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CASE SNIPPET
Year : 2021  |  Volume : 67  |  Issue : 4  |  Page : 247-248

Coronary sinus diverticulum and partial left-sided inferior vena cava in a patient with atrial fibrillation and Wolff-Parkinson-White syndrome


1 Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra, India
2 Department of Cardiology, Holy Family Hospital, Mumbai, Maharashtra, India

Date of Submission19-Aug-2020
Date of Decision21-Dec-2020
Date of Acceptance25-Jan-2021
Date of Web Publication22-Mar-2021

Correspondence Address:
S Yadav
Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_970_20

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How to cite this article:
Yadav S, Shaikh Z, Mahajan A, Lokhandwala Y. Coronary sinus diverticulum and partial left-sided inferior vena cava in a patient with atrial fibrillation and Wolff-Parkinson-White syndrome. J Postgrad Med 2021;67:247-8

How to cite this URL:
Yadav S, Shaikh Z, Mahajan A, Lokhandwala Y. Coronary sinus diverticulum and partial left-sided inferior vena cava in a patient with atrial fibrillation and Wolff-Parkinson-White syndrome. J Postgrad Med [serial online] 2021 [cited 2022 Jul 1];67:247-8. Available from: https://www.jpgmonline.com/text.asp?2021/67/4/247/312987




A 54-year-old man complaining of sudden onset of rapid palpitations, sweating, and giddiness was taken to a local hospital where the electrocardiogram (ECG) showed irregular wide complex tachycardia [[Figure 1], upper panel]. In view of persistent tachycardia despite pharmacological therapies, electrical cardioversion was performed. The episode terminated only after three shocks of 200 Joules. The patient was referred to our center for further management. The sinus rhythm ECG [[Figure 1], lower panel] was suggestive of preexcitation, with delta wave biphasic in lead V1, positive in lead V2, and negative in leads II/III, suggestive of a posteroseptal accessory pathway. The biphasic delta wave in V1 raised the possibility of a coronary sinus (CS) diverticulum. The patient was taken up for early ablation therapy.
Figure 1: The upper panel shows the electrocardiogram during the clinical episode. An irregular wide QRS tachycardia is seen with a ventricular rate approximating 250/min. The lower panel is the electrocardiogram in sinus rhythm, showing Wolff-Parkinson-White syndrome. The delta waves are biphasic in V1, positive in lead V2, and negative in leads II/III, suggesting a posteroseptal accessory pathway

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A guide wire passed from the right femoral vein was seen crossing over to the left side of the lower vertebral column. A venogram obtained using the access sheath showed a left sided inferior vena cava (IVC) up to the first lumbar vertebra [[Figure 2], Panel A], then crossing over to the right side and continuing to the right atrium. After introducing a catheter into the CS, an angiogram showed a moderate-sized goblet shaped diverticulum close to its mouth [[Figure 2], Panel B]. The electrophysiology study confirmed the presence of a posteroseptal accessory pathway, which was located at the neck of the CS diverticulum, where radiofrequency ablation was successful [[Figure 2], Panel C].
Figure 2: Panel A is a right femoral venogram showing right common iliac vein continuing into a left infra-renal inferior vena cava (**), which then drains into the left renal vein and after confluence with the right renal vein, continues into right sided supra-renal inferior vena cava (black arrow); Panel B is a coronary sinus venogram outlining the diverticulum (white arrow); Panel C shows the disappearance of preexcitation (*) during ablation; Panel D is a diagram of the full course of the partial left inferior vena cava

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A fast broad and irregular tachycardia should be considered as atrial fibrillation with Wolff-Parkinson-White (WPW) syndrome until proved otherwise, yet often this is misdiagnosed as ventricular tachycardia. Atrial fibrillation in WPW syndrome is often a consequence of degeneration of atrioventricular reentry tachycardia[1] and can be life-threatening if the rate is very fast, as in this patient. A partial left-sided IVC was a rare association in our patient. In partial left IVC, the left common iliac vein ascends as a duplicated left IVC and drains into the left renal vein, which then crosses the aorta anteriorly and joins the right IVC [[Figure 2], Panel D] in a normal fashion.[2] In the context of posteroseptal pathways, it is important to look for ECG signs related to CS abnormalities, which include a biphasic delta wave in lead V1, a notched negative delta wave in lead II and a prominent S wave in lead V6. There are instances of ablation procedures becoming prolonged and complicated for want of suspecting a CS diverticulum.[3] There is, therefore, a case to be made for CS venography in such suspected cases. With CS diverticulum, effective ablation can mostly be achieved at the neck of the diverticulum since the accessory pathway fibers converge in that area.[4]

Our case highlights the importance of the following: (i) Recognizing the classical ECG pattern of atrial fibrillation with WPW syndrome, (ii) ECG localization of the accessory pathway and when to suspect CS diverticulum in posteroseptal locations, and (iii) Utility of CS angiography in such cases.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Fujimura O, Klein GJ, Yee R, Sharma AD. Mode of onset of atrial fibrillation in the Wolff-Parkinson-White syndrome: How important is the accessory pathway? J Am Coll Cardiol 1990;15:1082-6.  Back to cited text no. 1
    
2.
Ghandour A, Partovi S, Karuppasamy K, Rajiah P. Congenital anomalies of the IVC-embryological perspective and clinical relevance. Cardiovasc Diagn Ther 2016;6:482-92.  Back to cited text no. 2
    
3.
Takahashi A, Shah DC, Jaïs P, Hocini M, Clementy J, Haïssaguerre M. Specific electrocardiographic features of manifest coronary vein posteroseptal accessory pathways. J Cardiovasc Electrophysiol 1998;9:1015-25.  Back to cited text no. 3
    
4.
Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J, et al. Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: Incidence and electrophysiological identification. Circulation 2002;106:1362-7.  Back to cited text no. 4
    


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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
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