Transcatheter Device Closure of Persistent Left Superior Vena Cava Connecting to the Upper Left Pulmonary Vein: A Rare Entity
Saturday, September 19, 2020
9:00 AM – 11:00 AM
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Ramez Morcos, MD, MBA: Disclosure information not submitted.
Overview: A 67-year-old female patient with a recent prior right basal ganglia and corona radiata stroke 3 weeks earlier presented with a new onset dysarthria. Magnetic resonance imaging confirmed an acute infarct in the left posterior frontal lobe. She was not a candidate for tissue plasminogen activator due to timeline of the presentation. A transesophageal echocardiogram (TEE) at another facility with agitated saline study had confirmed an intracardiac right-to-left shunt that was believed to be a patent foramen ovale (PFO), and a closure procedure was planned. She was on dual antiplatelet therapy. TEE with agitated saline, injected via the left arm, at our institution was positive with nearly simultaneous bubbles in right and left heart. Transesophageal echocardiography failed to demonstrate an atrial septal defect nor a sinus venosus defect. All pulmonary veins had normal drainage into the left atrium. Right heart catheterization was performed and saturation data were obtained. There was no saturation step-up to suggest a hemodynamically significant shunt. Superior cavoatrial junction was probed for anomalous venous connection, but none were identified. Selective angiography of the left innominate vein revealed a persistent left superior vena cava (LSVC). Selectively engagement and angiography of the L-SVC demonstrate drainage into the left upper pulmonary vein (LUPV) and the left atrium (Figure 1). Subsequently, computed tomography angiogram (CTA) with immediate and delayed images were obtained, confirming L-SVC traveling anterior to the aortic arch and left pulmonary artery, and ruled-out other abnormalities (Figure 2). Ultrasound Doppler of the left arm, along with bilateral lower extremities, did not show evidence of venous thrombosis. As this patient had multiple embolic events despite medical therapy, she was scheduled for transcatheter closure of the L-SVC (Figure 1). Largest diameter of the L-SVC measured 6.8 mm on angiography, a 10 mm AVP2 vascular plug was deployed in the mid segment successfully. Subsequent angiography revealed no flow through the device, with excellent flow through the innominate vein to the right SVC. Patient was discharged to rehab on dual antiplatelet therapy.At four-week follow-up, the patient was in stable condition and a transthoracic echocardiogram showed normal cardiac structures and a negative bubble study. This case represents a rare presentation of a persistent L-SVC with drainage into the LUPV complicated by recurrent embolic events. Transcatheter closure is a safe and feasible option in these patients