Persistent left superior vena cava and absence of innominate vein during coronary artery bypass surgery

Abstract

DesCripTionA 56-year-old man presented with acute left-sided chest pain at rest with associated dyspnoea. His heart rate was 35 beats/min and ECG revealed a complete heart block. A temporary cardiac pacing was implemented on the right side via transcutaneous leads. He was also diagnosed with non-ST elevation myocardial infarction due to raised cardiac enzymes and was managed with medical therapy. The pacemaker was removed after 3 days when he reverted to sinus rhythm. Coronary angiogram was subsequently performed and revealed a critically obstructed triple coronary vessel disease. Echocardiography revealed an ejection fraction of 40%, competent valves and normal chamber size. Coronary artery bypass graft (CABG) surgery was performed via median sternotomy. Interestingly, there were no innominate veins identified intraoperatively and a dilated coronary sinus was seen on transoesophageal echocardiography. Cardiopulmonary bypass was initiated following aortic and two-stage right atrial venous cannulation. The heart was cooled and intentionally stopped by antegrade cardioplegia. On lifting the heart, a left superior vena cava was identified adjacent to the left atrial appendage (figure 1). Two vein grafts were grafted to the posterior descending artery and distal left circumflex. The left internal mammary artery harvested was grafted to left anterior descending artery.Persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly due to the failure of left superior cardinal vein caudal to the innominate vein to regress in utero.

Persistent left superior vena cava transvenous lead extraction: A European experience

“…The more posterior position and the unfamiliarity of the location for the cardiac surgeon are likely to make an adequate repair more time-consuming. 17 Laser sheaths are associated with a higher risk of cardiovascular injury in TLE than rotational sheaths, particularly to the normal right-sided SVC. 4,18 Laser energy appears to cause thermal injury to the vein wall in the area of greatest angulation, so we suspect that the greater angulation encountered in a PLSVC might further increase this risk.…”

The Challenges of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Persistent Left Superior Vena Cava: A Case Report and Concise Literature Review

“…While in normal individuals the left cardinal vein devolves into the so called “Ligament of Marshall”, in some individuals its existence continues, resulting in a left-sided vein, which drains into the coronary sinus [ 5 ]. Often, the venous abnormality consists of the presence of a left as well as a right superior vena cava (SVC), which may or may not be joined by an innominate vein [ 6 ]. The presence of PLSVC is most frequently diagnosed accidentally and generally does not raise particular concerns within the healthy adult population [ 7 ].…”