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Cardiovascular Disease |

Findings of a Persistent Left Superior Vena Cava (PLSVC) During Permanent Pacemaker (PPM) Insertion

Hemal Bhatt, MD; Thomas Bustros, MD
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Lutheran Medical Center, New York City, NY


Chest. 2013;144(4_MeetingAbstracts):139A. doi:10.1378/chest.1689521
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Abstract

SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: PLSVC is the most common thoracic venous anomaly with the incidence of ~ 0.3%. It results from failure of closure of the left anterior cardinal vein during cardiac embryonic development and can complicate the placement of cardiac devices. We report a case of PLSVC discovered during the insertion of PPM requiring technical readjustments.

CASE PRESENTATION: A 71 year old female was referred for PPM insertion due to tachycardia-bradycardia syndrome. The left axillary vein was subsequently accessed after performing venography (Image 1). However, when the right ventricular lead was attempted to be passed fluoroscopically into the heart, it was noted that it did not crossed the midline and could not be advanced into the expected anatomical location (Image 2). Careful analysis of fluoroscopy and additional contrast venography demonstrated that the patient had a PLSVC. After multiple unsuccessful attempts were made to pass the lead through the anatomic anomaly and into the right ventricle via coronary sinus; the incision was closed and the device was implanted via the right venous system.

DISCUSSION: Serious complications such as arrhythmia, cardiogenic shock and coronary sinus thrombosis have been reported when catheters have been inserted via PLSVC. In our case, a venogram was performed and demonstrated patency of the left venous system; however, the run-off as contrast approached the SVC faded and the diagnosis of PLSVC was not immediately obvious. It was not until advancement of the lead was attempted and a second venogram was performed that the diagnosis was clear. Reasonable options to avoid encountering a PLSVC altogether during cardiac device placement would be to shoot an adequate venogram before the incision is made or to attempt access prior to making the incision. However, the former subjects all patients to contrast dye which may increase morbidity particularly in those with renal impairment, while the latter option adds some technical difficulty particularly with obese patients in whom the needle may not reach axillary vein and is not an option if one is planning a cut down procedure.

CONCLUSIONS: Physicians should be aware of venous anomalies such as PLSVC and be prepared to make technical readjustments during the placement of cardiac devices to avoid hemodynamic complications.

Reference #1: Carlos Gonzalez-Juanatey et al. Persistent LSVC draining into coronary sinus. Report of 10 Cases and Literature Review. Clinical Cardiology. 27, 515-518 (2004)

Reference #2: Schreve-steensma et al. Discovery of a persistent left superior vena cava during pacemaker implantation. Netherland Heart Journal. 2008 August; 16(7-8): 272-274.

DISCLOSURE: The following authors have nothing to disclose: Hemal Bhatt, Thomas Bustros

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