Case Studies of Interest

In this month’s issue of EP Lab Digest®, we feature several interesting case study articles. Archana Kodali, MD and Koroush Khalighi, MD, FAOP, FACC, FCCP from Easton Hospital in Pennsylvania describe the association of superior vena cava syndrome (SVCS) with an intracardiac device and antiphospholipid antibodies. A partial or complete obstruction of the superior vena cava results in a variety of symptoms called SVCS. The authors present a case study, and discuss both the presentation and management of SVCS. They write that even though the majority of SVCS cases are from an underlying malignancy, with the increased usage of intracardiac devices, there should be a high suspicion for clinical diagnosis in these settings.

Kenneth Yamamura, MD, FACC and Bonnie McDonald RN, CEPS, RCIS from the Pepin Heart Institute at Florida Hospital Tampa in Florida present a case of a 67-year-old woman with undiagnosed persistent left superior vena cava (PLSVC). This is the most common congenital venous anomaly in the chest, occurring in between 0.3-0.5% of all patients. A PLSVC can be accurately diagnosed by echocardiography, CT or MR imaging, or intraoperatively during vascular access by noting an unusual course of a guide wire, catheter, or pacing lead.

Finally, Alyssa M. Feldman, MS and colleagues from Winthrop University Hospital in New York describe a case of atrial fibrillation recurrence in which repeated cardioversion, contact pressure, patch placement, and preloading with sotalol helped result in a successful outcome. The patient was a 61-year-old man who was clinically obese, with an elevated body mass index of 40.6 kg/m2. Their case highlights the principles of changing patch placement and applying pressure over the patch to lower transthoracic impedance. In addition, increasing cardioversion energy delivered by the defibrillator proved useful in this case.

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PLSVC: Literature Review

LiemIn EP Lab Digest®’s August 2013 issue, authors L. Bing Liem, DO, Steven S. Lee, MD and Zachary Q. Umlauf, MS from El Camino Hospital in Mountain View, California, describe a scenario associated with increased difficulty in the placement of a right ventricular lead, especially when a right ventricular apical position is desired. A 67-year-old male was referred for implantation of an ICD; they were proceeding with their usual approach using a lateral left subclavian venous entry when a large persistent left superior vena cava (PLSVC) was identified. Since a right-sided approach was not feasible, they decided on a left-sided entry and use of a left ventricular lead delivery system to facilitate entry into the right ventricle. Check out the article for more information about this interesting case!

In February 2013, Antonio Navarrete, MD, FACC, CCDS and Louis Janeira, MD, Indiana University Health and Providence Medical Group in Terre Haute, Indiana, presented a case of Wolff-Parkinson-White (WPW) in a patient with PLSVC. The peculiar characteristics of this rare congenital vascular anomaly regarding catheter ablation are reviewed in the article. Drs. Navarrete and Janeira note that the true prevalence of PLSVC is unknown since the vast majority of cases are asymptomatic. However, it has been reported to occur in the general population in 0.3-0.5% and up to 12% if another congenital heart abnormality is present.

In 2008, Ronald W. Kidd, BSN, RCIS from Oklahoma Heart Hospital in Oklahoma City, Oklahoma, also provided information on some of the more unusual cases seen at his EP lab, including images of cases involving patients with PLSVC. He writes that one of the most interesting surprises that can be seen in the EP lab is PLSVC. He notes that in such cases the patient usually does not present with any associated symptoms that would cause the physician to consider the existence of this anomaly — it is often only discovered during the placement of a central line, pacemaker or ICD.