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2012 Summer Diagnose This

Heart & Vascular Institute Physician eNewsletter - Summer 2012

When a 58-year-old male presented with fatigue and shortness of breath, his history of atrial fibrillation (a-fib) was no surprise. But previous attempts at another hospital to surgically repair the a-fib and treat it with medications were unsuccessful. The patient had an ablation in 2009, followed by a Maze procedure in 2010. Despite these surgeries and medication, the flutter in his heart still could not be controlled—until he took his case to Cleveland Clinic.

Examination and Diagnosis

When he arrived at Cleveland Clinic, an echocardiogram revealed a left ventricle that was normal in size, though systolic function was below normal with an ejection fraction of 45 percent. The right ventricle was also normal in size, and the heart imaging showed no significant valvular abnormalities.

However, a CT scan showed persistent left superior vena cava (SVC) draining into the enlarged coronary sinus. No right-sided SVC was identified. This fact made the case a complex matter.

It was determined that the patient was born with a congenital heart defect where he only had a left-sided SVC and no right SVC. With the defect, access to the left atrium is much more complex, as with the persistent left SVC there is a very large coronary sinus.

Treatment

Cleveland Clinic executed the pulmonary vein isolation and left SVC-CS isolation with success. Now, one year after the ablation, the patient is still free of atrial fibrillation. During a follow-up exam and echocardiogram, the patient’s ejection fraction was 60 percent—a great improvement.

Discussion

This case is interesting because of the unique anatomical challenges and the redo nature of the procedure—he had failed prior ablation and Maze surgery. Experience in addressing rare, patient-specific anatomic anomalies and surgical revisions helped to produce a positive patient outcome.

Images

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Image 1: Note Left SVC draining into large Coronary sinus - (patient image). 
Click on the image for a larger view (image will open in a new window).

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Image 2:Note absence of Right SVC - (patient image).
Click on the image for a larger view (image will open in a new window).

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Image 3: For comparison, note the normal Right SVC draining into right atrium.
Click on the image for a larger view (image will open in a new window).

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