2024 FSA Podium and Poster Abstracts
P027: NAVIGATING INTRAOPERATIVE CHALLENGES TO IMPROVE PATIENT OUTCOMES: DIAGNOSING PERSISTENT LEFT SUPERIOR VENA CAVA IN CARDIAC SURGERY
Michael Aguad, MD1; Daniel Betterly, MD2; 1Department of Anesthesia, Memorial Healthcare System; 2Envision Physician Services
Introduction: The left superior vena cava (LSVC) is one of the many vessels that regress during embryologic development. However, in about 0.3 to 0.5% of the world’s population, it can persist and most commonly drains into the coronary sinus1. Most often, this persistent vessel does not cause symptoms in patients, however, its presence can impact management in patients requiring aortic cross clamp and retrograde cardioplegia. The following case discusses an intraoperative diagnosis of a persistent left superior vena cava (PLSVC) that altered the plan of care for a patient undergoing cardiopulmonary bypass with retrograde cardioplegia.
Case Report: This is a case of a 59-year-old male with a history of decompensated heart failure, NYHA Class IV Stage C, who presented to the emergency room in hypertensive emergency with worsening dyspnea, abdominal bloating and orthopnea. Echocardiography was performed preoperatively revealing severe aortic insufficiency (AI) with an ejection fraction of 60%, no details regarding the coronary sinus were provided. Cardiovascular surgery was consulted and determined to proceed with aortic valve replacement.
The patient was taken to the operating suite and underwent an uneventful induction and intubation. Following induction, a transesophageal echocardiogram (TEE) was performed that revealed a dilated coronary sinus measuring 2.3cm (Figure 1). A bubble study was performed with agitated heme administered into a PIV in the left arm, revealing evidence for a PLSVC not previously noted on preoperative echocardiography. A positive bubble study can be seen in the deep midesophageal 4-chamber view with bubbles entering the right atrium via the coronary sinus (Figure 2). After obtaining evidence of the PLSVC, we knew retrograde cardioplegia would be ineffective. In addition, with severe AI, anterograde cardioplegia would not provide adequate protection. After discussion with the surgeon, the plan was changed to perform anterograde cardioplegia and then immediately perform direct cardioplegia with coronary ostium cannula to protect the myocardium. The patient had adequate protection with no change in LV or RV function. Patient underwent the procedure without complications and was transferred to the ICU.
Discussion: Although rare amongst the general population, this anomaly is ten times more likely to be present among the congenital heart disease population2. The significance of a PLSVC can be somewhat benign, however, its impact becomes increasingly more important towards higher levels of care in the hospital. Its significance plays a role during central venous cannulation, pacemaker placement and cardiac surgery with retrograde cardioplegia3. When present, a PLSVC usually drains into the coronary sinus, although more rare, there are instances in which this vessel drains into the left atrium causing a right to left shunt4.
In conclusion, failure to diagnose a PLSVC while attempting to use retrograde cardioplegia can lead to inadequate myocardial protection and during surgery. Although this anomaly is uncommon amongst the general population, this case reveals findings on echocardiography that must be readily recognized by echocardiographers and anesthesia providers.
