a 56-year - old male visited our hospital with new york heart association functional class iv dyspnea and pitting edema in his lower extremities .
the patient had been diagnosed with tricuspid valve regurgitation and atrial fibrillation at an outside institution 10 years ago . however , the patient had refused surgical treatment at that time . physical examination and
laboratory tests demonstrated severe hepatomegaly , ascites , azotemia , and cardiac cirrhosis ( child - pugh class b ) .
echocardiography and cardiac magnetic resonance imaging showed severe tricuspid valve regurgitation , with a persistent left superior vena cava ( svc ) draining into the coronary sinus and absence of the innominate vein .
magnetic resonance imaging revealed left and right ventricular ejection fractions of 31.5% and 34.2% , respectively .
heart transplantation rather than a tricuspid valve surgery was recommended because of the biventricular dysfunction .
preoperative computed tomographic venography of the neck and brain was performed to evaluate the probable risk of a left svc ligation .
the diameters of the right and left svcs were 17 mm and 16 mm , respectively .
abundant collaterals were built up at the sigmoid sinus , which was considered adequate for draining venous blood from the left part of the head to the right svc .
this finding suggested that the risk of cerebral venous congestion after left svc ligation was minimal .
when opening the pericardium during heart transplantation , the recipient heart showed a large dilated distal part of the left svc draining into the coronary sinus . under moderate hypothermia , orthotopic heart transplantation was performed with the standard aorto - bicaval cannulation technique using an additional venous cannula on the left svc .
the donor heart was implanted using the standard bicaval technique . despite the preoperative evaluation suggesting
left svc ligation would be safe in this patient , the left svc was anastomosed to the right atrial appendage using an interconnecting conduit ( fig .
a tubular conduit 16 mm in diameter and 4 cm in length was constructed using the resected coronary sinus tissue to avoid size discrepancy and kinking .
after the orthotopic cardiac transplantation was completed using the bicaval anastomosis technique , the tubular conduit was anastomosed to the distal part of the left svc and to the right atrial appendage using continuous 5 - 0 polypropylene sutures .
the cardiopulmonary bypass and donor ischemic times were 354 minutes and 125 minutes , respectively .
the postoperative course was uneventful . a computed tomography angiogram at one month after the surgery demonstrated a patent conduit between the left svc and right atrial appendage ( fig .
the patient was discharged without any complications and did not show any sign of upper - body venous congestion at the six - month follow - up visit .
a left svc is an infrequent congenital abnormality with a prevalence of 0.3% to 0.5% in the normal population and 2.8% to 4.3% in patients with congenital heart disease . in the setting of cardiac transplantation
, a persistent left svc deserves consideration to determine the level of venous return during bypass as well as the bicaval anastomosis .
if a well - developed innominate vein is present , occlusion of the left svc by simple ligation or division will recreate a normal venous drainage through the innominate vein .
however , if the innominate vein is small or absent , occluding the left svc may increase the risk of neurovascular complications .
a persistent left svc can be preserved with several surgical techniques during orthotopic heart transplantation .
these surgical approaches include end - to - side anastomosis of the left svc to the right svc , end - to - end anastomosis of the left svc to the right atrial appendage ( direct anastomosis or anastomosis using a conduit ) , and anastomosis of both right and left svcs to the innominate vein of the donor graft [ 26 ] .
a previous study presented a case of orthotopic heart transplantation in a patient with a persistent left svc . in that patient
, the left svc was passed between the ascending aorta and pulmonary artery , and anastomosed to the right svc in an end - to - side fashion . in the present case
, there were abundant collaterals present at the sigmoid sinus , which might have prevented venous congestion if the left svc was occluded .
however , we decided to preserve the left svc to minimize this risk . connecting the left svc to the right svc behind the ascending aorta
was avoided because its passage was right - angled and posed a risk of compression by the aorta and pulmonary artery .
in addition , we constructed an interconnecting graft instead of using an in situ conduit , because there were issues such as a size discrepancy and risks of kinking and resultant blood stasis .
the coronary sinus tissue was resected , made into a tubular conduit with a diameter of 16 mm , and placed between the left svc and the right atrial appendage .
artificial conduits were not considered due to the risk of thrombo - occlusion and infection . in conclusion
, we successfully performed an orthotopic heart transplantation in a patient with a persistent left svc by reconstructing the left svc with an interconnecting conduit made from autologous coronary sinus tissue , which was anastomosed to the distal part of the left svc and to the right atrial appendage .
 a 56-year - old male presented with severe exertional dyspnea and pitting edema in the lower extremities . 
 the pre - operative evaluation demonstrated biventricular dysfunction associated with severe tricuspid valve regurgitation and a persistent left superior vena cava . 
 he was registered as a transplantation candidate , and orthotopic heart transplantation was performed using the standard bicaval technique . 
 the left superior vena cava was connected to the right atrial appendage after the construction of a conduit using the recipient s autologous coronary sinus tissue . 
 one - month postoperatively , computed tomography imagery demonstrated a patent conduit between the left superior vena cava and right atrial appendage . 
CASE REPORT
DISCUSSION