A Double Rarity: Lost intravascular Catheter Guidewire in Persistent Left Superior Vena Cava and Coronary Sinus - A Case Report.

Guidewire loss is a rare complication of central venous catheterization. A 65-year-old male was hospitalized in a high-dependency unit for exacerbation of chronic obstructive pulmonary disease, pneumonia, erythrocytosis, and clinical signs of heart failure. Upon admission, after an unsuccessful right jugular approach, a left jugular central venous catheter was placed. The next day, chest radiography revealed the catheter located in the left parasternal region, with suspected retention of the guidewire, visually confirmed by the presence of its proximal end inside the catheter. The left parasternal location of the catheter and the typical projection of the guidewire in the coronary sinus, later confirmed by echocardiography, raised suspicion of a persistent left superior vena cava (PLSVC). Agitated saline injected into the left antecubital vein confirmed bubble entry from the coronary sinus into the right atrium. After clamping the guidewire, the catheter was carefully retrieved along with the guidewire without any complications. This is the first reported case of guidewire retention in PLSVC and coronary sinus. It underscores the potential causes of guidewire loss and advocates preventive measures to avoid this potentially fatal complication.

Malposition of Central Venous Catheter into Coronary Sinus throughout the Persistent Left Superior Vena Cava and Other Complications Related to Catheterization.

This case concentrates on the persistent left superior vena cava (PLSVC), a rare vascular anomaly which contributes to central venous catheter (CVC) misplacement. A 72-year-old woman with renal insufficiency presented to the hospital with recurrent bleeding from her permanent CVC device placed in the right common jugular vein. An initial attempt to replace the device was unsuccessful, necessitating the placement of a secondary catheter in the left jugular vein. Shortly after the procedure, the patient developed swelling of the face and neck. Further diagnostic imaging, including a chest radiograph and computed tomography (CT), revealed CVC misplacement in the PLSVC and coronary sinus, thrombosis of the common jugular vein, and a posterior mediastinal hematoma. Conservative therapy of the mediastinal hematoma was implemented and proved effective in this case. A temporary CVC was inserted into the left femoral vein. Two months later, the catheter underwent further dysfunction and a decision was made to place a long-term permanent CVC via the right femoral vein. The patient is currently awaiting an arteriovenous fistula for dialysis use. This case emphasizes the importance of radiological techniques for CVC procedural placement, as well as the detection of congenital abnormalities. Providers regularly placing CVCs should have an in-depth knowledge of the possible complications and potential anatomical variations, especially as seen in high-risk patients.

Challenge Accepted: Lead Extraction in a Patient with Persistent Left Superior Vena Cava and Right Superior Vena Cava Occlusion.

Persistent left superior vena cava (PLSVC) is an anatomic variant that is relatively uncommon in the general population. Lead extraction through PLSVC is extremely rare. Due to unusual anatomy, the procedure carries challenges that require special considerations and careful planning. The authors report a case of lead extraction through a PLSVC with occluded right superior vena cava and highlight the challenges and outcomes of the procedure.

Minimally invasive redo tricuspid valve replacement in patient with persistent left superior vena cava.

INTRODUCTION: The management of cardiopulmonary bypass (CPB) is still challenging in certain circumstances, especially for patients with anatomical variations. This challenge is even harder for reoperations, which are associated with increased morbidity and mortality risk. CASE REPORT: We describe a minimally invasive, beating-heart redo tricuspid valve replacement in a 71-years old woman with persistent left superior vena cava. DISCUSSION: Preoperative planning via CT-scan, teamwork and custom-made management of CPB are crucial for reoperations with anatomical variations. The perfusionist has a pivotal role in constructing and managing the CPB. CONCLUSION: We describe a strategy achieving the benefits of minimally invasive endoscopic and beating-heart surgery (avoidance of resternotomy risk and associated morbidity, right ventricular protection) in reoperative tricuspid surgery with persistent upper left vena cava.

Coexisting Pulmonary Artery Sling and Persistent Left Superior Vena Cava.

Congenital vascular anomalies such as pulmonary artery sling and persistent left superior vena cava are rare vascular disorders. We describe a case of a patient who presented with pneumonia and was found to have a pulmonary artery sling as a potential cause of the pneumonia.

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.

A rare case of isolated persistent left superior vena cava diagnosed by echocardiography.

BACKGROUND: The persistent left superior vena cava (PLSVC) is an infrequent vascular variant. PLSVC with absent right superior vena cava, also known as isolated PLSVC, is an exceptionally rare entity. In this case we present a patient with isolated PLSVC draining to coronary sinus, diagnosed incidentally during echocardiography. CASE PRESENTATION: A 35-year-old man underwent a transthoracic echocardiography which showed an enormously dilated coronary sinus. Hand-agitated saline was injected via peripheral intravenous cannulas. The contrast appeared firstly in the coronary sinus before it opacified the right atrium. Since this was also visible by the right antecubital saline injection, it indicated an extremely rare case of PLSVC with the absence of right superior vena cava which was confirmed by cardiac magnetic resonance. CONCLUSIONS: The finding of a distinctively dilated coronary sinus in echocardiography led us to further investigation using agitated saline that revealed an infrequent anomaly termed isolated PLSVC. The in-depth diagnosis of this vascular variant is crucial considering that it may lead to important clinical implications, such as difficulties with central venous access, especially in the current era of a rapid development of cardiac device therapies.

Elucidating left atrial electrical potential with microelectrode catheter: A case of coronary sinus ostial atresia with small persistent left superior vena cava.

A 51-year-old woman presented with recurring palpitations. Electrocardiography revealed narrow QRS tachycardia with short RP configuration. Computed tomography showed coronary sinus (CS) ostial atresia along with a small persistent left superior vena cava (PLSVC). Electrophysiological study identified the retrograde earliest atrial activation site (EAAS) at the CS ostium without decremental properties, and para-Hisian pacing suggested retrograde atrioventricular nodal conduction. Using a 1.6-Fr microelectrode catheter distally placed in the CS via the PLSVC, EAAS was confirmed within the left atrium, not the CS ostium. Transseptal approach revealed a left lateral accessory pathway, which was successfully eliminated.

It's a long way to the top! Congenital venous anomalies and left isomerism limiting atrial fibrillation transcatheter ablation.

BACKGROUND: Atrial fibrillation is the most common sustained cardiac arrhythmia in adults and it is associated with a high burden of mortality and morbidity worldwide. Catheter ablation is increasingly used to improve symptoms and prognosis in selected patients. Lower limb venous access with subsequent transseptal approach to the left atrium is the standard procedure for atrial fibrillation catheter ablation. CASE PRESENTATION: We report an unusual case of complex venous anomaly with a left-sided inferior vena cava with hemiazygos continuation to a persistent left superior vena cava draining in an enlarged coronary sinus in a patient with persistent atrial fibrillation scheduled for transcatheter ablation. DISCUSSION: Lower limb venous anomalies may limit a standard transseptal approach to the left atrium thus precluding an effective catheter ablation procedure for atrial fibrillation. Alternative interventions, such as unconventional percutaneous access, thoracoscopic approach and "ablate and pace" procedures, may be necessary in patients with symptomatic atrial fibrillation and complex venous anomalies.

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.

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.

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.

Pacemaker implantation in a patient with isolated persistent left superior vena cava using a delivery catheter: a case report.

Background: Persistent left superior vena cava (PLSVC) with absent right superior vena cava, also termed 'isolated PLSVC', is extremely rare. Permanent pacemaker implantation in patients with isolated PLSVC is often difficult by the usual subclavian approach due to the unique anatomy. With the advent of delivery catheters in recent years, implantation using the same system has been reported. Case summary: A 47-year-old woman with symptomatic sick sinus syndrome was admitted to our institution for permanent pacemaker implantation. Preprocedural cardiac multidetector computed tomography (MDCT) showed isolated PLSVC. We performed pacemaker implantation successfully via the left subclavian approach, using the C315 delivery catheter system. The leads were stable on chest radiography, and the sensing and capture thresholds were unchanged. After the procedure, we integrated the delivery catheter images with cardiac MDCT using Ziostation, and they were well matched with the fluoroscopic images. At the 1-month follow-up, the patient was free of heart failure symptoms and had decreased levels of N-terminal prohormone of brain natriuretic peptide. Discussion: The C315 delivery catheter system was considered an option for permanent pacemaker implantation in patients with isolated PLSVC. When performing permanent pacemaker implantation in patients with unusual venous anatomy, integrating the delivery catheter images with cardiac MDCT allows for appropriate preoperative catheter selection.

Challenges and pitfalls during CRT implantation in patients with persistent left superior vena cava.

BACKGROUND: Persistent left superior vena cava (PLSVC) is a rare venous anomaly, affecting 0.3-0.5% of the general population. Cardiac resynchronization therapy (CRT) implantation in patients with PLSVC is challenging due to a complex anatomy. Moreover, data on CRT implantation in this patient population is scarce. Our aim was to report a series of patients with PLSVC and CRT implantation focusing on challenges and pitfalls. METHODS: Electronic medical databases on patients with CRT implantation at the University Heart Centers in Zurich, Switzerland, and Lübeck, Germany, were screened for individuals with a PLSVC. Clinical and demographic characteristics as well as procedural data were reported in all patients. RESULTS: This study presents six cases with a median age of 66 years. CRT implantation was successful in five patients, leading to a reduced QRS duration and improved left ventricular ejection fraction. Atrial fibrillation, ischemic cardiomyopathy, valvular heart disease, and dilated cardiomyopathy were observed in this group as underlying conditions. Specialized tools, such as active fixation left ventricular leads, were utilized. One patient experienced major complications. CONCLUSIONS: This case series shows that although challenging, conventional endovascular CRT implantation is feasible in PLSVC patients. Specialized tools for visualization and fixation may help. Our experiences highlight the importance of preprocedural evaluation of the anatomy and precise intervention planning.