Benz, Dominik C.

Eriksson, Urs

Krasniqi, Nazmi

Stieger, Ruedi

Tanner, Felix C.

Wagnetz, Ute

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The ARISTOTLE Committees and Investigators. Apixaban versus warfarin inpatients with atrial fibrillation. N Engl J Med 2011;365:981–992.12. Turpie AGG, Bauer KA, Davidson BL, Fisher WD, Fent M, Huo MH, Sinha U,Gretler DD, EXPERT Study Group. A randomized evaluation of betrixaban, anoral factor Xa inhibitor, for prevention of thromboembolic events after totalknee replacement (EXPERT). Thromb Haemost 2009;101:68–76.13. Rosendaal FR, Cannegieter SC, van der Meer FJM, Briet E. A method to deter-mine the optimal intensity of oral anticoagulant therapy. Thromb Haemost 1993;69:236–239.14. Connolly SJ, Pogue J, Eikelboom J, Flaker G, Commerford P, Franzosi MG,Healey JS, Yusuf S; ACTIVE W Investigators. Benefit of oral anticoagulant overantiplatelet therapy in atrial fibrillation depends on the quality of internationalnormalized ratio control achieved by centers and countries as measured bytime in therapeutic range. Circulation 2008;118:2029–2037.15. Baker WL, Cios DA, Sander SD, Coleman CI. Meta-analysis to assess the qualityof warfarin control in atrial fibrillation patients in the United States. J Manag CarePharm 2009;15:244–252.16. ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation foratrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for pre-vention of Vascular Events (ACTIVE W): a randomized controlled trial. Lancet2006;367:1903–1912.17. Nozawa T, Inoue H, Iwasa A, Okumura K, Jong-dae L, Shimizu A, Hayano M,Yano K. Effects of anticoagulation intensity on hemostatic markers in patientswith non-valvular atrial fibrillation. Circ J 2004;68:29–34. PubMed PMID:14695462.18. Sadanaga T, Sadanaga M, Ogawa S. Evidence that D-dimer levels predictsubsequent thromboembolic and cardiovascular events in patients withatrial fibrillation during oral anticoagulant therapy. Cardiol J Am Coll 2010;55:2225–31.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/eht092Online publish-ahead-of-print 21 March 2013Isolated persistent left superior vena cava draining into the left atriumof an otherwise normal heartDominik C. Benz1, Nazmi Krasniqi1,2, Ute Wagnetz1, Ruedi Stieger3, Felix C. Tanner1,2, and Urs Eriksson1,2,4*1Department of Medicine, GZO – Zurich Regional Health Centre, Wetzikon, Switzerland; 2Department of Cardiology, Cardiovascular Center, University Hospital, Zurich,Switzerland; 3Rosenklinik am See AG, Rapperswil, Switzerland; and 4Division of Cardioimmunology, Department Cardiovascular Research, Institute of Physiology, Universityof Zurich, Switzerland* Corresponding author. Email: urs.eriksson@gzo.chA 63-year-old male presented with progressiveright-sided hemiparesis, facial palsy, and aphasia.He had been scheduled for neoadjuvant chemo-therapy for relapsing adenocarcinoma of the leftcolic flexure, and a left-sided port-a-cath wasimplanted 7 days ago. The CCT scan revealedseveral already well-demarked ischaemic brainlesions. Treatment with aspirin and statin wasinitiated.Chest X-ray revealed an unusual left-sideddownward course of the port-a-cath catheterto the left atrium. Injection of agitated salineinto the left cubital vein showed microbubblesin the left atrium (Panel A). In contrast, injectioninto the right arm resulted in opacification of theright atrium (Panel B). TEE demonstrated an iso-lated left-sided superior vena cava draining intothe left atrium between the left atrial appendageand the left upper pulmonary vein (Panel C). Theinnominate vein was absent, while there wasnormal course of the right superior vena cava.Except for a very small left ventricular diverticu-lum, cardiac anatomy was otherwise normal.Retrospective analysis of a former thoracic CTscan (Panel D) and MR angiography (Panel E)confirmed the persistent left superior venacava (PLSVC). To our knowledge, there has not been described yet an isolated defect of LSVC draining into the left atrium assingle anomaly without atresia of coronary sinus, any septal defects and any valvular abnormalities.PLSVC draining to the left atrium is clinically relevant as it predisposes to paradoxical embolism, particularly in the contextof venous injections into the left arm, device implantation, or central vein cannulation from the left side.Supplementary material is available at European Heart Journal online.Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: journals.permissions@oup.comBetrixaban compared with warfarin in patients with AF 1505

Isolated persistent left superior vena cava draining into the left atrium of an otherwise normal heart

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