Implantation of a resynchronization implantable cardioverter defibrillator in a patient with persistent left superior vena cava

Implantation of resynchronization implantable cardioverter defibrillator was performed in a patient with persistent left superior vena cava. A dual coil defibrillation lead was inserted in the right ventricle apex via a small innominate vein. Left ventricular and atrial leads were implanted through persistent left superior vena cava. Left ventricular lead was easily implanted into the postero lateral vein. Pacing thresholds and sensing values were excellent and remained stable at 18 months follow-up.Presence of persistent left superior vena cava generally makes transvenous lead implantation difficult. However when a favorable coronary sinus anatomy is also present, it may facilitate left ventricular lead positioning in the coronary sinus branches.     

Usefulness of a lead delivery system consisting of a fixed-shaped sheath and a lumenless bipolar lead in a patient with absent right and persistent left superior vena cava: A case report

We report the case of an 84-year-old female with symptomatic bradycardia due to a complete atrioventricular block, who carried absent right and persistent left superior vena cava (SVC). Implantation of a pacing lead, particularly within the right ventricle (RV) in a patient with this venous anomaly is accompanied by technical difficulties. However, the apparatus consisting of a fixed-curve sheath (Model C315-S10, Medtronic, Inc., Minneapolis, MN, USA) and a lumenless fixed-screw pacing lead (Model 3830, Medtronic), allowed a rapid delivery into the RV without any complications. By rotating the Model C315-S10 sheath in the counterclockwise direction in the right atrium, its tip faced the tricuspid orifice, advanced across the tricuspid valve and confronted the RV lower septum near the apex. Then the RV-lead was fixed with acceptable pacing and sensing parameters. Utilizing a lumenless pacing lead and a preformed sheath to deliver it is a novel approach that could be helpful in pacemaker implantation in patients with absent right and persistent left SVC.     

All is not lost, when lead goes in the wrong direction

Left sided superior vena cava (SVC) is an uncommon anomaly noted in the general population. It adds complexity to the procedure, when attempting to place pacing or defibrillator devices into the heart. Here we report a case where the leads were placed through the left sided SVC into the right sided chambers giving an interesting X-ray appearance.     

Successful Implantation of Transvenous Pacing System via Persistent Left Superior Vena Cava and Coronary Sinus in Small Children

Transvenous pacemaker implantation tends to be difficult in the setting of a persistent left superior vena cava (SVC) and an absent or inaccessible right SVC. We report two small children in whom transvenous pacing leads were successfully inserted via a persistent left SVC. This technique was safe in our cases; however, favorable long-term result has yet to be demonstrated.     

Successful Implantation of Transvenous Pacing System via Persistent Left Superior Vena Cava and Coronary Sinus in Small Children

Transvenous pacemaker implantation tends to be difficult in the setting of a persistent left superior vena cava (SVC) and an absent or inaccessible right SVC. We report two small children in whom transvenous pacing leads were successfully inserted via a persistent left SVC. This technique was safe in our cases; however, favorable long-term result has yet to be demonstrated.     

Refractoriness of the sheep superior vena cava myocardial sleeve

The cardiomyocytes in the superior vena cava (SVC) myocardial sleeve have distinct action potentials and ionic current profiles, but the refractoriness of these cells has not been reported. Using standard intracellular microelectrode techniques, we demonstrated in sheep that the effective refractory period (ERP) of the cardiomyocytes in the SVC (114.7 +/- 6.5 ms) is shorter than that in the inferior vena cava (IVC) (166.7 +/- 6.2 ms), right atrial free wall (RAFW) (201.0 +/- 6.0 ms) and right atrial appendage (RAA) (203.1 +/- 5.8 ms) (P < 0.05). The right atrial cardiomyocyte ERP was heterogeneously shortened by acetylcholine, a muscarinic type 2 receptor (M(2)R) agonist. After perfusion with 15 microM acetylcholine, the shortest ERP occurred in the SVC (the ERP in the SVC, IVC, RAFW and RAA was 53.6 +/- 2.7, 98.9 +/- 2.2, 121.8 +/- 6.0 and 109.7 +/- 5.1 ms, respectively; P < 0.05). Carbachol (1 microM), another M(2)R agonist, produced a similar effect as acetylcholine. Furthermore, we used methoctramine, a M(2)R blocker, 4-DAMP, a muscarinic type 3 receptor (M(3)R) blocker, and tropicamide, a muscarinic type 4 receptor (M(4)R) blocker to inhibit the acetylcholine-induced ERP shortening of SVC cardiomyocytes, and found that the 50% inhibitory concentration for methoctramine, 4-DAMP and tropicamide was 5.91, 45.72 and 80.34 nM, respectively. Therefore, we conclude that the sheep SVC myocardial sleeve is a unique electrophysiological region of the right atrium with the shortest ERP both under physiological condition and under cholinergic agonist stimulation. M(2)R might play a major role in the response of the SVC myocardial sleeve to parasympathetic nerve tone. The association between the distinct refractoriness in SVC and atrial fibrillation originating from the region deserves further investigation.     

Phrenic nerve injury after catheter ablation of atrial fibrillation

Phrenic Nerve Injury (PNI) has been well studied by cardiac surgeons. More recently it has been recognized as a potential complication of catheter ablation with a prevalence of 0.11 to 0.48 % after atrial fibrillation (AF) ablation. This review will focus on PNI after AF ablation. Anatomical studies have shown a close relationship between the right phrenic nerve and it's proximity to the superior vena cava (SVC), and the antero-inferior part of the right superior pulmonary vein (RSPV). In addition, the proximity of the left phrenic nerve to the left atrial appendage has been well established. Independent of the type of ablation catheter (4 mm, 8 mm, irrigated tip, balloon) or energy source used (radiofrequency (RF), ultrasound, cryothermia, and laser); the risk of PNI exists during ablation at the critical areas listed above. Although up to thirty-one percent of patients with PNI after AF ablation remain asymptomatic, dyspnea remain the cardinal symptom and is present in all symptomatic patients. Despite the theoretical risk for significant adverse effect on functional status and quality of life, short-term outcomes from published studies appear favorable with 81% of patients with PNI having a complete recovery after 7 +/- 7 months. CONCLUSION: Existing studies have described PNI as an uncommon but avoidable complication in patients undergoing pulmonary vein isolation for AF. Prior to ablation at the SVC, antero-inferior RSPV ostium or the left atrial appendage, pacing should be performed before energy delivery. If phrenic nerve capture is documented, energy delivery should be avoided at this site. Electrophysiologist's vigilance as well as pacing prior to ablation at high risk sites in close proximity to the phrenic nerve are the currently available tools to avoid the complication of PNI.     

Tracer mixing: sites of tracer infusion and sampling

Controversy exists in the literature concerning the correct infusion and sampling sites in studies measuring substrate turnover rates. To investigate this problem, we examined the results obtained with various infusion and sampling sites in 7 anesthetized dogs. [1-14C]lactate was infused by a primed continuous infusion method in three different sites (the left ventricle, ascending aorta, and the aortic arch) in a sequential fashion; samples were obtained simultaneously from five sites (femoral artery, carotid artery, pulmonary artery, superior vena cava and inferior vena cava) for each of the three different infusion sites. [U-13C]lactate was also infused in a femoral vein and simultaneous samples were obtained in the carotid artery and femoral artery for analysis of the stable isotope. [14C]lactate analysis demonstrated that infusion of the tracer into the left ventricular chamber resulted in a uniform distribution in the systemic circulation. Infusion into the ascending aorta near the aortic valve resulted in uniform distribution of tracer in four out of five experiments. Tracer infusion into the aortic arch resulted in nonuniform systemic distribution of tracer. The [U-13C]lactate results showed that infusion into the femoral vein gives uniform systemic distribution, similar to that observed with left ventricular infusion. The pulmonary artery lactate specific activities varied from those in the superior vena cava. Thus, this study shows that the tracer must be infused in the left ventricle or upstream from this chamber to obtain optimal systemic distribution. Vena caval sampling, especially superior vena caval sampling, will not give a consistent mixed venous concentration of the lactate tracer. Therefore, aortic tracer infusion with vena caval sampling may lead to errors in determining substrate turnover values.     

Anomalous caudal vena cava passing through the vertebral canal in a calf

A 15-day-old female Holstein-Friesian calf with an anomalous caudal vena cava was examined macroscopically, roentgenologically, and histologically. The calf, weighing 43 kg, had severe scoliosis. A common renal vein merged into a single venous trunk formed by the union of the left and right common iliac veins. The trunk entered the vertebral canal through the left intervertebral foramen formed by the last (13th) thoracic and the first lumbar vertebrae. The trunk continued along the ventral side of the narrowing spinal cord inside the canal, and then ran out the left intervertebral foramen formed by the 8th and 9th thoracic vertebrae and emptied via the right azygos vein into the cranial vena cava. In contrast, the hepatic vein passed through the foramen vena cava independently of the trunk and entered the right atrium directly. The pathogenesis of the present anomaly may be explained as follows: The right subcardinal vein, failing to make connection with the liver, shunted directly into the right azygos vein derived from the right supracardinal vein. The body axis began to curve before ossification of the vertebrae occurred. Consequently, the developing right supracardinal vein, located close to the spinal cord, is thought to have become enclosed in the vertebrae with the spinal cord during the early fetal stages.     

Cardiac resynchronization therapy device implantation in a patient with persistent left superior vena cava without communicating innominate vein - should we proceed from the same side? - A dilemma revisited

Persistent left superior vena cava (PLSVC) is an uncommon congenital anomaly. We report a case of implantation of cardiac resynchronization therapy - pacemaker (CRT-P) device in a 38-year-old lady with idiopathic dilated cardiomyopathy. After left axillary vein puncture, we faced an unexpected entry of left subclavian to PLSVC draining into the coronary sinus (CS). The target posterolateral vein which had been identified before, seemed to have an acute angle at its entry into the CS. Hence, at this stage we were in a dilemma, whether to switch to the right side or to continue from the same side. We continued the procedure from the left side and completed it successfully after some manipulation and improvisation.     

Radiofrequency Ablation Of Typical Atrial Flutter Via Right Subclavian/jugular Vein Access In A Patient With Implanted Filter In The Inferior Vena Cava

Radiofrequency ablation of Cavotricuspid Isthmus-dependent Atrial Flutter (CTI AFL), a usual and safe therapeutic procedure in interventional electrophysiology with a high success rate, aiming to induce permanent block of conduction over CTI, is normally performed via the femoral access, which allows practical access to the CTI through the inferior vena cava (IVC). In rare cases of obstruction of IVC, ablation of CTI can be performed only through the superior vena cava (SVC) access. We present a case of typical atrial flutter that was ablated through the right subclavian/jugular veins because of iatrogenic obstruction of the IVC due to a previously implanted thrombus filter. Furthermore we discuss about how we resolved access-related problems of instability during catheter ablation on CTI.     

β-Adrenergic stimulation induces pro-arrhythmic activity in the caval vein myocardial tissue

Electrical activity of the right superior vena cava (SVC) is considered as a source of the atrial fibrillation. We have shown that bioelectrical properties of the SVC myocardium differ from those of the working atrial myocardium. Electrically evoked action potential duration in SVC is significantly shorter, the resting membrane potential in both stimulated and quiescent SVC preparations is significantly more positive than in atria. Activation of β-adrenoreceptors in SVC myocardium leads to a series of action potentials, and this process depends on protein kinase A. Probably, β-adrenergic stimulation enhances SVC arrhythmogenesis in vivo.     

A Case of Budd-Chiari Syndrome Associated with Alveolar Echinococcosis

Although alveolar echinococcosis (AE) can cause a serious disease with high mortality and morbidity similar to malign neoplasms. A 62-year-old woman admitted to a hospital located in Sivas, Turkey, with the complaints of fatigue and right upper abdominal pain. On contrast abdominal CT, a 54×70×45 mm sized cystic lesion was detected in the left lobe of the liver that was seen to extend to the posterior mediastinum and invade the diaphragm, esophagus, and pericardium. The cystic lesion was seen to be occluding the inferior vena cava and left hepatic vein at the level where the hepatic veins poured into the inferior vena cava. Bilateral pleural effusion was also detected. We discussed this secondary Budd-Chiari Syndrome (BCS) case, resulting from the AE occlusion of the left hepatic vein and inferior vena cava, in light of the information in literature.     

Gluconeogenesis by the fetal sheep liver in vivo

Hepatic gluconeogenesis is an important source of glucose postnatally. Whether hepatic gluconeogenesis contributes to fetal glucose supply has not been studied directly in vivo. Previous studies of gluconeogenesis in fetal sheep have assessed total fetal glucose production, and the results have been controversial. To assess the specific role of the liver in gluconeogenesis in fetal sheep, we placed catheters in the right or left hepatic vein, umbilical vein and the inferior vena cava of six fetal sheep (mean gestational age 134 days) and infused a radioactive gluconeogenic substrate (14C-lactate or 14C-alanine) into the fetal inferior vena cava. We measured 14C-glucose radioactivity (dpm/ml) in the right or left hepatic vein and calculated the arteriovenous difference in 14C-glucose radioactivity (dpm/ml) across the right or left liver lobe. We found that only 0.35% of the 14C substrates perfusing either the right or the left hepatic lobe of the fetal liver were converted to 14C-glucose. Even when considerable glucose was released by the liver, the percentage of substrates converted to glucose remained very low (maximum 1.7%), indicating that gluconeogenesis did not contribute significantly to the glucose released. We conclude that gluconeogenesis by the fetal liver contributes negligibly to the glucose supply in fetal sheep.     

Correlations between changes of the right and left atrial pressures and systemic hemodynamics parameters following catecholamines intravenous injections in cats

In acute experiments on anesthetized cats, intravenous injection of epinephrine and norepinephrine caused different changes of right and left artrial pressures. These shifts mostly (82%) had similar directions: in these experiments, both right and left atrial pressures could be decreased (I group of animals) or increased (II group). The number of animals in these groups was equal. However, in 18% of the experiments, right atrial pressure was decreased, while left atrial pressure was increased. The changes of the left atrial pressure was, as a rule, more significant as compared with right atrial pressure shifts. In the I group of animals, systolic right atrial pressure was not changed, and systolic left atrial pressure was decreased. In the II group of animals, systolic pressure in both atria was augmented. Diastolic pressure was decreased in both atria in all the animals. When the atrial pressures were decreased, the increases of the superior and inferior vena cava flows, venous return and cardiac output were more significant as compared with animals in which the atrial pressures had been elevated. The changes of the superior and inferior vena cava flows were more obvious in animals following epinephrine injection as compared with animals in which norepinephrine was injected. The right atrial pressure returned to the initial level more rapidly than the left atrial pressure, and the time dynamics of the shifts of the right atrial pressure was similar to that of the superior vena cava flow. The temporal changes of the left atrial pressure were identical to the time changes of the cardiac output. We concluded that character of changes of the mean, systolic, and diastolic right and left atrial pressures following catecholamines injections was not correlated with the direction of venous return and cardiac output shifts, and was depending on intracardiac hemodynamics.     

Ostium of the collection stem of the anterior cardiac veins (vv. cardiacae anteriores) in the vena cava, inferior

In 1 of 150 studied cases, we found the collection stem of anterior cardiac veins that emptied into the inferior vena cava. This collection stem had eight tributaries: two right atrial veins, five anterior cardiac veins and a right marginal vein. The caliber of the collection stem was increasing gradually from its beginning (2.8 mm) to its orifice (4.5 mm). The orifice of the collection stem was in the inferior vena cava, at a distance of 10 mm from its ostial valve, and was itself provided with a semilunar valve.     

The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or subclavian veins is performed with a micro-convex ultrasound probe, using a neonatal abdominal preset with a probe frequency of 10 Mhz at a depth of 10-12 cm. Following insertion of the guidewire into the vein, the probe is shifted to the right supraclavicular fossa to obtain a view of the superior vena cava (SVC), right pulmonary artery and ascending aorta. Under real-time ultrasound view, the guidewire and its J-tip is visualized and pushed forward to the lower SVC. Insertion depth is read from guidewire marks using central venous catheter. CVC is then inserted following skin and venous dilation. The supraclavicular fossa view is most suitable for right IJV CVC insertion. If other insertion sites are chosen the right supraclavicular fossa should be within the sterile field. Scanning of the IJVs, brachiocephalic veins and SVC can reveal significant thrombosis before venipuncture. Misplaced CVCs can be corrected with a change over guidewire technique under real-time ultrasound guidance. In conjunction with a diagnostic lung ultrasound scan, this technique has a potential to replace chest radiograph for confirmation of CVC tip position and exclusion of pneumothorax. Moreover, this view is of advantage in patients with a non-p-wave cardiac rhythm were an intra-cardiac electrocardiography (ECG) is not feasible for CVC tip position confirmation. Limitations of the method are lack of availability of a micro-convex probe and the need for training.     

HEMIAZYGOS CONTINUATION TO CORONARY SINUS WITH NORMAL LEFT INNOMINATE VEIN

A case is described of absent hepatic segment of the inferior vena cava with hemiazygos continuation and drainage into the coronary sinus with associated atrial septal defect and patent ductus arteriosus. In all previously reported cases of inferior vena caval anomalies with persistent hemiazygos, the hemiazygos joined the homolateral superior vena cava. To our knowledge this is the first case to be reported of a patient who had hemiazygos continuation to the coronary sinus with a normal left innominate vein and a single right superior vena cava.     

4:2:1 conduction of an AF initiating trigger

A 44 year old male with idiopathic dilated cardiomyopathy was undergoing persistent atrial fibrillation (AF) ablation. Following antral ablation, AF terminated into a regular narrow complex rhythm. Earliest activation was mapped to a focus in the superior vena cava (SVC) which was conducted in a 2:1 ratio to the atria which in turn was conducted with 2:1 ratio to the ventricles, resulting in an unusual 4:2:1 conduction of the SVC tachycardia. 1:1 conduction of the SVC tachycardia to the atrium preceded initiation of AF. During AF, SVC tachycardia continued unperturbed. Sinus rhythm was restored following catheter ablation of the focus.