Imaging in cardiology P.P. Sharma, H.J. Vidaillet, T. Tak
Figure 1. AX Catheter from left subelavian vein entering the left superior vena cava. B: Catheter from right superior vena cava to coronarysinus and then to the left superior vena cava. C: Two-dimensional echo showing dilated coronary sinus in the parasternal longs-axis view (see arrow). D: Two-dimensional echo showing the dilated coronary sinus in the apical four-chamber view (see arrow).
Persistent- left superior vena cava diagnosed during pacemaker Implantation An 81-year-old male was admitted with symptomatic bradycardia. A wire introduced through the left subclavian vein at the time ofpacemaker implantation showed a course suggestive of a persistent left superior vena cava (PLSVC). Search with a deflectable electrophysiology catheter did not show any direct connection between right and left superior vena cava (figure LA). A permanent pacemaker was implanted on P.P. Sharma. H.J. Vidaillet. T. Tak. Marshfleld Clinic, 1000 North Oak Avenue, Marshfield WI 54449, US.
Netherlands Heart Journal, Volume 10, Number 11, November 2002
the right side using the right subclavian vein. Figure LB shows the pacemaker lead entering the right superior vena cava, right atrium, coronary sinus and subsequently the left superior vena cava. A twodimensional echocardiogram showed a dilated coronary sinus (figures 1C and LD). PLSVC is seen rarely during pacemaker implants via the left subclavian vein. It is usually accidentally cannulated resulting in an unexpected course of the pacemaker wire or catheter, along the left side of the aortic knob. It has been observed in 0.3% ofthe general population in autopsy studies. During early embryological development, venous return from the head and arms normally drains into the right atrium via the left and right anterior cardinal veins. At approximately eight weeks gestation, the left brachiocephalic vein develops as a bridge between the 467
Imaging in cardiology
Persistent LSVC
Normal heart RSVC
LSCRSVCl
Ligament of Marshall
Vein of Marshall
Great cardiac vein
Great cardiac vein
Figure 2. Schematic showing ligament/vein of Marshall in normal hearts and presence ofpersistent left superior vena cava (PESVC). [Reproduced with permission from Hursts: The Heart, 10th edition (2001), The McGraw-Hill Companies, Inc.] left and right anterior cardinal veins. The portion of the left anterior cardinal vein caudal to the bridging left brachiocephalic vein normally collapses, then degenerates leaving only the right anterior cardinal vein which becomes the superior vena cava. If the caudal portion of the left anterior cardinal vein remains patent, it becomes a PLSVC which drains into the right atrium via a dilated coronary sinus. Its vestigeal remnant in normal adults is the ligament of Marshall (figure 2). Both vein and ligament are a potential source of arrhythmias. In at least 67% of cases of PLSVC, the right anterior cardinal vein remains patent as well, resulting in bilateral or double superior vena cavae.E References 1
Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience. Chest 2001;120(1 ):139-44.
468
2
Dearstine M, Taylor W, Kerut EK. Persistent left superior vena cava: Chest x-ray and echocardiographic findings. Echocardiog-
3
Sarodia BD, Stoller JK Persistent left superior vena cava: Case report and literature review. Resp Care 2000;45(4):416.
raphy2000;17(5):453-5.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer and W. Jaarsma.
Netherlands Heart Joumal, Volume 10, Number 11, November 2002
Figure 1. AX Catheter from left subelavian vein entering the left superior vena cava. B: Catheter from right superior vena cava to coronarysinus and then to the left superior vena cava. C: Two-dimensional echo showing dilated coronary sinus in the parasternal longs-axis view (see arrow). D: Two-dimensional echo showing the dilated coronary sinus in the apical four-chamber view (see arrow).
Persistent- left superior vena cava diagnosed during pacemaker Implantation An 81-year-old male was admitted with symptomatic bradycardia. A wire introduced through the left subclavian vein at the time ofpacemaker implantation showed a course suggestive of a persistent left superior vena cava (PLSVC). Search with a deflectable electrophysiology catheter did not show any direct connection between right and left superior vena cava (figure LA). A permanent pacemaker was implanted on P.P. Sharma. H.J. Vidaillet. T. Tak. Marshfleld Clinic, 1000 North Oak Avenue, Marshfield WI 54449, US.
Netherlands Heart Journal, Volume 10, Number 11, November 2002
the right side using the right subclavian vein. Figure LB shows the pacemaker lead entering the right superior vena cava, right atrium, coronary sinus and subsequently the left superior vena cava. A twodimensional echocardiogram showed a dilated coronary sinus (figures 1C and LD). PLSVC is seen rarely during pacemaker implants via the left subclavian vein. It is usually accidentally cannulated resulting in an unexpected course of the pacemaker wire or catheter, along the left side of the aortic knob. It has been observed in 0.3% ofthe general population in autopsy studies. During early embryological development, venous return from the head and arms normally drains into the right atrium via the left and right anterior cardinal veins. At approximately eight weeks gestation, the left brachiocephalic vein develops as a bridge between the 467
Imaging in cardiology
Persistent LSVC
Normal heart RSVC
LSCRSVCl
Ligament of Marshall
Vein of Marshall
Great cardiac vein
Great cardiac vein
Figure 2. Schematic showing ligament/vein of Marshall in normal hearts and presence ofpersistent left superior vena cava (PESVC). [Reproduced with permission from Hursts: The Heart, 10th edition (2001), The McGraw-Hill Companies, Inc.] left and right anterior cardinal veins. The portion of the left anterior cardinal vein caudal to the bridging left brachiocephalic vein normally collapses, then degenerates leaving only the right anterior cardinal vein which becomes the superior vena cava. If the caudal portion of the left anterior cardinal vein remains patent, it becomes a PLSVC which drains into the right atrium via a dilated coronary sinus. Its vestigeal remnant in normal adults is the ligament of Marshall (figure 2). Both vein and ligament are a potential source of arrhythmias. In at least 67% of cases of PLSVC, the right anterior cardinal vein remains patent as well, resulting in bilateral or double superior vena cavae.E References 1
Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience. Chest 2001;120(1 ):139-44.
468
2
Dearstine M, Taylor W, Kerut EK. Persistent left superior vena cava: Chest x-ray and echocardiographic findings. Echocardiog-
3
Sarodia BD, Stoller JK Persistent left superior vena cava: Case report and literature review. Resp Care 2000;45(4):416.
raphy2000;17(5):453-5.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer and W. Jaarsma.
Netherlands Heart Joumal, Volume 10, Number 11, November 2002
