14. Persistent Left Superior Vena Cava

Published on 02/03/2015 by admin

Last modified 22/04/2025

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History

This patient with a history of mechanical aortic valve replacement, New York Heart Association class III heart failure, 25% left ventricular ejection fraction, and a left bundle branch block with a QRS of 160 ms was addressed for implantation of a biventricular pacemaker.

Intervention

A left-sided axillary vein puncture was performed, with the guide wire revealing a left-sided persistent superior vena cava (PLSVC) (Figure 14-1). Contrast injection did not reveal the presence of posterolateral tributaries of the coronary sinus. Because of this and the absence of an innominate vein, venous access was switched to the right side with retrograde cannulation of the coronary sinus (Figure 14-2). A balloon catheter was placed in the great cardiac vein and allowed visualization of a lateral vein that was suitable for lead implantation (Figure 14-3). A bipolar coronary sinus lead was implanted in the lateral vein over a 0.014-inch angioplasty guide wire (Figure 14-4). Right ventricular and atrial pacing leads were implanted, with final position of the leads shown in Figure 14-5.

Outcome

PLSVC is the most frequent venous anomaly of the thorax and may be found in 0.4% of device patients.¹ It results from nonobliteration of the left anterior cardinal vein during embryogenesis, which otherwise becomes the ligament of Marshall.² This condition is asymptomatic, but results in possible technical difficulty in patients requiring cardiac resynchronization therapy. A left-sided access results in anterograde, or downstream, cannulation of a dilated coronary sinus via the PLSVC. Visualization of posterolateral branches may be difficult because balloon-occlusion venography is impossible and direct contrast injection may not reveal tributaries because of rapid washout. It is often easier to implant the coronary sinus lead via right-sided access with retrograde cannulation of the coronary sinus (as in the present case). In approximately 30% of patients² the presence of an innominate vein bridging the two superior vena cavas will avoid having to cross over to a right-sided access. Occlusive balloon angiography may be performed in the great cardiac vein, revealing tributaries either upstream via retrograde filling (these branches are impossible to access via the PLSVC because of the different angulations, as illustrated in Figure 14-2) or downstream via anterograde filling by collaterals.

FIGURE 14-1 Posteroanterior view of a left-sided venous access with the J-wire tracking down the PLSVC into the coronary sinus and right atrium.

FIGURE 14-2 Posteroanterior fluoroscopic view after right-sided venous access and retrograde cannulation of the coronary sinus with a guiding catheter and 0.035-inch guide wire. Note that the guide wire may be mistaken to be in the pulmonary artery in this view (the cranial excursion of the guide wire and a left anterior oblique view showing a posterior course of the guide wire allow the operator to make the correct diagnosis).

FIGURE 14-3 Left anterior oblique 40-degree view showing a balloon catheter subselecting a lateral branch. Note that access to this branch would be impossible via the left-sided persistent superior vena cava (PLSVC) (curved arrow). The dotted lines outline the contours of the coronary sinus and PLSVC.

FIGURE 14-4 Positioning of the coronary sinus lead in the lateral vein over a 0.014-inch angioplasty guide wire.

Figure 14-5 Final position of the leads in the 40-degree left anterior oblique (left) and posteroanterior (right) views.

Selected References

1. Biffi M., Bertini M., Ziacchi M. et al. Clinical implications of left superior vena cava persistence in candidates for pacemaker or cardioverter-defibrillator implantation. Heart Vessels. 2009;24:142–146.

2. Ratliff H.L., Yousufuddin M., Lieving W.R. et al. Persistent left superior vena cava: case reports and clinical implications. Int J Cardiol. 2006;113:242–246.