Thoracoscopic surgery for atrial fibrillation in a patient with persistent left superior vena cava: a case report

A persistent left superior vena cava (PLSVC) is an anomaly of the thoracic venous system that flows into the right atrium via an enlarged coronary sinus. When performing pulmonary vein isolation and left atrial appendage closure, the PLSVC can interfere with the procedure. We have performed thoracoscopic surgery on such a patient and would like to share our experience.

The patient is a 70-year-old male with a 1-year history of repeated tachycardia with chest discomfort due to paroxysmal atrial fibrillation. Contrast-enhanced computed tomography revealed the presence of a PLSVC that flows into the right atrium. The hepatic vein flows directly into the right atrium, whereas the inferior vena cava enters the thoracic cavity next to the descending aorta and flows into the parazygous vein and PLSVC. We performed thoracoscopic stapler closure of the left atrial appendage and epicardial clamp-isolation of the pulmonary veins and the PLSVC. There was concern that the PLSVC would interfere with the visual field needed to perform the procedure. We carefully removed the adhesions to the surrounding tissue and provided mobility to the PLSVC and expanded it ventrally. As a result, the procedure could be performed safely and without complications.

Our results demonstrate that in cases where catheter ablation is difficult for anatomical reasons, thoracoscopic stapler closure of the LAA and epicardial clamp-isolation of pulmonary veins may be a viable option.