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- Transoesophageal echocardiography
- persistent left superior vena cava
- absent right superior vena cava
- CT imaging
- coronary sinus
- CT scanning
- echocardiography (three-dimensional)
A patient with fever of unknown origin was transferred from a peripheral hospital for transoesophageal echocardiography (TOE) to exclude infective endocarditis. No vegetations were identified; however, a large coronary sinus (CS, 3.5 cm) was noted (panel A and video 1). Persistent left-sided superior vena cava (SVC) was confirmed following agitated saline contrast injection into the left antecubital vein with early contrast enhancement of the CS before the right atrium. TOE was not able to visualise the right SVC in any view (panel B, the right SVC would normally be seen in the area marked X). Right arm agitated saline contrast injection also opacified the CS before the right atrium, suggestive of an absent right SVC (panel C, video 2). There was no TOE evidence of anomalous pulmonary veins, atrial septal defect or other congenital cardiac abnormalities. The patient's visceral organs were normally positioned. Volume rendered imaging with 320-slice cardiac CT confirmed the TOE findings (panel D).
Persistent left-sided SVC is a rare anomaly of the venous return to the heart, occurring in 0.5% of healthy people.1 Absent right SVC is even rarer, especially in cases with visceroatrial situs solitus with an incidence of 0.07–0.13%.2 This case highlights the importance of detailed anatomic assessment in patients with a dilated CS, with both left and right arm agitated saline contrast injections during TOE and confirmation of venous anatomy with CT. This has implications during insertion of central venous and pulmonary artery catheters or transvenous pacing leads and with the use of retrograde cardioplegia during cardiopulmonary bypass. Associated cardiac electrical instability affecting the sinus node may also be present.3
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.
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