Rodríguez FJA, Almazán-Soo A

Language: Spanish
References: 18
Page: 106-112
PDF size: 177.46 Kb.

ABSTRACT

Background: Persistent left superior vena cava (PLSVC) is a structural, asymptomatic and infrequent anomaly, present in 0.5% of the general population. Typically the diagnosis reveals itself unexpectedly at the time of pacemaker implantation, when it acquires anatomic relevancy. Several techniques are used for the transvenous approach to enter the central venous circulation; the left subclavian vein has become a common access site for electrode implantation and, occasionally, one can find an anomalous venous structure such as a PLSVC. Placement of electrodes through this anomalous venous structure can prove challenging, if not impossible. The present report tries to explore aspects of transimplantation diagnosis from a practical point of view. It also address the knowledge of anatomy, implant technique and radiographic orientation. Case presentation: Twenty-six-year-old woman with confirmed Symptomatic Sick Sinus Syndrome variety Sinus Arrest. The diagnosis of PLSVC was discovered unexpectedly at the time of the transvenous approach. The tip for the diagnosis was the “unusually medial” position of the lead, and the venogram showed the venous traject towards the coronary sinus and drainage into the right atrium. An active-fixation screw-in electrode was positioned in the anterosuperior margin of the free wall of the right atrium. After 24 months of successful placement of the pacemaker, the patient is asymptomatic. Discussion: PLSVC is a rare congenital vascular abnormality. Besides its association with congenital anomalies, its most relevant clinical implication is the association with disturbances of cardiac rhythm, impulse formation and conduction. The ontogenetic development of the sinus node, the atrioventricular node, and the His bundle might be heavily influenced by the lack of regression of the left cardinal vein. When isolated, the PLSVC is usually not recognized until left superior approach to the heart is required, when it becomes a relevant anatomic finding. In fact, it can complicate the positioning of left-sided pacemaker and cardioverter-defibrillator leads. In patients with poor handling through the coronary sinus, a right approach is recommended after visualization of a right superior vena cava entering the right atrium by echocardiography or contrast venography since its absence or hypoplasia (which is reported in 10% of the cases with PLSVC) may represent a major obstacle and would suggest an epicardial implantation. Conclusion: Today, the preferred approach for pacemaker lead implantation is via the left subclavian vein and the operator must be aware of this venous anomaly that may technically complicate the electrode positioning. This kowledge may be useful for other medical specialties that require the implant of left sided transvenous subclavian catheters, like in critical care settings, nephrology, onco-hematology, and anesthesiology.

REFERENCES

1. Robert M, Freedom, et al: Persistence of the Left Superior Vena Cava and Related Anomalies: En Congenital Heart Disease: Textbook of Angiocardiography, Futura Publishing Company, 1997: 209-303.

2. Duffy SJ, Alison JF: Images in cardiology. Permanent pacemaker implantation via a persistent left superior vena cava. Clin Cardiol 2001; 24: 526.

3. Fraser RS, Dvorkin J, Rossall RE, Eidem R: Left superior vena cava: A review of associated congenital heart lesions, catheterization data and roentgenologic findings. Am J Med 1961; 31: 711­716.

4. Sarodia BD, Stoller JK: Persistent left superior vena cava: case report and literature review. Respir Care 2000; 45: 411-6.

5. Winter FS: Persistent left superior vena cava: survey of world literature and report of thirty additional cases. [Resumen] Angiology 1954; 5: 90-132.

6. Batista-Villareal E, Criales JL: Vena cava superior izquierda persistente. Hallazgo incidental en tomografía computada helicoidal. Gac Med Méx 2001; 137: 87-89.

7. Morillas P, Frutos A, Valero R, Rodríguez JA, Bertomeu V: Persistencia de la vena cava superior izquierda. Rev Esp Cardiol 2000; 53: 1655.

8. Geissler W, Albert M: Persistierende linke ober Hohlvene und Mitralstenose. [Resumen] Z Gesamte Inn Med 1956; 11: 865.

9. Orwitz S, Esquivel J, Attie F, Lupi E, Espino-Vela J: Clinical diagnosis of persistent left superior vena cava by observation of jugular pulses. Am Heart J 1973; 86: 756-63.

10. Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A: Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience. Chest 2001; 120: 139-44.

11. Anderson RH, Latham RA. The cellular architecture of the human atrioventricular node, with a note on its morphology in the presence of a left superior vena cava. J Anat 1971; 109: 443-455.

12. James TN, Marshall TK: Persistent fetal dispersion of the atrioventricular node and His bundle within the central fibrous body. Circulation 1976; 53: 1026-1034.

13. Meijboom WB, Vanderheyden M: Biventricular pacing and persistent left superior vena cava: case report and review of the literature. [Resumen] Acta Cardiol 2002; 57: 287-90.

14. Zerbe F, Bornakowski J, Sarnowski W: Pacemaker electrode implantation in patients with left superior vena cava. Br Heart J 1992; 67: 65-66.

15. Huang YL, Wu MT, Pan HB, Yang CF: Aberrant course of Swan-Ganz catheter revealing persistent left superior vena cava. [Resumen] Zhonghua Yi Xue Za Zhi 2002; 65: 403-6.

16. Higgs AG, Paris S, Potter F: Discovery of left-sided superior vena cava during central venous catheterization. Br J Anaesth 1998; 81: 260-1.

17. De la Prada FJ, Sastre M, Forteza JF, Morey A, Munar MA, Alarcon A: Persistence of the left superior vena cava discovered during the implantation of a hemodialysis catheter. Nefrologia 2002; 22: 199-201.

18. Favale S, Bardy GH, Pitzalis MV, Dicandia CD, Traversa M, Rizzon P: Transvenous defibrillator implantation in patients with persistent left superior vena cava and right superior vena cava atresia. Eur Heart J 1995; 16(5): 704-7.