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.