Ginormous Coronary Sinus with Persistent Left Superior Vena Cava

Abstract

An echocardiogram is the most common diagnostic imaging done in chest pain evaluation workup. Persistent left superior vena cava is a rare thoracic congenital anomaly but commonly reported one in the literature. Dilated coronary sinus on echocardiogram is a signal to think of persistent left superior vena cava which can be presented with atypical chest pain and palpitation but is often asymptomatic. As a catheter from left subclavian approach can incidentally advance to the right side of the heart, early awareness of PLSVC is crucial to prevent unwanted procedure related complications. atrioventricular groove in left parasternal long axis and apical 4-chamber views (Figure 2). Since dilated CS is a relatively rare finding, the differential diagnosis should include right-sided heart disease with pressure and volume overload, unroofed coronary sinus, and anomalous venous drainage into the coronary sinus. A TTE with agitated normal saline contrast injected into the left antecubital vein verified the presence of air bubbles entering the coronary sinus first and then in the right atrium, suggestive of a persistent left superior vena cava (PLSVC) draining directly into the coronary sinus (Figure 3). DiscussionPLSVC has been recognized as a rare venous anomaly but the most commonly reported congenital thoracic venous anomaly with a prevalence of 0.3% to 0.5% of general population [1]. During the early stage of fetal life, the thoracic venous system is mainly composed of anterior and posterior cardinal veins. While the proximal part of left cardinal vein combines with right anterior cardinal vein remaining as the SVC, the distal portion usually dissipates, forming a ligament of Marshall. However, a failure of the left cardinal vein degeneration leads to the persistent left SVC. Saline agitated TTE (bubble study) is the gold standard to confirm the diagnosis. The following TTE findings are part of diagnostic criteria: (1) the presence of a dilated coronary sinus in the absence of evidence of elevated right-sided filling pressures; (2) enhancement of the dilated coronary sinus before the right atrium