Side matters: An intriguing case of persistent left superior vena-cava

Area of Science:

• Cardiology
• Radiology
• Anatomy

Background:

• Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly, typically draining into the coronary sinus.
• PLSVC can lead to severe complications during central venous catheterization, including arrhythmias and cardiac arrest.

Observation:

• A case of PLSVC was diagnosed using transthoracic echocardiogram (TTE) in a patient with congestive heart failure.
• A dilated coronary sinus was noted on TTE, with agitated saline injection into the left antecubital vein confirming PLSVC via coronary sinus filling before the right atrium.

Findings:

• Transthoracic echocardiogram (TTE) identified a persistent left superior vena cava (PLSVC).
• Cardiac computed tomography confirmed the PLSVC diagnosis.
• The patient presented with congestive heart failure and severe left ventricular systolic dysfunction.

Implications:

• Accurate diagnosis of PLSVC is critical for patients requiring central venous catheter procedures, such as those needing an implantable cardioverter-defibrillator.
• Physicians should suspect PLSVC when guidewire courses leftward towards the coronary sinus during central line placement.
• Pre-procedural imaging is essential to identify PLSVC and mitigate risks associated with central venous catheterization.