Dual-chamber ICD-CRT implantation in a patient with persistent left superior vena cava: testing skills

Abstract

A persistent left-superior vena cava (PLSVC) is an uncommon identification with a form of 0.3% to 0.5% of persons in the common population [1][2][3][4][5]. Nevertheless, it is the most common thoracic venous anomaly [6][7][8][9][10]. Typically, the left superior vena cava fades post embryological developement. The identification can be missed by the manifestation of a standard right superior vena cava. This subject did not have an ordinary or rest of a right superior vena cava. Furthermost of the individuals do not present the symptoms, and the presence of the persistent left superior vena cava is by the way found during or after insertion of a central venous catheter (CVC) or pacemaker electrodes. The correct report of a PLSVC and lack of a right superior vena cava has significant clinical repercussions in definite circumstances, such as oncological therapy, totally implantable vessels catheters, hemodynamic checking in intenive care unit (ICU) or the correct location of pacemakers [1][2][3][4][5][6][7][8][9][10]. The further clinical relevance of the described anomaly could be due to common tachyarrhythmia and conduction disturbances [11][12][13][14][15]. The PLSVC usually descends vertically, anterior, and to the left of the aortic arch and main pulmonary artery. It runs adjacent to the left atrium (LA) before turning medially, piercing the pericardium to run in the posterior atrioventricular (AV) groove [16]. In about 90% of cases, it drains into the coronary sinus (CS); alternative sites include the inferior vena cava, hepatic vein, and LA. The entry into LA is invariably associated with an atrial septal defect ASD [17,18].In this case, we describe a female patient, 63 years old, with hypertension and dilated cardiomyopathy, without coronary artery disease. She was recovered from sudden cardiac death, with previous events of syncope, dyspnea on habitual exertion, and pre-syncope that began 6 months ago. She also was in use of acetylsalicylic acid 100 daily, carvedilol 25 twice a day, digoxin 0.25 mg per day, furosemide 40 mg daily, atorvastatin 40 mg daily, spironolactone 50 mg daily. The basal eletrocardiogram (ECG) presented sinus rhythm and QRS complex duration 170 ms. The 24-hour Holter monitoring showed sinus rhythm, with minimum -average -maximum heart rate (HR) of 39, 56 and 93 bpm, respectively, as well as, 6737 polymorphic ventricular ectopic beats and 5 episodes of non-sustained ventricular tachycardya, being the highest composed 16 beats at 180 bpm. The transthoracic echocardiogram showed: LA 4,3 cm, LVED 6,3 cm, LVES 5,8 cm, LVEF 17,2%, left ventricular mass index 139,3 g/m 2 , andd diffuse hypokinesia of the left ventricle. The coronary angiography did not present any new obstruction.The patient was submitted to general anesthesia by an anesthesiologist, and 2 g of cefazolin was administered intravenously. During the surery, a persistent left superior vena cava (PLSVC) was perceived. The left venography revealed a lack of contrast filling in an innominate vein (IV) and a quadripolar diagnostic ...