The Trouble with Double: Clinical Implications of Double SVC

1Cleveland Clinic Foundation, Cleveland, OH
2Government Medical College, Nagpur, Nagpur, India
3Cleveland Clinic Foundation, Cleveland, OH
4Cleveland Clinic Foundation. Cleveland, OH

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 216

Case Presentation:

A 20‐year‐old healthy female presented with history of dizziness for 1 year, with recent increase in frequency and duration. She had no vertigo and no aggravating or relieving factors. She denied any hearing loss, Tinnitus, palpitations, unsteady gait, vomiting, headache, double vision, visual loss, slurred speech, paresthesias of the face or body, weakness, or incoordination. Examination revealed bradycardia with a pulse of 40 and blood pressure of 112/60 without orthostasis. She had no nystagmus and a normal cardiovascular and neurological exam. CBC, BMP, TSH, chest x‐ray, and head CT were normal. EKG showed bradycardia with a heart rate of 42 and left anterior fascicular block Echo showed normal valves and function but a dilated coronary sinus. Cardiac MRI showed bilateral SVC with right SVC draining inlo the right atrium and left SVC draining into the coronary sinus. Also soon wore a left‐sided aortic arch and an aberrant right subclavian artery. The patient continued to have symptoms and was persistently bradycardic on telemetry. The decision was made to implant a pacemaker using a right subclavian approach in order to avoid the abnormal anatomy of Ihe left‐sided venous system. The patient tolerated the procedure well and is asymptomatic on follow‐up.

Discussion:

Double superior vena cava due to persistent left superior vena cava (PLSVC) is the most common venous anomaly of the thorax. It is present in 0.5%–2% of the general population and in 10% of patients with congenital heart disease. It is usually not recognized until left cephalic or subclavian approach is used for transcatheter procedures. This case illustrates thai the incidental finding of a large or dilated coronary sinus during echocardiography should raise the question of an aberrant systemic or pulmonary drainage into this vein. PLSVC may be associated with other congenital malformations of the heart and great vessels and with abnormalities of pacemaker and conduction tissue; therefore, appropriate investigations should be undertaken. TTie PLSVC through its aberrant communications with the atria may promote the initiation and maintenance of atrial fibrillation and sudden dealh. Introduction of any line into the PLSVC may be mistaken for placement in either subclavian or carotid artery, mediastinum, pericardium, left internal mammary vein, or superior intercostal veins. Serious complications including angina, antiythmia, cardiogenic shock, and even cardiac arrest have been reported when a guide wire or catheter is manipulated via persistent LSVC.

Conclusions:

(1) Awareness among hospitalists about PLSVC would prevent unnecessary anxiety, when a postprocedure x‐ray shows a guide wire or left‐sided venous catheter take an unusual left‐sided downward course crossing to the right at a lower level of Ihe coronary sinus instead of crossing up at the level of the innominate vein. (2) PLSVC may cause technical difficulties, leading to misplacement of catheters and injury to vessel walls.

Author Disclosure:

R. Bahuva, none; A. Satra, none; S. Kandpal, none: S. Manda, none

To cite this abstract:

Bahuva R, Satra A, Kandpal S, Manda S. The Trouble with Double: Clinical Implications of Double SVC. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 216. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/the-trouble-with-double-clinical-implications-of-double-svc/. Accessed May 23, 2019.

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