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A 34 year old woman presented with increasing shortness of breath, and a secundum atrial septal defect (ASD) was diagnosed by transthoracic echocardiography. A preoperative transoesophageal echocardiogram demonstrated a large secundum ASD with left to right shunt, and a dilated right ventricle (RV) with a pulmonary artery systolic pressure of 60 mm Hg (below left, * indicates ASD). The coronary sinus (CS) was noted to be dilated, and an injection of contrast into the left antecubital vein resulted in opacification of the CS and then the right atrium (RA) (below right). Injection into the right antecubital vein was then performed leading to the normal sequence of opacification. All pulmonary veins were shown to drain normally into the left atrium (LA). The surgical findings were that of a 3 × 2 cm secundum ASD and a large CS receiving the left superior vena cava (LSVC). The LSVC was drained via a sucker in the CS. A persistent LSVC is the most common congenital anomaly involving the systemic veins. In most cases the LSVC drains into the RA by way of the CS, and the systemic venous return is physiologically normal. Preoperative identification of the anomaly is important, however, because the caval cannulation may need to be altered in order to drain the LSVC adequately during cardiopulmonary bypass. If a surgical procedure requiring an open RA is planned, the LSVC should be cannulated either directly or via the CS ostium. In addition the use of retrograde cardioplegia will be precluded.
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