Case Report
A 30-year-old male presented by repeated attacks of exertional chest
pain over the past 2 months that were precipitated by moderate exertion
and last for few minutes and relieved by rest. No past medical history
of any risk factors. Physical examination was unremarkable except for a
harsh grade III/VI ejection systolic murmur heard over the second aortic
area.
Electrocardiogram, chest x-ray (CXR) and routine laboratory workup were
all unremarkable.
Echocardiography showed an evidence of subaortic flow turbulence with a
visible subaortic membrane and mild aortic regurgitation (Movies 1,2).
The Aortic valve was trileaflet with normal leaflets thickness and
excursion (Movie 3). The maximum peak systolic velocity that can be
obtained across the subaortic area was 2.8 m/sec, and the peak and mean
gradients across the subaortic area were 31 and 16 mmHg respectively
(Figure 1A).
However, the parasternal long view showed a grossly dilated coronary
sinus that measured 2.3x2.3 cm (Figure 1B) despite normal right sided
structures with no evidence of elevated pulmonary artery systolic
pressure. So, persistent left superior vena cava was suspected. Contrast
echocardiography using agitated saline injection in the left antecubital
vein showed an opacification of the coronary sinus before the right
ventricular outflow tract (Movie 4, Figure1C). Injection of agitated
saline was repeated on the right antecubital vein as well and showed
opacification of right ventricular outflow tract (RVOT) with clear
coronary sinus (Movie 5, Figure 1D), suggesting the persistence of the
right SVC as well. Computed tomography (CT) of the chest with contrast
confirmed the persistence of both right and left SVCs (Figures 1E,1F).
The patient was reassured, and
chest pain improved on betablocker therapy and we requested a regular
follow up in cardiology outpatient clinic.