Transcatheter Occlusion of a Persistent Left Superior Vena Cava to the Left Atrium Using the Transseptal Approach Jeffrey D. Zampi, MD, Nathaniel R. Sznycer-Taub, MD, and Ronald G. Grifka* MD A persistent left superior vena cava (LSVC) is a common venous anomaly, occurring in up to 10% of patients with congenital heart defects. Usually, a LSVC drains into the coronary sinus, then to the right atrium. The LSVC can drain directly to the left atrium, resulting in a right-to-left shunt and systemic desaturation. Historically, surgery has been used to address this lesion. Transcatheter occlusion of the LSVC is an alternative to surgery. We report the novel use of the transseptal approach to access the LSVC, and device occlusion using the Amplatzer Vascular Plug-II. V C 2013 Wiley Periodicals, Inc. Key words: superior vena cava; transcatheter; occlusion; intervention INTRODUCTION A left superior vena cava (LSVC) is a common vari- ant of venous anatomy. In the majority of cases, the LSVC drains to the coronary sinus, then to the right atrium, resulting in the normal return of venous blood to the right heart. Occasionally, the LSVC connects to the left atrium, resulting in a right-to-left shunt, sys- temic desaturation, and other possible sequelae. A number of reports discuss surgical treatment for a LSVC. Recently, several reports discuss transcatheter occlusion of a LSVC, using the left internal jugular vein and the off-label use of a septal occlusion device. We present a novel approach to address this vascular anomaly, using a transseptal procedure to afford access to the LSVC, then occlusion using a vascular occlusion device. CASE REPORT A 12-year-old young man presented to an emergency room with acutely altered mental status. There was concern that otitis media had progressed to mastoiditis. A thorough evaluation revealed several scattered, small cerebral embolic lesions, and thrombus in the right in- ternal jugular vein and sagittal sinus. His systemic oxy- gen saturation was 91%. A hypercoaguable work-up was unremarkable. An echocardiogram confirmed nor- mal cardiac size and function, an intact atrial septum, and bilateral superior vena cavae with a small “bridging” left brachiocephalic vein. Through a left arm IV, an agitated saline microbubble injection dis- played dense opacification of the left atrium from the persistent LSVC draining to the left atrium. A cardiac catheterization documented the LSVC entering the superior “roof” of the left atrium (not the usual unroofed coronary sinus), a small left brachiocephalic vein, and a normal size right superior vena cava (RSVC). The presumed mechanism of the cerebral emboli was thrombus from the head and neck veins that embolized through the left brachiocephalic vein and LSVC to the left atrium, then into the systemic ar- terial circulation. Due to the thrombus in the right internal jugular vein and sagittal sinus, there was concern for compromised venous drainage from the right head and arm. Since de- vice occlusion of the LSVC could result in transient compromised drainage of the left head and arm, the LSVC was not occluded at that time. He was treated University of Michigan Congenital Heart Center, Ann Arbor, Michigan Conflict of interest: Nothing to report. *Correspondence to: Ronald G. Grifka, University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital, Floor 11, Cardiology, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4204. E-mail: rgrifka@med.umich.edu Received 13 November 2012; Revision accepted 17 February 2013 DOI: 10.1002/ccd.24884 Published online 21 February 2013 in Wiley Online Library (wileyonlinelibrary.com). V C 2013 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 83:99–103 (2014)