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Objective: This study aimed to assess the use of two‐dimensional (2D) ultrasound combined with high‐definition flow (HD‐flow) render mode and spatiotemporal image correlation (STIC) in diagnosing and classifying fetal persistent left superior vena cava (PLSVC). Methods: Overall, 114 cases of fetal PLSVC were diagnosed using 2D ultrasound combined with STIC, and 114 normal fetuses of the same gestational week were selected. These cases were retrospectively analyzed to evaluate the effectiveness of the diagnostic approach. Results: All 114 PLSVC cases were diagnosed using 2D ultrasound combined with STIC. Although the diagnostic coincidence rate of PLSVC in the HD‐flow combined with STIC was similar to that in the 2D ultrasound combined with HD‐flow (96.8 vs 96.2%), 2D ultrasound with STIC enabled dynamic visualization of the PLSVC, furthering prenatal diagnosis. These cases were classified as type I PLSVC: 80 cases of type Ia, 29 cases of type Ib, and 5 cases of type Ic. Seventy isolated PLSVC cases (61.4%) were noted, whereas 44 cases (35.6%) were associated with concomitant structural abnormalities. Intracardiac structural malformations accounted for the highest proportion (n = 53, 58.89%), followed by single umbilical artery and facial/bodily abnormalities (n = 10, 11.11%). Conclusion: Combining HD‐flow and STIC complements 2D ultrasound in diagnosing and classifying fetal PLSVC, demonstrating significant clinical relevance. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Persistent left superior vena cava (PLSVC) is one of the anatomical variations, which can make device implantation more challenging and lead to incorrect lead placement, dislodgement, and procedure failure. Conduction system pacing (CSP) can be an alternative to traditional CRT implantation. Herein, we describe a brief case report of successful LBBAP‐optimized CRT (LOT‐CRT) via an innominate vein in a patient with PLSVC. [ABSTRACT FROM AUTHOR]

Comprehension of cardiac anatomy is critical for health care providers and allied health professionals in the pursuit of an accurate and timely patient diagnosis. Many times, when these anomalies are discovered, they are incidental findings from an asymptomatic patient during cardiovascular imaging. One specific anomaly which requires keen attention to detail and critical decision-making abilities is a persistent left superior vena cava (PLSVC). On a transthoracic echocardiogram (TTE), PLSVCs are discovered with the addition of agitated saline, commonly known as bubble studies. Because these anomalies are left-sided, it is critical for the sonographer and IV (intravenous)-trained staff to administer agitated saline through an IV on the left arm. Although rare, PLSVC may correlate with other cardiac pathologies, thus indicating the magnitude of a sonographer's attention to surrounding anatomy (such as a dilated coronary sinus) and the necessity of appropriate IV location. This case study demonstrated the significance of a strategically thinking sonographer while diagnosing a PLSVC on TTE with agitated saline, which could have been missed if the IV line were not initiated on the left arm. [ABSTRACT FROM AUTHOR]

Persistent left superior vena cava (PLSVC) is a rare congenital anomaly. We presented PLSVC in a patient with end-stage renal disease (ESRD) requiring hemodialysis. The left internal jugular vein was utilized for central venous access due to difficult central vascular access, resulting in a diagnosis of PLSVC draining in the left atrium. This case underscores the importance of awareness of anatomical variations before central catheter placement.

A devastating admission to a tertiary hospital intensive care unit led to the discovery of a case of congenital duplicated superior vena cava (DSVC). Following the insertion of a temporary left internal jugular vein catheter, a subsequent chest X-ray indicated that the left catheter was not reaching the right heart. This resulted in a chest computed tomography scan with contrast, which confirmed the diagnosis of DSVC. The asymptomatic nature of these conditions reduces their prevalence. To date, there is no documented history of DSVC patients in Palestine. Therefore, it is important to report such a case to highlight the needs for larger studies in the future that aim to define the characteristics and varying features of patients with DSVC and the associated clinical findings.

Benjamin Palić,1,2 Marija Goluža Sesar,3 Kristina Galić,3 Gojko Bogdan,4 Zrinko Prskalo1 1Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina; 2Department of Pathophysiology, School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina; 3Department of Pulmonology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina; 4Department of Radiology, University Clinical Hospital Mostar, Mostar, Bosnia and HerzegovinaCorrespondence: Benjamin Palić, Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina, Email benjamin314palic@gmail.comAbstract: 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.Keywords: intraoperative complication, central venous catheter, persistent left superior vena cava, congestive heart failure, chronic obstructive lung disease

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. [ABSTRACT FROM AUTHOR]

This article discusses the challenges of performing catheter ablation for certain types of tachycardia in patients with a persistent left superior vena cava (PLSVC), a common venous anomaly. The presence of PLSVC can lead to the enlargement of the coronary sinus and the dislocation of common target sites for ablation. The article presents two case studies illustrating the difficulties encountered during ablation procedures in patients with PLSVC. The authors emphasize the importance of careful mapping and targeting of alternative sites for effective ablation. [Extracted from the article]

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. [ABSTRACT FROM AUTHOR]

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. Access the CME test here and search by article title. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Persistent left superior vena cava (PLSVC) is not uncommon venous return anomaly (0.3-05% of the general population). It is usually asymptomatic but can complicate transvenous cardiac interventions, particularly implantations of cardiac pacemakers. We present a case of need for pacemaker implantation in a patients with PLSVC. Case presentation: An 84-year-old woman was referred to hospital with frequent syncopal episodes, dizziness, and fatigue. Electrocardiogram showed atrial fibrillation with bradycardia (35-40 bpm). The patient was fully investigated and was qualified for permanent single-chamber pacemaker implantation. The patient had an isolated PLSVC. Additionally, she had right breast cancer; therefore we performed left axillary access for pacemaker implantation. The pacing lead was inserted via left axillary vein through the PLSVC to the coronary sinus. Afterwards, we looped lead in the right atrium, which helped us to put it through the tricuspid valve and implant the lead in apex of right ventricle. All lead measurements at implantation were acceptable. The patient was discharged three days post-implantation without any complications. In a 1-year follow-up we have noticed good lead parameters at interrogation and stable lead position on the X-ray. Conclusion: Certainly, clinicians must be aware of this anomaly and the challenges it presents during pacemaker implantation in affected patients, as well as potential solutions to address these challenges.

Abstract 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.

The knowledge of different anatomic venous variants of central vessels is essential to improve the safety of procedures like central venous access and tunneled central catheter (TCC) placement. Persistent left superior vena cava (PLSVC) is an uncommon variant seen in 0.5 to 2% of common population, in 80 to 90% of which PLSVC commonly drains into the right atrium (RA) via the coronary sinus. We describe a rare case of PLSVC draining into RA through common channel with suprahepatic inferior vena cava, encountered while placing TCC into left internal jugular vein. This report highlights the radiological findings and the implications of this anatomic anomaly.

This study aims to define the associated anomalies with PLSVC, and to compare single PLSVC and bilateral superior vena cava in terms of accompanying anomalies and pregnancy outcomes. This was a retrospective study of the fetuses diagnosed with single and/or bilateral SVC at a tertiary fetal medicine center during 8 years. We detected 16 cases of single PLSVC and 84 cases of bilateral SVC. We found an association between the PLSVC and cardiac and extracardiac anomalies. Comparison between single PLSVC and BSVC cases revealed significant differences in the occurrence of heterotaxy and right isomerism. The study highlights the importance of prenatal diagnosis in PLSVC cases. Isolated PLSVC with situs solitus may be considered a benign finding, but larger studies are needed to understand the clinical implications of PLSVC in relation to chromosomal anomalies. Routine screening protocols should include three-vessel and trachea views to detect PLSVC. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Most neonates with persistent left superior vena cava (PLSVC) have no clinical symptoms or hemodynamic changes, and this anomaly is only found during cardiac catheterization, pacemaker implantation, or central venous catheterization. Electrocardiogram (ECG) localization is helpful for the application of the peripherally inserted central catheter (PICC) technique in neonates with PLSVC. Objective To explore the characteristic waveforms of the P wave when a PICC under ECG localization is applied in neonates with PLSVC. Study Design The observation and management strategies for the P wave changes during catheter insertion (CI) of two neonates with PLSVC admitted to our institution between January and July 2020, who underwent PICC line insertion, were summarized. Results The characteristic P wave changes in two children with a PICC line inserted via the PLSVC were observed. When a wide inverted P wave appeared on ECG, the catheter was immediately withdrawn by 0.5 cm, a bidirectional P wave gradually appeared and then disappeared. After that, the catheter was further withdrawn by 0.5 cm. After catheterization, the optimal position of the PICC was confirmed by X-ray photography and bedside B-ultrasound. The PICC line was removed as scheduled after indwelling for 18 and 29 days, respectively, in the two cases, and no PICC-related complications occurred during indwelling. Conclusion The characteristic P wave changes on ECG during CI provide important clinical reference values for the application of the PICC technique under ECG localization in neonates with PLSVC. Key Points Electrocardiogram localization. Peripherally inserted central catheter. Persistent left superior vena cava. [ABSTRACT FROM AUTHOR]

The persistent left superior vena cava is the systemic venous system malformation observed in 0.1–0.5% of the general population. It can result in many obstacles in pacemaker implantation. The report presents a case of a 62-year-old male patient who underwent an upgrade of his implantable cardioverter-defibrillator to a cardiac resynchronization therapy defibrillator. The patient initially had a one- -chamber cardioverter-defibrillator implanted in 2014. Due to advanced symptomatic dilated cardiomyopathy co-existing with significant nonspecific intraventricular conduction delay, the patient was qualified for a device upgrade in 2023, i.e. implantation of additional atrial and left ventricular electrodes. The obstruction in the brachiocephalic vein and the presence of the persistent left superior vena cava were revealed in the course of the procedure. The result was a successful upgrade to cardiac resynchronization therapy defibrillator with the combination of the defibrillation right ventricular lead implanted originally through the right superior vena cava and the atrial and left ventricular electrodes implanted through the persistent left superior vena cava. The presented case describes the acceptable approach in the course of implantable cardioverter-defibrillator upgrade to cardiac resynchronization therapy defibrillator in the case of the persistent left superior vena cava and the brachiocephalic vein obstruction. [ABSTRACT FROM AUTHOR]

Introduction: Left bundle branch pacing has gained significant momentum in the last few years. The procedure involves deploying the lead deep inside the interventricular septum through left subclavian vein. We aimed at analyzing the feasibility, efficacy and long‐term outcome of left bundle branch pacing (LBBP) using lumen‐less lead through the right subclavian vein. Methods: This was a retrospective‐institutional, single center observational study done in consecutive patients who underwent LBBP using 3830 selectsecuretm lead. Left subclavian venous access was the primary strategy for lead implantation. Patients requiring right sided approach due to venous obstruction or persistent left superior‐vena‐cava (PLSVC) for LBBP were included in the study. Results: Right sided approach was successful in 16 out of 19 (84%) attempted patients. C315‐His catheter was used in all patients without modifying its curvature. PLSVC (n = 7), left venous obstruction (n = 7), right sided device upgradation (n = 1) and left pocket infection (n = 1) were the reasons for right sided approach. Mean follow‐up duration was 17 ± 12 months. LBBP resulted in reduction in QRS duration from 137.3 ± 37.8 ms to 122.3 ± 9.5 ms (p −.13) and increase in LV ejection fraction from 46.2 ± 16.3% to 54.4 ± 11.6% (p −.11). The mean fluoroscopy duration and radiation dose were significantly high in right sided approach (n = 16) as compared to left sided approach (n = 293). In patients requiring cardiac‐resynchronization therapy (CRT), right sided LBBP resulted in reduction in QRS duration from 171.8 ± 18.5 to 125.5 ± 11.9 ms (p −.0001) and increase in LVEF from 29.1 ± 3.8 to 45.1 ± 11.9% (p −.005). Conclusion: Right sided LBBP is feasible, safe and effective in patients requiring pacing for symptomatic bradyarrhythmia and CRT. Further development in dedicated tools for right‐sided approach would help in reducing the fluoroscopy‐duration and radiation‐dose. [ABSTRACT FROM AUTHOR]

A 50‐year‐old woman underwent catheter ablation for atrial fibrillation. Preoperative computed tomography revealed a left‐sided variant of the right top pulmonary vein (PV) and a persistent left superior vena cava. The right top PV was successfully isolated through a wide antral circumferential ablation line simultaneously with the right PVs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The knowledge of different anatomic venous variants of central vessels is essential to improve the safety of procedures like central venous access and tunneled central catheter (TCC) placement. Persistent left superior vena cava (PLSVC) is an uncommon variant seen in 0.5 to 2% of common population, in 80 to 90% of which PLSVC commonly drains into the right atrium (RA) via the coronary sinus. We describe a rare case of PLSVC draining into RA through common channel with suprahepatic inferior vena cava, encountered while placing TCC into left internal jugular vein. This report highlights the radiological findings and the implications of this anatomic anomaly. [ABSTRACT FROM AUTHOR]

Abstract Background Persistent left superior vena cava (PLSVC) is the most common variant of systemic venous drainage. In the absence of the right superior vena cava (RSVC), implantation of a right ventricular pacing lead may be challenging. Therefore specific implantation techniques and experiences in PLSVC are worth reporting. Case presentation We present a case report of a 90-year-old Caucasian female patient with PLSVC during single chamber pacemaker implantation due to the third-degree atrioventricular block. With common implantation techniques, we did not even reach the right ventricle. Therefore slittable CPS Direct ™ Universal sheath was employed to overcome the acute angle from PLSVC to tricuspid valve and ensure more fixation stability for longer 100-cm right ventricular lead placement. Conclusion This case demonstrates safe implantation of 100-cm long right ventricular bipolar active fixation pacing lead using common slittable CPS Direct ™ Universal sheath after failed attempts with „C“ and „J“ stylet shaped electrode. This sheath provides different angle towards tricuspid valve and more fixation stability in patient with PLSVC and absent connection to right atrium.

This paper summarized the experience of using Sherlock 3CG tip confirmation system for bilaterally placement of peripherally inserted central catheters (PICC) and related nursing countermeasures in a patient with double superior vena cava. In order to meet the treatment needs, PICC catheters were placed on both sides twice, with the catheter tips located in the right and left superior vena cava. The patient's first choice of the right upper arm for catheterization was smooth, and the second choice of the left side for catheterization was smooth. The Sherlock 3CG tip confirmation system was used for positioning. The P wave of the catheter sent to the reserved length continued to be negative. The results of computer tomography (CT) showed that the patient had permanent left superior vena cava. The X-ray positioning was performed to confirm that the tip of the catheter was located in the left superior vena cava. After comprehensive evaluation by the multidisciplinary team, the catheter indwelling length was adjusted, The patient's condition was closely observed, and health education was strengthened in many aspects. Indwelling catheter was successfully placement without complications. (本文总结了应用Sherlock 3CG尖端定位技术为1例急性髓系白血病伴有双侧上腔静脉患者双侧置入经外周静脉穿刺中心静脉导管(PICC)的护理对策。本例患者为满足治疗需求分别于两次经两侧置入PICC导管, 导管尖端分别位于右、左两侧上腔静脉。患者首次选择右侧上臂置管过程顺利, 再次置管选择左侧置入过程顺利, 应用Sherlock 3CG技术定位, 导管送至预留长度范围P波持续呈负波, 查看计算机断层扫描(CT)结果提示患者存在永存左上腔静脉, 行X光定位确认导管尖端位于左侧上腔静脉。经多学科团队综合评估, 调整导管留置长度, 密切观察患者情况, 加强多方面健康宣教, 导管留置成功, 无并发症发生。)

BackgroundA peripherally inserted central catheter (PICC) is a specialized type of long-term intravenous catheter commonly employed for administering chemotherapy. The operation and management of PICC should exclusively be carried out by trained healthcare professionals equipped with the requisite knowledge of anatomy, procedural technique and patient care. Persistent left superior vena cava (PLSVC) is a vascular malformation which is typically asymptomatic in clinical presentation, almost always identified during invasive surgery or imaging examinations.Case presentationHerein, we detailed a case involving a breast cancer patient whose PLSVC was identified during the placement of PICC because of the negative P-wave in electrocardiogram (ECG). Subsequent examination, including chest x-ray imaging, postoperative enhanced CT of the chest, ECG, and consultation with an experienced imaging physician confirmed that the patient's variant type was PLSVC type I. 2160. Removal of the catheter was deemed unnecessary, as the catheter tip was appropriately positioned and no other concomitant cardiovascular malformations were detected.ConclusionThe PLSVC is a vascular anomaly and is relatively uncommon within the general population. The operator should possess a thorough familiarity with the potential anatomical variations of left superior vena cava, and specialized case profile should be established for patients diagnosed with PLSVC.

Background: Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF). Methods and results: Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4 ± 8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow‐up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%). Conclusion: Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC. [ABSTRACT FROM AUTHOR]

Abstract Background Wolff–Parkinson–White syndrome is characterized by a short PR interval (delta-wave), long QRS complex, and the appearance of paroxysmal supraventricular tachycardia. Patients with Wolff–Parkinson–White syndrome usually have one accessory pathway, whereas cases with multiple accessory pathways are rare. Persistent left superior vena cava is a vascular anomaly in which the vein drains into the right atrium through the coronary sinus at the junction of the left internal jugular and subclavian veins due to abnormal development of the left cardinal vein. The simultaneous presence of multiple accessory pathways and persistent left superior vena cava has not been reported before. Case presentation A 56-year-old Japanese man with a 5-year history of palpitations was referred for radiofrequency catheter ablation due to increased frequency of tachycardia episodes in the previous 2 months. Persistent left superior vena cava was confirmed by transthoracic echocardiography and computed tomography. An electrophysiological study revealed that the accessory pathways were located in the left lateral wall, anterolateral wall, and posteroseptal region. They were completely ablated with radiofrequency energy application. Conclusions We reported an extremely rare case of a patient with multiple accessory pathways and persistent left superior vena cava. Our case may suggest a potential embryological relationship between the multiple accessory pathways and persistent left superior vena cava.

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.

Persistent left superior vena cava (PLSVC) is a common congenital anomaly of the thoracic venous system. It is usually asymptomatic and is detected when cardiovascular imaging is performed for unrelated reasons. Its presence can complicate catheter placement within the right side of the heart, as well as cardiac procedures. In most cases PLSVC can go unnoticed and only becomes pertinent when patients require cardiac imaging or surgery. Once found, it puts patients at risk for cardiac interventions. Here we present a case that highlights the practical implications of PLSVC where a patient developed flash pulmonary oedema after gastrointestinal procedures – in this case, laparoscopic cholecystectomy – as well as endoscopic retrograde cholangiopancreatography (ERCP). Management is also discussed, leading to the resolution of symptoms. The report will also propose a pathophysiologic mechanism leading to this complication that is not well understood in the medical literature.

Key Clinical Message Awareness of persistent left superior vena cava (PLSVC) with unroofed coronary sinus is crucial. Pre‐ and perioperative evaluation of this association is necessary for surgical plan. Creating an intra‐atrial tunnel to divert LSVC to right atrium without obstructing the mitral valve or the pulmonary veins is the safe surgical approach. Abstract Unroofed coronary sinus syndrome is a rare congenital heart defect representing less than 1% of all atrial septal defect (ASD) types, and may be associated with persistent left superior vena cava (PLSVC) which may be missed during preoperative diagnosis. Herein, we present a case of a 2‐year‐old patient who underwent an operation for repair of a coronary sinus‐type ASD; however, PLSVC was detected intraoperatively. An antra‐atrial tunnel has created to divert the flow of PLSVC into the right atrium along with the repair of the ASD.

Background: Persistent left superior vena cava (PLSVC) is the most common variant of systemic venous drainage. In the absence of the right superior vena cava (RSVC), implantation of a right ventricular pacing lead may be challenging. Therefore specific implantation techniques and experiences in PLSVC are worth reporting. Case presentation: We present a case report of a 90-year-old Caucasian female patient with PLSVC during single chamber pacemaker implantation due to the third-degree atrioventricular block. With common implantation techniques, we did not even reach the right ventricle. Therefore slittable CPS Direct ™ Universal sheath was employed to overcome the acute angle from PLSVC to tricuspid valve and ensure more fixation stability for longer 100-cm right ventricular lead placement. Conclusion: This case demonstrates safe implantation of 100-cm long right ventricular bipolar active fixation pacing lead using common slittable CPS Direct ™ Universal sheath after failed attempts with „C" and „J" stylet shaped electrode. This sheath provides different angle towards tricuspid valve and more fixation stability in patient with PLSVC and absent connection to right atrium. [ABSTRACT FROM AUTHOR]

Slow pathway (SP) mapping and modification can be challenging in patients with persistent left superior vena cava (PLSVC) due to anatomic variance of the Koch triangle (KT) and coronary sinus (CS) dilation. Studies using detailed 3-dimensional (3D) electroanatomic mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition are lacking. The purpose of this study was to describe a novel technique of SP mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal CS anatomy. Seven patients with PLSVC and dual atrioventricular (AV) nodal physiology who underwent SP modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal reentrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing mapping of the right atrial septum and proximal CS in sinus rhythm was performed. SP ablation targets were consistently identified by an area in the right atrial septum with the latest activation time and multicomponent atrial electrogram adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the midanterior CS ostium. Ablation in this area led to successful SP modification, reaching standard clinical endpoints with a median of 43 seconds of radiofrequency energy or 14 minutes of cryoablation without complications. High-resolution activation mapping of the KT in sinus rhythm can facilitate localization and safe SP ablation in patients with PLSVC [Display omitted] [ABSTRACT FROM AUTHOR]

Atrial tachycardias (AT) are common cardiac arrhythmia disorder for congenital heart disease (CHD). The anatomic substrate that surgical suture lines, scar tissue, or prosthetic material may cause pre‐existing atrial conduction abnormalities which leads to the underlying mechanism of reentrant ATs. Radiofrequency Catheter ablation (RFCA) is used in the treatment of atrial tachycardia in CHD patients. However venous system abnormalities may complicate the procedure. We report that ablation of a case with atrial tachycardia with challenging anatomy (persistent left superior vena cava draining into the left atrium, coronary sinus agenesis, inferior vena cava (IVC) agenesis, azygos system drained to the superior vena cava, and repaired ventricular septal defect). This case report discusses the key points of access to cardiac chambers and mapping in very rare challenging anatomy. [ABSTRACT FROM AUTHOR]

Introduction: Total anomalous pulmonary venous connection (TAPVC) is a common cyanotic congenital heart disease seen in developing countries at tertiary referral centers. Association with persistent left superior vena cava (LSVC) without innominate vein (H-connection) is an extremely rare condition which makes the surgical correction extremely challenging. Materials and Methods: This was a retrospective case record review of 18 patients with TAPVC in the presence of LSVC without innominate vein (without H-connection) at our institution from January 2007 to February 2021. We detail our experience of our modified surgical technique for this complex anatomy using various modifications for each type of TAPVC with LSVC in the absence of innominate vein. Results: Out of 18 patients of TAPVC with LSVC, 17 patients survived and are being followed up regularly. There was one mortality (5.5%) in a 5-month-old infant with double-outlet right ventricle with ventricular septal defect with severe pulmonary arterial hypertension with infracardiac TAPVC who died in intensive care unit on the 5th postoperative day. Conclusion: In our experience, the modified surgical technique for treating this complex variant of TAPVC is especially useful for favorable long-term outcomes with minimal incidence of recurrent pulmonary venous obstruction.

In embryonic life developmental malformation of thoracic veins can lead to anomalies of the Superior vena cava and major thoracic veins like Azygos system. Double superior vena cava and double azygos vein are rare congenital anomaly with the incidence of 0.3%. These types of congenital anomalies may or may not be presented with clinical symptoms. This case was noted during the routine cadaveric dissection of thoracic region and heart for medical students in department of Anatomy, we found double superior vena cava (persistent left superior vena cava) along with double (paired) azygos vein in a female cadaver. Right superior vena was formed by the union of right subclavian and right internal jugular vein which receives the arch of right azygos before it opened into the right atrium. Left superior vena cava was formed by the union of left subclavian and left internal jugular vein and it also receives the arch of left azygos vein before it entered into the right atrium. In present case coronary sinus was separated from left persistent superior vena cava and it opened in the persistent left superior vena cava. There was no communication between both the superior vena cava. On right side Azygos vein was normal and open into right superior vena cava. On the left side hemiazygos was in continuation with the accessory azygos vein and it also forming the arch and opened into persistent left superior vena cava. There were no other congenital anomalies present in the heart. These types of congenital anomalies extremely very rare where the left superior vena cava opens into the right atrium directly and coronary sinus opens in to this left superior vena cava. Majority of such types of cases remain asymptomatic. Some cases may be detected accidently during diagnostic or surgical procedures like cardiac angiography, cardiac catheterization, by- pass and dialysis or during autopsy or institutional cadaveric dissection.

Tunneled central venous catheters and ports provide a long-term method of delivering nutrition, hydration, or medications in children. When these devices are no longer needed, it is best practice to remove them entirely. Complications associated with having long-term venous access devices or the process of device removal include site infections, venous thrombosis or occlusion, device fracture, and possible migration of fractured fragments. We present a case of catheter fragmentation that occurred in a pediatric patient during removal of a 3-year-old left chest port that had been placed into a left superior vena cava (SVC). [ABSTRACT FROM AUTHOR]

Introduction: Anomalous cardiac veins are not rare and pulmonary vein (PV) isolation for atrial fibrillation (AF) treatment should include these veins. Pulsed‐field ablation (PFA) is a novel technology for AF ablation with excellent efficacy and safety profile. In this case series, we describe our first experience of isolation of anomalous cardiac veins using PFA in patients with AF. Methods: We report a series of patients with congenital anomalies of the cardiac veins and AF, treated with PFA. All patients underwent cardiac computed tomography for procedural planning. Results: We included five patients (four males). Anomalous cardiac veins included a connection of a left common ostium to the coronary sinus, a partial and complete drainage of the right superior PV into the superior vena cava (SVC) with and without additional atrial septal defect, a persistent left SVC and an anomalous posterior PV. All anomalous PVs were isolated using PFA. No phrenic nerve palsy or other complications occurred. PFA of an abnormal right superior PV draining into the distal SVC was possible without affecting the sinus node. After a median of 4 months, four patients were free of recurrence. One patient had recurrent AF and perimitral reentry tachycardia, probably facilitated by PFA in the mitral isthmus region during isolation of an anomalous connection of the left common ostium to the coronary sinus. Conclusions: Using systematic preprocedural imaging and three‐dimensional‐electroanatomic mapping, the currently available PFA system seems well suited, efficient, and versatile for the treatment of AF in patients with anomalous cardiac veins. [ABSTRACT FROM AUTHOR]

Introduction: Total anomalous pulmonary venous connection (TAPVC) is a common cyanotic congenital heart disease seen in developing countries at tertiary referral centers. Association with persistent left superior vena cava (LSVC) without innominate vein (H-connection) is an extremely rare condition which makes the surgical correction extremely challenging. Materials and Methods: This was a retrospective case record review of 18 patients with TAPVC in the presence of LSVC without innominate vein (without H-connection) at our institution from January 2007 to February 2021. We detail our experience of our modified surgical technique for this complex anatomy using various modifications for each type of TAPVC with LSVC in the absence of innominate vein. Results: Out of 18 patients of TAPVC with LSVC, 17 patients survived and are being followed up regularly. There was one mortality (5.5%) in a 5-month-old infant with double-outlet right ventricle with ventricular septal defect with severe pulmonary arterial hypertension with infracardiac TAPVC who died in intensive care unit on the 5th postoperative day. Conclusion: In our experience, the modified surgical technique for treating this complex variant of TAPVC is especially useful for favorable long-term outcomes with minimal incidence of recurrent pulmonary venous obstruction. [ABSTRACT FROM AUTHOR]

Objective: Rare coexistence of disease or pathology Background: Situs inversus totalis (SIT) is an uncommon condition characterized as a congenital disorder in which the visceral organs are inverted relative to their typical anatomical position. SIT with double superior vena cava (SVC) is an even rarer presentation. Due to the underlying anatomical difference, the diagnosis and treatment of gallbladder stones in patients with SIT are challenging. Case Report: We report the case of a 24-year-old male patient who presented with an intermittent history of epigastric pain for 2 weeks. Clinical assessment and radiological investigations confirmed gall bladder stones with evidence of SIT and double superior vena cava (SVC). The patient underwent elective laparoscopic cholecystectomy (LC) with an inverted laparoscopic approach. The recovery from the operation went smoothly, the patient was discharged from the hospital the following day, and the drain was removed on the third postoperative day. Conclusions: Because anatomical variations in the SIT can affect localization of symptoms in patients with complicated gallbladder stones, the diagnosis of patients who have abdominal pain and SIT necessitates both a high index of suspicion and a thorough assessment. Although LC is considered to be a technically challenging surgery and calls for modification of the standard protocol, it is nevertheless feasible to perform the procedure effectively. To the best of our knowledge, this is the first time that LC has been documented in a patient who has SIT and double SVC. [ABSTRACT FROM AUTHOR]

Background: Unroofed coronary sinus is a congenital cardiac anomaly usually associated with persistent left superior vena cava. Premature restriction or closure of foramen ovale is described in association with hypoplastic left heart syndrome. Abdominal peritoneal bands when present manifest clinically. Case report: A 27 years, gravida 2, presented with intrauterine fetal death at 24 weeks gestation due to fetal congestive cardiac failure, cardiomegaly and hydrops. Perinatal autopsy showed absent coronary sinus with cardiac veins draining directly into the heart. There was no persistent left superior vena cava. The foramen ovale was restricted prematurely. The ductus arteriosus was present and non-restrictive. Abdomen showed a cysto-colic peritoneal band. Conclusion: This is the first report showing a triad of (1) complete absence of coronary sinus without left superior vena cava (type-II); (2) premature restriction of foramen ovale without hypoplastic left heart; and (3) a cysto-colic peritoneal band between the gall bladder and colon. [ABSTRACT FROM AUTHOR]

Introduction: We report a case of hydrocephalus caused by diffuse villous hyperplasia of the choroid plexus (DVHCP) associated with chromosome 9 tetrasomy. Fluid management in the patient, although difficult, was done by a ventriculo-femoro-atrial (VFA) shunt. Case: The patient was a young girl aged 6 years and 1 month who had a birth weight of 3402 g and a gestational age of 40 weeks. She presented with a failed ventriculo-atrial (VA) shunt five years after its placement. Ventricular enlargement was not noted at birth, but marked hydrocephalus was confirmed by MRI six months later. A ventriculo-peritoneal (VP) shunt was then placed. Six months later, it became difficult to control the fluid in the abdomen; hence, 9 months after the initial operation, her VP shunt was replaced with a VA shunt, which also failed about 5 years after its placement. This was due to a thrombus in the atrial catheter that deviated to the superior vena cava. Although an attempt was made to reconstruct the VA shunt using the left internal jugular vein, stable placement of the catheter was difficult because of the persistent left superior vena cava (PLSVC). Shunt dysfunction and infection reoccurred. Finally, a VFA shunt placement was performed after choroid plexus ablation to obtain spinal fluid control. Conclusion: In childhood hydrocephalus, shunt replacement or rerouting is unavoidable. VFA shunts, although rarely utilized, can be an option for drainage routes. [ABSTRACT FROM AUTHOR]

Heart failure with reduced ejection fraction (HFrEF) is a chronic and debilitating disease, which requires extensive diagnostic and treatment resources in order to achieve an acceptable quality of life for the patient. While optimal medical treatment remains at the core of the disease's management, interventional cardiology also plays a very important role. However, in very rare situations, interventionists might find cases especially challenging due to the presence of venous anomalies, such as persistent left superior vena cava (PLSVC), anomalies that may go undiscovered during the patient's lifetime until venous cannulation is necessary. While these types of malformations also pose challenges in regards to standard pacemaker implantation, cardiac resynchronization (CRT) devices pose several additional challenges due to the complexity of the device and the necessity of finding an optimal position for the coronary sinus (CS) lead. We present the case of a 55-year-old male patient with advanced heart failure due to dilated cardiomyopathy (DCM) and LBBB who was a candidate for CRT-D therapy, describing the investigations that led to the discovery of the PLSVC as well as the technique and results of the intervention, while comparing our case to similar cases found in recent literature. [ABSTRACT FROM AUTHOR]