Persistent Left Superior Vena Cava: An Illustrative Example

Abstract

To the Editor: Persistent left superior vena cava is an infrequently encountered anatomic malformation characterized by the persistence of the left cardinal vein, which normally regresses during embryogenesis. In most patients, the persistent left superior vena cava drains into the right atrium through the coronary sinus without significant hemodynamic issues or associated cardiovascular anomalies.1Ratliff HL Yousufuddin M Lieving WR et al.Persistent left superior vena cava: Case reports and clinical implications.Int J Cardiol. 2006; 113: 242-246Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Because most patients present asymptomatically, this unique abnormality is often detected as an unexpected finding during vascular procedures or cardiac surgery. We describe the incidental discovery of a persistent left superior vena cava in a patient who presented for coronary artery surgery. A 68-year-old man with multivessel disease presented for coronary artery bypass graft surgery. The preoperative transthoracic echocardiogram was unremarkable. A pulmonary artery catheter was inserted using the right internal jugular vein and advanced approximately 51 cm. Persistent left superior vena cava was suspected because of the length that the catheter had to be inserted before obtaining a pulmonary capillary wedge pressure waveform. A chest radiograph demonstrated that the catheter followed an unusual course into the pulmonary artery (Fig 1). The diagnosis was confirmed during the surgery when a direct inspection revealed a massively enlarged coronary sinus that drained the persistent left superior vena cava. Anterograde cardioplegia was used exclusively as a result. Our case demonstrated the typical venous drainage of a persistent left superior vena cava. The presence of persistent left superior vena cava can provide substantial difficulties during central venous or pulmonary artery catheter insertion, a pacemaker or cardiac resynchronization therapy device implantation, and cardiac surgery. For example, the advancement of vascular catheters through a persistent left superior vena cava into the coronary sinus occasionally can induce fatal arrhythmias.2Bass SP Young AE. Paediatric cardiac arrest during Hickman line insertion.Paediatr Anaesth. 1997; 7: 83-86Crossref PubMed Google Scholar The detection of an isolated persistent left superior vena cava during the insertion of a pacemaker or implantable cardioverter-defibrillator devices may require a change in vascular access to allow for easier lead navigation.3Kilickap M Altin T Akyurek O et al.DDD pacemaker implantation in a patient with persistent left superior vena cava and absent right superior vena cava: a four-year follow-up report.Can J Cardiol. 2005; 21: 1221-1223Google Scholar Furthermore, as our case highlighted, persistent left superior vena cava may affect cardiac surgery, as a retrograde cannula typically is placed into the coronary sinus for cardioplegia delivery.4Shahian DM Retrograde coronary sinus cardioplegia in the presence of persistent left superior vena cava.Ann Thorac Surg. 1992; 54: 1214-1215Abstract Full Text PDF PubMed Google Scholar In addition, life-threatening complications have been reported from the manipulation of this abnormal vascular anomaly, including cardiogenic shock and coronary sinus thrombosis.5Kurtoglu E Cakin O Akcay S et al.Persistent left superior vena cava draining into the coronary sinus: A case report.Cardiol Res. 2011; 2: 249-252PubMed Google Scholar None.