RESUMEN
A 34-year-old woman was seen in the emergency department for shortness of breath and chest pain. During a pandemic, it is easy to 'think horses and not zebras', and with a patient presenting with the classic coronavirus symptoms it would have been easy to jump to that as her diagnosis. After a careful history and examination, it became clear that there was another underlying diagnosis. Chest X-ray, echocardiogram and CT scan revealed marked right ventricular dilatation and pulmonary hypertension, alongside a persistent left superior vena cava (PLSVC). Further investigation with cardiac MRI and coronary angiography at a tertiary centre demonstrated that she not only have a PLSVC but also a partial anomalous pulmonary venous drainage and sinus venosus atrial septal defect. This case highlights the importance of considering all differentials and approaching investigations in a logical manner.
Asunto(s)
COVID-19/diagnóstico , Dolor en el Pecho/fisiopatología , Disnea/fisiopatología , Defectos del Tabique Interatrial/diagnóstico por imagen , Hipertensión Pulmonar/diagnóstico por imagen , Hipertrofia Ventricular Derecha/diagnóstico por imagen , Vena Cava Superior Izquierda Persistente/diagnóstico por imagen , Síndrome de Cimitarra/diagnóstico por imagen , Adulto , Cateterismo Cardíaco , Dolor en el Pecho/etiología , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Diagnóstico Diferencial , Dilatación Patológica/complicaciones , Dilatación Patológica/diagnóstico por imagen , Dilatación Patológica/fisiopatología , Disnea/etiología , Ecocardiografía , Electrocardiografía , Femenino , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/fisiopatología , Humanos , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/fisiopatología , Hipertrofia Ventricular Derecha/complicaciones , Hipertrofia Ventricular Derecha/fisiopatología , Imagen por Resonancia Magnética , Vena Cava Superior Izquierda Persistente/complicaciones , Vena Cava Superior Izquierda Persistente/fisiopatología , SARS-CoV-2 , Síndrome de Cimitarra/complicaciones , Síndrome de Cimitarra/fisiopatología , Tomografía Computarizada por Rayos X , Presión VentricularAsunto(s)
Cateterismo Cardíaco/instrumentación , Seno Coronario/anomalías , Anomalías de los Vasos Coronarios/terapia , Defectos del Tabique Interatrial/terapia , Vena Cava Superior Izquierda Persistente/terapia , Seno Coronario/diagnóstico por imagen , Seno Coronario/fisiopatología , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/fisiopatología , Femenino , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/fisiopatología , Humanos , Persona de Mediana Edad , Vena Cava Superior Izquierda Persistente/diagnóstico por imagen , Vena Cava Superior Izquierda Persistente/fisiopatología , Resultado del TratamientoRESUMEN
In patients with persistent left superior vena cava (PLSVC), transvenous device implantation for cardiac resynchronization therapy (CRT) may be challenging. We present a complex case with successful, high-density electroanatomic mapping (EAM) guided corrective His bundle pacing (CHBP) following failed CRT upgrade in a patient with PLSVC, congenital heart disease, and pacing-associated heart failure. CHBP restored physiological conduction in left bundle branch block with complete conduction block leading to clinical improvement and cardiac remodeling. The presented case supports the growing evidence that EAM-guided CHBP may be considered a feasible alternative to conventional CRT when venous anatomy is not favorable for left ventricular lead implantation.
Asunto(s)
Fascículo Atrioventricular/fisiopatología , Bloqueo de Rama/terapia , Terapia de Resincronización Cardíaca/métodos , Mapeo Epicárdico/métodos , Cardiopatías Congénitas/terapia , Insuficiencia Cardíaca/terapia , Vena Cava Superior Izquierda Persistente/terapia , Anciano , Bloqueo de Rama/fisiopatología , Femenino , Cardiopatías Congénitas/fisiopatología , Insuficiencia Cardíaca/etiología , Humanos , Vena Cava Superior Izquierda Persistente/fisiopatologíaAsunto(s)
Dolor en el Pecho/diagnóstico , Defectos del Tabique Interventricular , Tomografía Computarizada Multidetector/métodos , Vena Cava Superior/diagnóstico por imagen , Tabique Interventricular/diagnóstico por imagen , Adolescente , Técnicas de Imagen Cardíaca/métodos , Ecocardiografía/métodos , Defectos del Tabique Interventricular/diagnóstico , Defectos del Tabique Interventricular/fisiopatología , Humanos , Masculino , Vena Cava Superior Izquierda Persistente/diagnóstico , Vena Cava Superior Izquierda Persistente/fisiopatologíaRESUMEN
AIMS: The impact of persistent left superior vena cava (PLSVC) in atrial fibrillation (AF) patients undergoing radiofrequency catheter ablation (RFCA) is not well known. We performed this analysis to evaluate the electrophysiological characteristics of PLSVC and its role in triggering and maintaining AF. METHODS AND RESULTS: Patients with AF referred to two tertiary hospitals were screened and patients with PLSVC in pre-RFCA imaging studies were enrolled. Among 3967 patients, PLSVC was present in 36 patients (0.9%). There were four morphological types of PLSVC: type 1, atresia of the right superior vena cava (SVC) (n = 2); type 2A, dual SVCs with an anastomosis between right and left SVCs (n = 15); type 2B, dual SVCs without an anastomosis (n = 16); type 3, PLSVC draining into the left atrium (LA; n = 2); and unclassified in one patient. Thirty-two patients underwent RFCA and electrophysiology study focusing on PLSVC: PLSVC was the trigger of AF in 48.4% of patients and the driver of AF in 46.9% of patients. Cumulatively, PLSVC was a trigger or driver of AF in 22 patients (68.8%). Whether to ablate PLSVC was determined by the results of electrophysiology study, and no significant difference in the late recurrence rate was observed between patients who did and did not have either trigger or driver from PLSVC. CONCLUSION: Pre-RFCA cardiac imaging revealed PLSVC in 0.9% of AF patients. This study demonstrated that PLSVC has an important role in initiating and maintaining AF in substantial proportion of patients. Electrophysiology study focusing on PLSVC can help to decide whether to ablate PLSVC.