A Rare Case of an Isolated Persistent Left Superior Vena Cava

Authors' Affiliations

Sanskrita Nemalikanti, MD; Department of Internal Medicine, East Tennessee State University, Johnson City, TN Matthew Colna, MD; Department of Internal Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

102

Name of Project's Faculty Sponsor

Michael Donovan

Faculty Sponsor's Department

Internal Medicine

Classification of First Author

Medical Resident or Clinical Fellow

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

Introduction A persistent left superior vena cava (PLSVC) with an absent right superior vena cava (SVC) is a rare anomaly with an incidence of 0.07% to 0.13%. During embryonic development, the primary atrium receives blood from paired superior caval veins connected through the common cardinal vein. In the 12th week, the left SVC usually obliterates and only the right SVC remains. Unusually, the right SVC may involute with a persisting left SVC. Case Description A 57-year-old male with hypertrophic cardiomyopathy with ICD, coronary artery disease with PCI to left circumflex artery, hypertension, and hyperlipidemia presented to the hospital with chest pain. ECG showed normal sinus rhythm with right bundle branch block but no acute ischemic changes. Troponin and BNP were minimally elevated at 0.038 and 502, respectively. Chest X-ray showed mild pulmonary congestion and the presence of an ICD with an unusual lead course. The patient received IV furosemide and home doses of aspirin, clopidogrel, rosuvastatin, losartan, and metoprolol succinate were restarted. The patient was noted to have a 2-minute run of accelerated idioventricular rhythm on telemetry overnight, which raised the suspicion for ongoing ischemia, and was started on IV heparin. Coronary angiography revealed nonobstructive coronaries with a patent circumflex stent and a newly reduced ejection fraction (EF) on ventriculography. A transthoracic echocardiogram confirmed EF of 30-35% and revealed a dilated coronary sinus (CS). Agitated saline injected from both the right and left arm showed opacification of CS before the right atrium (RA). A follow-up CT venography confirmed an isolated PLSVC with absent right SVC. Discussion Isolated PLSVC is usually an asymptomatic incidental finding. It commonly drains into the CS and RA, but in a minority of cases may drain into the left atrium without any hemodynamic consequences. However, it may pose challenges during central venous catheterization, intracardiac electrode placement or cardiopulmonary bypass requiring cannulation of SVC. Thus, patients with dilated CS on echocardiography should be further examined with agitated saline or with venous angiography to identify this rare anomaly and prevent future complications during invasive procedures.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

A Rare Case of an Isolated Persistent Left Superior Vena Cava

D.P. Culp Center Ballroom

Introduction A persistent left superior vena cava (PLSVC) with an absent right superior vena cava (SVC) is a rare anomaly with an incidence of 0.07% to 0.13%. During embryonic development, the primary atrium receives blood from paired superior caval veins connected through the common cardinal vein. In the 12th week, the left SVC usually obliterates and only the right SVC remains. Unusually, the right SVC may involute with a persisting left SVC. Case Description A 57-year-old male with hypertrophic cardiomyopathy with ICD, coronary artery disease with PCI to left circumflex artery, hypertension, and hyperlipidemia presented to the hospital with chest pain. ECG showed normal sinus rhythm with right bundle branch block but no acute ischemic changes. Troponin and BNP were minimally elevated at 0.038 and 502, respectively. Chest X-ray showed mild pulmonary congestion and the presence of an ICD with an unusual lead course. The patient received IV furosemide and home doses of aspirin, clopidogrel, rosuvastatin, losartan, and metoprolol succinate were restarted. The patient was noted to have a 2-minute run of accelerated idioventricular rhythm on telemetry overnight, which raised the suspicion for ongoing ischemia, and was started on IV heparin. Coronary angiography revealed nonobstructive coronaries with a patent circumflex stent and a newly reduced ejection fraction (EF) on ventriculography. A transthoracic echocardiogram confirmed EF of 30-35% and revealed a dilated coronary sinus (CS). Agitated saline injected from both the right and left arm showed opacification of CS before the right atrium (RA). A follow-up CT venography confirmed an isolated PLSVC with absent right SVC. Discussion Isolated PLSVC is usually an asymptomatic incidental finding. It commonly drains into the CS and RA, but in a minority of cases may drain into the left atrium without any hemodynamic consequences. However, it may pose challenges during central venous catheterization, intracardiac electrode placement or cardiopulmonary bypass requiring cannulation of SVC. Thus, patients with dilated CS on echocardiography should be further examined with agitated saline or with venous angiography to identify this rare anomaly and prevent future complications during invasive procedures.