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Right-to-Left Anatomic Shunt Associated With a Persistent Left Superior Vena Cava: The Importance of Injection Site in Demonstrating the Shunt

Nandhitha N. Thaiyananthan, MD; Frank J. Jacono, III, MD; Sanjay R. Patel, MD, MS, FCCP; Jeffrey A. Kern, MD, FCCP; James K. Stoller, MD, MS, FCCP
Author and Funding Information

From the Pulmonary, Critical Care and Sleep Medicine Division (Dr. Thaiyananthan), Department of Medicine (Drs. Jacono and Kern), and Cleveland Louis Stokes Veterans Affairs Medical Center (Dr. Patel), University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; and Lerner College of Medicine (Dr. Stoller), Respiratory Institute, Cleveland Clinic, Cleveland, OH.

James K. Stoller, MD, MS, FCCP, Respiratory Institute, A90, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: stollej@ccf.org


© 2009 American College of Chest Physicians


Chest. 2009;136(2):617-620. doi:10.1378/chest.08-2641
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Anatomic right-to-left shunt causes hypoxemia that can pose a diagnostic challenge to clinicians. Among the many possible causes of right-to-left shunt, persistent left-sided superior vena cava (PLSVC) with an “unroofed” coronary sinus represents an uncommon congenital anomaly in which detection by saline-contrast echocardiogram (bubble echo) or contrast-enhanced CT scan requires injection of contrast in the left arm. We present the case of an elderly man with hypoxemia on the basis of a right-to-left shunt accompanying a PLSVC with unroofed coronary sinus in whom the shunt escaped initial detection following a bubble echo with contrast injected into the right arm. This case reminds pulmonary clinicians, who are frequently called on to assess the cause of hypoxemia, that specifying a contrast injection into the left arm is required in the pursuit of this specific shunt-producing anomaly.

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