© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12654
Echocardiography
Persistent Left and Absent Right Superior Vena Cava: Combined Functional and Anatomic Assessment with Transthoracic Echocardiography and Computed Tomography Christopher Naoum, M.B.B.S.,* Vincent Khoury, M.B.B.S., M.Phil.,* Lloyd Ridley, M.B.B.S.,† and Seymour Maze, M.B.Ch.B.* *Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia; and †Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
(Echocardiography 2014;31:E267–E268) Key words: cardiac imaging, contrast echocardiography, superior vena cava, temporal resolution, transthoracic echocardiography
Figure 1. A. Two-dimensional transthoracic echocardiography (TTE) in the parasternal long-axis view demonstrating a dilated CS. B. M-mode echocardiography showing contrast appearing within the CS before the right ventricle following injection of agitated saline into the right upper limb. C, D. Three-dimensional computed tomography reconstructions demonstrating drainage of a persistent left superior vena cava into a dilated CS (C) and confluence of the left and right brachiocephalic veins into the leftsided superior vena cava (D). LV = left ventricle; LA = left atrium; CS = coronary sinus; RV = right ventricle; BCV = brachiocephalic vein; PLSVC = persistent left superior vena cava. Address for correspondence and reprint requests: Christopher Naoum, M.B.B.S., Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales, 2137, Australia. Fax: +61 2 9767 8395; E-mail: [email protected]
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Naoum, et al.
A 42-year-old man underwent transthoracic echocardiography (TTE) with agitated saline injection to evaluate isolated marked dilatation of the coronary sinus (CS) (Fig. 1A). Following intravenous agitated saline injection into the left arm, contrast first appeared in the CS implying venous drainage of the left upper body directly into this vessel (movie clip S1). Similarly, with right arm injection contrast initially opacified the CS before appearing in the right-sided cardiac chambers as demonstrated in Figure 1B using M-mode echocardiography (Vivid 7, GE Healthcare, Horten, Norway) with its superior temporal resolution. Together, these findings suggest drainage of both upper limbs directly into the CS via a persistent left superior vena cava (PLSVC), and based on the sequence of chamber opacification following right arm injection, likely atresia of the right superior vena cava (RSVC). Computed tomography (CT) (Definition, Siemens AG, Erlangen, Germany) was subsequently performed and confirmed these anomalies with confluence of both left and right brachiocephalic veins into a PLSVC, which drained into the CS (Fig. 1C, D). PLSVC is a commonly identified thoracic venous anomaly and should be suspected in any patient with a dilated CS. It occurs when the left superior cardinal vein fails to regress during embryological development resulting in persistent left-sided venous drainage.1 In most patients, however, the RSVC is also present and its absence is extremely uncommon.2,3 In isolation, PLSVC is generally asymptomatic, however,
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anatomical characterization of such anomalies is important because of the implications for patients undergoing cardiac device implantation with transvenous leads or retrograde cardioplegia during cardiac surgery. Thoracic CT provides anatomical confirmation, however, as highlighted in this case, TTE with selective bilateral upper limb contrast injection is a simple and accurate modality for characterizing venous return patterns and making the diagnosis. References 1. Goyal SK, Punnam SR, Verma G, et al: Persistent left superior vena cava: A case report and review of literature. Cardiovas Ultrasound 2008;6:50. 2. Arat N, Sokmen Y, Golbasi Z: Persistent left superior vena cava with absent right superior vena cava and coronary sinus dilation mimicking a paracardiac mass. Tex Heart Inst J 2007;34:492–493. 3. Sheikh AS, Mazhar S: Persistent left superior vena cava with absent right superior vena cava: Review of the literature and clinical implications. Echocardiography 2014; 31:674–679.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Two-dimensional TTE in a modified four-chamber view demonstrating contrast appearance within the CS prior to the right-sided chambers following agitated saline injection into the left upper limb. LV = left ventricle; RV = right ventricle; RA = right atrium; CS = coronary sinus.
Echocardiography
Persistent Left and Absent Right Superior Vena Cava: Combined Functional and Anatomic Assessment with Transthoracic Echocardiography and Computed Tomography Christopher Naoum, M.B.B.S.,* Vincent Khoury, M.B.B.S., M.Phil.,* Lloyd Ridley, M.B.B.S.,† and Seymour Maze, M.B.Ch.B.* *Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia; and †Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
(Echocardiography 2014;31:E267–E268) Key words: cardiac imaging, contrast echocardiography, superior vena cava, temporal resolution, transthoracic echocardiography
Figure 1. A. Two-dimensional transthoracic echocardiography (TTE) in the parasternal long-axis view demonstrating a dilated CS. B. M-mode echocardiography showing contrast appearing within the CS before the right ventricle following injection of agitated saline into the right upper limb. C, D. Three-dimensional computed tomography reconstructions demonstrating drainage of a persistent left superior vena cava into a dilated CS (C) and confluence of the left and right brachiocephalic veins into the leftsided superior vena cava (D). LV = left ventricle; LA = left atrium; CS = coronary sinus; RV = right ventricle; BCV = brachiocephalic vein; PLSVC = persistent left superior vena cava. Address for correspondence and reprint requests: Christopher Naoum, M.B.B.S., Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales, 2137, Australia. Fax: +61 2 9767 8395; E-mail: [email protected]
E267
Naoum, et al.
A 42-year-old man underwent transthoracic echocardiography (TTE) with agitated saline injection to evaluate isolated marked dilatation of the coronary sinus (CS) (Fig. 1A). Following intravenous agitated saline injection into the left arm, contrast first appeared in the CS implying venous drainage of the left upper body directly into this vessel (movie clip S1). Similarly, with right arm injection contrast initially opacified the CS before appearing in the right-sided cardiac chambers as demonstrated in Figure 1B using M-mode echocardiography (Vivid 7, GE Healthcare, Horten, Norway) with its superior temporal resolution. Together, these findings suggest drainage of both upper limbs directly into the CS via a persistent left superior vena cava (PLSVC), and based on the sequence of chamber opacification following right arm injection, likely atresia of the right superior vena cava (RSVC). Computed tomography (CT) (Definition, Siemens AG, Erlangen, Germany) was subsequently performed and confirmed these anomalies with confluence of both left and right brachiocephalic veins into a PLSVC, which drained into the CS (Fig. 1C, D). PLSVC is a commonly identified thoracic venous anomaly and should be suspected in any patient with a dilated CS. It occurs when the left superior cardinal vein fails to regress during embryological development resulting in persistent left-sided venous drainage.1 In most patients, however, the RSVC is also present and its absence is extremely uncommon.2,3 In isolation, PLSVC is generally asymptomatic, however,
E268
anatomical characterization of such anomalies is important because of the implications for patients undergoing cardiac device implantation with transvenous leads or retrograde cardioplegia during cardiac surgery. Thoracic CT provides anatomical confirmation, however, as highlighted in this case, TTE with selective bilateral upper limb contrast injection is a simple and accurate modality for characterizing venous return patterns and making the diagnosis. References 1. Goyal SK, Punnam SR, Verma G, et al: Persistent left superior vena cava: A case report and review of literature. Cardiovas Ultrasound 2008;6:50. 2. Arat N, Sokmen Y, Golbasi Z: Persistent left superior vena cava with absent right superior vena cava and coronary sinus dilation mimicking a paracardiac mass. Tex Heart Inst J 2007;34:492–493. 3. Sheikh AS, Mazhar S: Persistent left superior vena cava with absent right superior vena cava: Review of the literature and clinical implications. Echocardiography 2014; 31:674–679.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Two-dimensional TTE in a modified four-chamber view demonstrating contrast appearance within the CS prior to the right-sided chambers following agitated saline injection into the left upper limb. LV = left ventricle; RV = right ventricle; RA = right atrium; CS = coronary sinus.
