Letter to the Editor Left-sided or transposed inferior vena cava ascending as hemiazygos vein and draining into the coronary sinus via persistent left superior vena cava: case report Yesim Guray, Nizamettin Selcuk Yelgec, Umit Guray * , Mehmet Birhan Yylmaz, Ayca Boyaci, Sule Korkmaz Turkiye Yuksek Ihtisas Hospital, Cardiology Department, Ankara, Turkey Received 19 October 2002; accepted 24 December 2002 1. Introduction Left persistent superior vena cava occurs in f 0.3% of the general population and 4.3% in patients with congenital heart disease. Left-sided inferior vena cava has been well- described and occurs in f 0.2–0.5% of the general popu- lation. In most cases left inferior vena cava crosses over to the right via the left renal vein or more inferiorly and crossover is usually anterior but rarely posterior to the aorta [1]. Entire transposition of the inferior vena cava to the left with hemiazygos continuation is extremely rare although it has been previously described [2]. We report a case of a left- sided (transposed) inferior vena cava communicating with the hemiazygos vein which is draining into the dilated coronary sinus via persistent left superior vena cava. 2. Case report A 56-year-old woman was admitted in April 2002 with complaints of dyspnoea and palpitation. Physical examina- tion revealed an irregular and rapid pulse rate and 2/6 apical pansystolic murmur. The ECG showed incomplete right bundle branch block and atrial fibrillation with rapid ven- tricular rate. A plain chest radiograph revealed enlarged cardiac silhouette with mildly increased pulmonary vascu- larity. Two-dimensional echocardiography demonstrated normal left ventricular function with dilated left and right atria. A moderate degree of mitral regurgitation was also present. Pulmonary peak systolic pressure was calculated from the tricuspid regurgitant jet signal by Doppler echo- cardiography and found to be 40 mmHg. Additionally an echo-free chamber was visualised behind the left atrium. When agitated saline was injected into a peripheral vein in the left arm, a large, dilated coronary sinus draining into the right atrium was visualised. Atrial septal defect could not be excluded. With these findings the patient was referred to the cardiac catheterization laboratory to exclude atrial septal defect. Right and left heart catheterization was performed from the right femoral vein and femoral artery. After advancing a 6Fr Cournand catheter from the right femoral vein, the catheter was passed to the left of the lumbar spine. Oxygen saturation and the pressure waveform confirmed that the catheter was in the venous system. As the catheter was further advanced, it was noted to ascend superiorly near the left side of the cardiac silhouette and then turned to the right with an acute angle beneath the patient’s left clavicle. Then the Cournand catheter was exchanged with a 6Fr pigtail catheter. A cavography was performed and showed opacification of the left-sided inferior vena cava which was draining into a dilated coronary sinus and then the right atrium (Fig. 1). After cavography, the pigtail catheter was further advanced to the right atrium. Pulmonary artery could not be selectively engaged because of insufficient length of pigtail catheter. A right heart angiography was performed. Main pulmonary artery and its major side branches were clearly visualized. At the late phase of right heart angiography, a dilated left atrium with intact intera- trial septum was opacified. Coronary arteriography was then performed and did not show any evidence of luminal narrowing. Left ventriculography showed normal wall mo- tion with mild to moderate degree of mitral regurgitation. There was no increase in oxygen saturation between the high left sided inferior vena cava and right atrium or between the right atrium and right ventricle. The oxygen 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(03)00154-2 * Corresponding author. Address: Boncuk sokak 7/2, 06600, Kurtulus, Ankara, Turkey. Tel.: +90-312-4323383. E-mail address: umitguray@hotmail.com (U. Guray). www.elsevier.com/locate/ijcard International Journal of Cardiology 93 (2004) 293 – 295