Persistent Left Superior Vena Cava: What is the ... - Casecag.com

Persistent Left Superior Vena Cava:What is the Significance?Mark W. Lucia, M.D.Anesthesiology House Officer – PGY32011 Year End Cardiac Anesthesia TEE Conference

DisclosuresUnfortunately…”No”

OverviewDiscuss the prevalence, variants, diagnosis andpractical significance of the incidental finding of apersistent left superior vena cavaPresent a clinical case of an incidental persistentLSVC in a patient undergoing double valve repair

LSVC Defined

LSVC DefinedThe LSVC is the anatomical variant that results when the leftanterior cardinal vein fails to involute in embryologicdevelopmentEstimated prevalence 0.1% - 0.3% in general populationLeftAnteriorCardinalVeinInvolutesNormalAnn Thorac Surg 2001;71:1389-1395

LSVC DefinedThe LSVC most commonly (90%) empties into the coronary sinusA LSVC is associated with the presence of other congential cardiacanomalies (e.g., ASD, VSD, cor triatriatum, mitral atresia)+/- Innominate veinPosterior View90%Anterior ViewAnn Thorac Surg 2001;71:1389-1395

LSVC VariantsThe LSVC may also drain into the left atrium or left upperpulmonary veinThe innominate vein is variably present+/- Innominate veinAnn Thorac Surg 2001;71:1389-1395

LSVC Diagnosis

LSVC DiagnosisHigh fidelity imaging modalities (e.g., MRA) with contrast willclearly define the presence and variant of a persistent LSVCIndian Pacing Electrophysiol. J 2010;10(1):58-61

LSVC DiagnosisAngiography can also be useful to define LSVC anatomyRANephrol. Dial. Transplant. (2003) 18 (7): 1410-1411.

LSVC DiagnosisBoth TEE and TTE can allow for the diagnosisNormally, the coronary sinus diameter is approximately 8.5 mm inadult normal subjects † , values > 10 mm should be suspectThe coronary sinus is most effectively imaged with TEE in either theME 4-C view (w/retroflexion) or the 90º bicaval view (w/right rotation &slight withdrawal)†Circulation 1995;92:436-441

LSVC TEE DiagnosisME 4-C view (with retroflexion)

LSVC TEE DiagnosisME bicaval view modified (with right rotation and withdrawal)

LSVC TEE DiagnosisAgitated saline contrast injection into a left upper extremity IV isrecommended to help define the presence and drainage pattern of aLSVC(1 mL air + 1 mL blood + 8 mLs of saline)

LSVC TEE DiagnosisChoose the TEE view that permits the best vantage point tosimultaneously assess the SVC and coronary sinusInject your 10 mLs of contrast medium and flush it in while yourintraoperative sonographer waits at the ready to capture the imageIf contrast exits the SVC first then a LSVC is less likely (i.e. itcould still be present but emptying into the left atrium or the leftupper pulmonary vein)If contrast exits the dilated coronary sinus first then a LSVC islikelyIf contrast exists both the SVC and the coronary sinussimultaneously then a LSVC is likely in the setting of an intactinnominate vein

Clinical Case Presentation

Clinical Case Presentation68 YOF with NYHA Class IV CHF presented for double valverepair (MV repair + TV repair)

Clinical Case PresentationUpon assessment of the TR a severely dilated coronary sinuswas noted. What is the significance?

Clinical Case PresentationBecause the degree of coronary sinus dilation was > 3x theexpected diameter a LSVC should have been suspected27 mm(Normal Mean CS diameter = 8.5 mm)

Clinical Case PresentationThe remarkable dimension of the coronary sinus wascommunicated to the surgical team, but neither staff membersuggested provocative testing to rule out a LSVCUltimately CPB was initiated when shortly thereafter thesurgeon discovered the LSVC draining into the coronary sinusThe LSVC was temporarily ligated to permit safe delivery ofretrograde cardioplegia throughout the case.

Clinical Case PresentationFailure to ligate the LSVC will permit pressure and potentiallyair emboli to challenge the venous cerebral circulation becausethe LSVC is in continuity with the left internal jugular vein.Pressurizing the LIJ could result in a watershed stroke of the leftbrain by impeding cerebral venous drainage

Clinical Case PresentationDiagnosis: Persistent LSVC draininginto the coronary sinus with an intactinnominate vein.Innominate Vein

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