Intraoperative recognition of persistent left superior vena cava during right internal jugular central line placement...

Persistent left superior vena cava is a rare congenital venous anomaly, present in approximately 0.3-0.5% of the general population and in up to 10% of patients with congenital heart disease. Although typically asymptomatic and often discovered incidentally, persistent left superior vena cava may complicate central venous catheter placement and transesophageal echocardiography confirmation during cardiac surgery. Unrecognized persistent left superior vena cava can lead to misinterpretation of guidewire position, unnecessary catheter manipulation, and procedural delays.

A 65-year-old white woman (body mass index 26 kg/m²; American Society of Anesthesiologists physical status III) with severe degenerative mitral regurgitation, hypertension, and well-controlled type 2 diabetes mellitus presented for elective mitral valve repair. After uneventful induction of general anesthesia, a right internal jugular central venous catheter was placed under ultrasound guidance without resistance, arrhythmia, or abnormal waveform. Intraoperative transesophageal echocardiography-using standard bicaval, midesophageal four-chamber, and midesophageal long-axis views-failed to visualize the guidewire or catheter tip within the superior vena cava or right atrium despite correct placement technique and a normal central venous pressure waveform. Given stable hemodynamics and appropriate venous return, the catheter was secured in place, and mitral valve repair proceeded without incident. Postoperative contrast-enhanced computed tomography identified a persistent left superior vena cava draining into an enlarged coronary sinus, accounting for the atypical guidewire trajectory. The central line remained functional throughout, and the patient was extubated on postoperative day 1. She experienced an uncomplicated recovery and was discharged home on postoperative day 4.

When transesophageal echocardiography fails to confirm central venous catheter position despite proper technique, rare anatomical variants such as persistent left superior vena cava should be considered. Employing targeted transesophageal echocardiography interrogation of the coronary sinus and adjunctive imaging modalities can facilitate prompt recognition. Awareness of persistent left superior vena cava prevents unnecessary catheter manipulation, reduces procedural delays, and enhances patient safety during cardiac surgery.