDCT) images. Radiological pitfalls, differential diagnoses, and the clinical importance of PLSVC will be highlighted.

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.

Tunnelled haemodialysis catheter insertion into the persistent left superior vena cava

Persistent left superior vena cava is an uncommon abnormality of the venous system. Most commonly, it is diagnosed incidentally during central vein catheterisation on the left side or pacemaker implantation. We present the case of a patient with persistent left superior vena cava, which was diagnosed after the attempted insertion of tunnelled haemodialysis catheter through the left internal jugular vein. The presence of the persistent left superior vena cava was confirmed by cardiac echography and angio-computed tomography scan. The 19-cm long tunnelled haemodialysis catheter was inserted into persistent left superior vena cava through the left internal jugular vein with good long-term function.

Gradual diagnosis and clinical importance of prenatally detected persistent left superior vena cava with absent right superior vena cava - a case report and literature review

Persistent left superior vena cava is a malformation of cardinal veins. We report a case of a secundigravida who had many fetal ultrasound examinations – first performed by an obstetrician (who described fetal mediastinum as “abnormal”), second by other obstetrician, who performed basic fetal echocardiographic examination and diagnosed persistent left superior vena cava. The woman was referred to a tertiary center for detailed fetal echocardiography. The diagnosis of persistent left superior vena cava with agenesis of the right superior vena cava was confirmed. The anomaly had no influence on fetal hemodynamic stability, fetal life, delivery and early postnatal period. After delivery, the neonate was under observation for further anomalies, aortic coarctation in particular. Prenatal and postnatal management was summarized. Literature review is presented.

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.

Cardiac implantable electronic devices in patients with persistent left superior vena cava-A single center experience

BACKGROUND

There are limited data on cardiac implantable electronic device implantation (CIED) in patients with persistent left superior vena cava (PLSVC).

OBJECTIVE

To describe the outcomes of implanting CIEDs with a focus on cardiac resynchronization therapy (CRT) in patients with PLSVC.

METHODS

We identified all patients with a PLSVC that underwent CIED implantation from December 2008 until February 2019 at our institution by querying the electronic medical record (n = 34). We then identified controls in a 3:1 fashion (n = 102) by matching on device type (CRT vs non-CRT). Procedure success, complications, fluoroscopy and procedural time were recorded. Outcomes were compared using a two-way analysis of variance test and conditional regression modeling for continuous and categorical variables, respectively.

RESULTS

A total of 34 patients with PLSVC underwent 38 procedures. Four patients underwent dual chamber system implantation followed by a subsequent upgrade to CRT. Thirteen patients underwent CRT implantation: one was implanted via the right subclavian while the rest were implanted via the PLSVC. Left ventricular (P = .06). Procedure and fluoroscopy times were significantly higher in the PLSVC as compared with the control group (97.7 vs 66.1 minute, P < .001 and 18.1 minute vs 8.7 minutes, P = .005, respectively).

CONCLUSION

CIED implant in patients with PLSVC is feasible but technically more challenging and appears to be associated with higher risk of right ventricular lead dislodgment.

Impact of persistent left superior vena cava on radiofrequency catheter ablation in patients with atrial fibrillation

AIMS

The impact of persistent left superior vena cava (PLSVC) in atrial fibrillation (AF) patients undergoing radiofrequency catheter ablation (RFCA) is not well known. We performed this analysis to evaluate the electrophysiological characteristics of PLSVC and its role in triggering and maintaining AF.

METHODS AND RESULTS

Patients with AF referred to two tertiary hospitals were screened and patients with PLSVC in pre-RFCA imaging studies were enrolled. Among 3967 patients, PLSVC was present in 36 patients (0.9%). There were four morphological types of PLSVC: type 1, atresia of the right superior vena cava (SVC) (n = 2); type 2A, dual SVCs with an anastomosis between right and left SVCs (n = 15); type 2B, dual SVCs without an anastomosis (n = 16); type 3, PLSVC draining into the left atrium (LA; n = 2); and unclassified in one patient. Thirty-two patients underwent RFCA and electrophysiology study focusing on PLSVC: PLSVC was the trigger of AF in 48.4% of patients and the driver of AF in 46.9% of patients. Cumulatively, PLSVC was a trigger or driver of AF in 22 patients (68.8%). Whether to ablate PLSVC was determined by the results of electrophysiology study, and no significant difference in the late recurrence rate was observed between patients who did and did not have either trigger or driver from PLSVC.

CONCLUSION

Pre-RFCA cardiac imaging revealed PLSVC in 0.9% of AF patients. This study demonstrated that PLSVC has an important role in initiating and maintaining AF in substantial proportion of patients. Electrophysiology study focusing on PLSVC can help to decide whether to ablate PLSVC.

A case of cardiac resynchronization therapy in a patient with coronary sinus ostial atresia and persistent left superior vena cava

Coronary sinus ostial atresia is rare and usually not clinically relevant, but it should be noted in cases of cardiac resynchronization therapy. A rare case of successful left ventricular lead implantation for cardiac resynchronization therapy via the left superior vena cava in a patient with coronary sinus ostial atresia is reported. The persistent left superior vena cava associated with these cases tends to be smaller than usual in its diameter and difficult to identify, since the direction of venous drainage is reversed. Therefore, in the present case, it was useful to use a small-diameter, soft inner catheter as a guiding catheter to perform selective imaging and avoid vascular injury. In addition, it appeared to be important to plan the surgical strategy using prior imaging information, since it would be difficult to obtain the backup needed for lead insertion.

〈

Learning objective: Cardiac resynchronization therapy via the left superior vena cava with coronary sinus ostial atresia is generally possible without problems if prior imaging information is available, such as three-dimensional computed tomography and the venous phase of coronary angiography. It is important to determine whether there is a persistent left superior vena cava before the procedure. Thromboprophylaxis remains controversial in this situation.〉

Imaging Approach to Misplaced Central Venous Catheters

Central venous catheters (CVCs) are commonly used in patients in a variety of clinical settings, including the intensive care unit, general ward, and outpatient settings. After placement, the radiologist is frequently requested to evaluate the location of CVCs and deem them suitable for use. An understanding of the ideal location of catheter tips as well as the approach to identifying malpositioned catheter tips is essential to prevent improper use, recognize and/or prevent further injury, and direct potential lifesaving care. An approach to CVC placement based on tip location can be helpful in localization and guiding management.

Electrophysiological features and radiofrequency catheter ablation of supraventricular tachycardia in patients with persistent left superior vena cava

BACKGROUND

The electrophysiological features and roles of persistent left superior vena cava (PLSVC) in supraventricular tachycardia (SVT) are not known.

OBJECTIVE

The purpose of this study was to elucidate the electrophysiological features and roles of PLSVC in patients with SVT.

METHODS

We included 37 patients with PLSVC (mean age 43.5 ± 17.1 years; 35.1% men) and 510 patients without PLSVC (mean age 43.9 ± 18.8 years; 48.2% men) who underwent an electrophysiology study for SVT. The number of induced tachycardias, location of the slow pathway (SP) or accessory pathway (AP), and radiofrequency catheter ablation (RFCA) outcomes were compared between patients with and without PLSVC. During RFCA of the left AP, a coronary sinus (CS) catheter was placed into the left superior vena cava (left superior vena cava group) or the great cardiac vein (great cardiac vein group). The RFCA outcomes were compared between the groups.

RESULTS

In patients with PLSVC, 40 tachycardias were induced: atrioventricular nodal reentrant tachycardia (AVNRT) (n = 19), atrioventricular reentrant tachycardia (n = 17), and focal atrial tachycardia (n = 4). Among patients with AVNRT, an SP in the CS was significantly more frequent in patients with PLSVC than in those without PLSVC (47.4% vs 3.8%; P < .001). In patients with the left AP, the number of RFCA attempts and recurrence were lower in the great cardiac vein group than in the left superior vena cava group.

CONCLUSION

An SP in the CS is prevalent in patients with AVNRT and PLSVC. It is useful to place a CS catheter into the great cardiac vein in patients with a left AP and PLSVC.

Multidetector-row CT imaging evaluation of superior and inferior vena cava normal anatomy and caval variants: Report of our cases and literature review with embryologic correlation

Objective

To assess the potential of multidetector-row computed tomography imaging and its reformations in the evaluation of the superior and inferior vena cava normal anatomy and their anatomical variants, and to make a brief review of caval embryogenesis and developmental errors.

Methods

We retrospectively reviewed a total of 1000 whole-body computed tomography scans performed between January 2010 and December 2016 to assess the normal superior and inferior vena cava anatomy and their variants.

Results

The normal superior and inferior vena cava anatomy was found in 88.9% of patients, whereas multiple variants were found, ranging from the superior or inferior vena cava duplication, to the azygos continuation of the inferior vena cava.

Conclusions

Computed tomography is a powerful tool to analyse superior and inferior vena cava anatomical variants. The knowledge and assessment of normal caval anatomy and of its anatomical variants is mandatory in the correct pre-operative planning in surgical and radiological interventions. Knowledge of caval variants is helpful in the differential diagnosis of abdominal or mediastinal masses, to avoid misdiagnosis, as well as in the screening of associated congenital pathologic conditions.