Persistent left superior vena cava diagnosed by contrast transesophageal echocardiography

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increaseof LV and RV end-diastolic dimensions;and (4) increaseof early diastolic mitral flow velocity. From these observations,we conclude that compressionof capsulated PLE causedLV collapseresulting in a significant limitation of LV diastolic filling and a reduction in stroke volume. RV diastolic filling may also have been limited by indirect compressionof capsulatedPLE, although the RV collapse could not be seen becauseof the limitations of the echo window. To our knowledge, this is the first report of LV collapse due to capsulated PLE. PLE is not uncommon, especially after open-heart surgery, and it seemsto be clinically important to examine the potential compression effect on the LV and/or the RV in patients with PLE. Two-dimensional echocardiography wasuseful in evaluating LV diastolic collapsecausedby compressionby capsulated PLE.

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Fig. 1. Parasternal long-axis view of the left ventricle utilizing conventional transthoracic echocardiography. A REFERENCES markedly dilated coronary sinus (CS) is noted. The de1. ArmstrongWF, SchiltBF, HelperDJ, DillonJC, Feigenbaum scendingthoracic aorta (arrows) is also visualized for reference. H. Diastoliccollapseof the right ventriclewith cardiactamponade:an echocardiographic study. Circulation 1982;65: 1491-6. 2. SinghS, WannLS, SchuchardGH, KlopfensteinHS, LeimgruberPP, KeelanMH, BrooksHL. Right ventricular and anomaliesof the systemicvenous return. The incidenceof right atria1collapsein patientswith cardiactamponade-a PLSVC is reported to be 0.3% to 0.5% in the general combinedechocardiographic andhemodynamic study. Circupopulation.’ The diagnosis can be established by twolation 1984;70:966-71. 3. HurstJW, SchlantRC,RackleyCE,Sonnenblick EH, Wenger dimensionalechocardiography. It should be suspectedby NK. The heart, arteriesand veins.NewYork: McGraw-Hill the presenceof dilated coronary sinus, and confirmed by InformationServiceCompany,1990:1361. contrast echocardiography. The injection of an echo4. JonesMR. Vine DL. Attas M. Todd EP. Late isolatedleft ventriculartamponade. Clinical,hemodynamic, andechocar- contrast solution into the left antecubital vein will opacify diographicmanifestations of a previouslyunreportedpostop- the dilated coronary sinus,whereasthe injection into the erative complication.J Thorac CardiovascSurg 1979;77: right antecubital vein will not. However, the diagnosisof 142-6. PLSVC is difficult to confirm by conventional contrast 5. GondiB, NandaNC. Two-dimensional echocardiographic diechocardiographyin the presenceof suboptimal precordial of mediastinal hematoma causing cardiac tamponade. agnosis windows,pulmonary hypertension, or severetricuspid reAm J Cardiol1984;53:974-6. 6. Conrad SA, Byrnes TJ. Diastolic collapse of the left and right gurgitation. In this latter condition, the regurgitation ventricles in cardiac tamponade. AM HEART J 1988;115:475-8. bounces back the echo-contrast material into the right atrium and the coronary sinusfollowing the contrast injection into either antecubital veins. In this situation, the use of transesophagealechocardiography (TEE) may be beneficial becauseit provides excellent visualization of the corPersistent left superior vena cava onary sinusand the right atrium.2 This report presentsthe diagnosed by contrast transesophageal first description of the useof contrast TEE in the diagnoechocardiography sis of PLSVC in an adult patient. A 75-year-old white man with a history of chronic atria1 Farooq Chaudhry, MD, and Miguel Zabalgoitia, MD. fibrillation, hypertension, and renal insufficiency was hosSan Antonio, Texas pitalized for work-up of upper gastrointestinal bleeding. On physical examination, except for an irregular pulseand lateral displacementof the point of maximal impulse,the Presenceof persistent anterior cardinal vein, commonly cardiovascular examination wasunremarkable. A chest xreferred to aspersistent left superior vena cava (PLSVC), ray film revealed an enlargedcardiac silhouette and a toris consideredto be one of the most frequently encountered tuous aorta. The electrocardiogram showedatria1 fibrillation and nonspecific ST-T abnormalities. After the diagnosisof duodenalulcer wasestablished,an echocardiogram From the Section of Cardiology, University of Texas Health Science Cenwasperformed to evaluate the enlarged cardiac silhouette ter. seenon chest x-ray film. A vascular structure posterior to Reprint requests: Miguel Zabalgoitia, MD, University of Texas Health Scithe left atrium, consistent with a dilated coronary sinus, ence Center, Division of Cardiology, 7703 Floyd Curl Drive, San Antonio, TX 78284-7872. wasnoted (Fig. 1). The presenceof PLSVC wassuspected. 414131310 In addition, severetricuspid regurgitation and pulmonary

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Fig. 2. Time sequence of contrast transesophageal echocardiographic images following selective intravenous injections of agitated solution into the right arm. Rl shows opacification of the right superior vena cava (arrows). R2 shows opacification of the right atrium (RA) and right ventricle (RV), which occurred before opacification of the coronary sinus (CS). R3 shows the absence of opacification of the coronary sinus (arrolus). AO, Aorta; LA, left atrium; LAA, left atria1 appendage; LV, left ventricle; RVOT, right ventricular outflow tract.

hypertension (right ventricular systolic pressure = 49 mm Hg) was documented by Doppler. Contrast study was performed by injecting 10 cm3 of agitated 5 % dextrose in water solution selectively into the right and left antecubital veins during simultaneous transthoracic echocardiographic images. Opacification of the dilated coronary sinus was seen not only after injection of the left, but also after injection of the right antecubital vein. Thus the diagnosis of PLSVC was equivocal. Contrast TEE was performed utilizing the same contrast injection technique. Contrast TEE allowed visualization of the time sequence of the echo-contrast within the right atrium first and then into the coronary sinus following injection of the right antecubital vein (Fig. 2). Following injection of the left antecubital vein (Fig. 3), opacification of the coronary sinus first and then the right atrium was seen. No other structural abnormalities were noted. The presence of PLSVC draining into the coronary sinus is of no hemodynamic significance. However, it is important to recognize this condition, as it can have important clinical implications. PLSVC is often accompanied by

other congenital abnormalities, particularly atria1 septal defect. Other less common associated conditions are anomalous pulmonary venous return and tetralogy of Fallot.3 Because of the abnormal venous connection in PLSVC, technical difficulties in venous catheterization may occur when the procedure is attempted from the left jugular, left subclavian, or left antecubital veins. Electrical instability has been reported in this anomaly during cannulation of the left venous system.4 If the existence of PLSVC is not suspected preoperatively, serious technical difficulties may arise during open-heart surgery at the time of cannulation of the “superior vena cava” for cardiopulmonary bypass. In this report, contrast TEE revealed in detail the anatomic relationship of the dilated coronary sinus with the right atrium, right ventricle, and right ventricular outflow tract. These unique views allowed for a time sequence of the anomalous drainage of the left superior vena cava into the coronary sinus. In addition, TEE provided an excellent visualization of the atria1 septum that excluded the possibility of an associated atria1 septal defect. If dilatation of the coronary sinus is noted on the two-dimensional echocar-

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3. Time sequence of contrast transesophageal echocardiographicimagesfollowing selective intravenous injections of agitated solution into the left arm. Ll showsno opacification of the right superior vena cava (arrows). L2 showsopacification of the coronary sinus (CS), which occurred immediately before opacification of the right atrium and right ventricle (RV). L3 showsopacification of the coronary sinus(arrows). AO, Aorta; LA, left atrium; RVOT, right ventricular outflow tract.

Fig.

diogram, the presence of PLSVC should be considered. Contrast echocardiography, utilizing the standard precordial windows, should be obtained first. However, if the diagnosisof PLSVC is equivocal, or if the possibility of an associatedatria1 septal defect cannot be excluded, contrast TEE should be performed.

Percutaneous recanalization thrombosis

pulsed dye laser of experimental venous

Guy Meyer, MD, SergeMakowski, MD, P. Gabriel Steg, MD, Patrick Bruneval, MD, and Rene Gourgon, MD. Paris, France

REFERENCES

1. SniderAR,PortsTA, SilvermanNH. Venousanomalies of the coronarysinus:detectionby M-mode,two-dimensional and contrast echocardiography. Circulation 1979;60:721-7. 2. Seward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr, Edwards WD, Nichols BA, Freeman WK, Tajik AJ. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clin Proc 19%%;63:649-80. 3. Fraser RS, Dvorkin J, Rossall R, Eiden R. Left superior vena cava. A review of associated congenital heart lesions, catheterization data and raentgenologic findings. Am d Med 1961;31:711-6.

4. JamesTN, MarshallTK, EdwardsJE. Cardiacelectricinstability in the presence 1976;54:6%9-97.

of a left superior

vena cava. Circulation

The treatment of venous thrombosis and pulmonary embolismremainsdifficult. Pulseddye laserscan ablate fresh thrombus and venous emboli with someselectivity,1, 2and their energy can be percutaneously conveyed through opFrom

the Lahoratoire

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