Hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus: A case report

This is a case report of a 45‐year‐old patient admitted with the symptom of bilateral leg swelling. Ultrasonography revealed a hyperechoic mass in the right lobe of the liver, which invaded the right hepatic vein (RHV) and extended into the inferior vena cava (IVC) and right atrium (RA). Based on the high alpha‐fetoprotein (AFP) level and the ultrasonography findings, the patient was diagnosed as having hepatocellular carcinoma (HCC) with a RHV, IVC, and RA tumor thrombus and secondary Budd–Chiari syndrome (BCS). HCC with a tumor thrombus extending into the IVC and RA has rarely been observed, and as a cause of secondary BCS, this type of HCC has been even more rarely reported.     

Superior vena caval obstruction by lipomatous hypertrophy of the right atrium

A structural abnormality was suspected when passage of a Swan-Ganz catheter was obstructed at the distal superior vena cava (SVC). At autopsy, lipomatous hypertrophy of the right atrium markedly narrowed the lumen at the SVC-right atrial junction.     

Echocardiographic assessment of the inferior vena cava wall motion for studies of right heart dynamics and function

Using subcostal echocardiography, 97 patients with diseases involving the right side of the heart and 15 normal subjects were examined in order to study the inferior vena cava (IVC) wall motion. All cases had a diagnostic cardiac catheterization and routine echocardiogram. The jugular pulse (JP) was recorded in 35 random cases contemporary to the IVC and tricuspid valve (TV) tracings. The aim of the study was to evaluate the variations of the IVC diameters in different cardiopathies and in relation to the right atrial mean pressure and the time-relationship of the IVC wall motion related to the cardiac rhythm and cycle, respiratory events, and JP and TV waves. The a, b, v, and y waves were identified on the IVC tracings and related to the respective waves of the JP and the points of closure and opening of the TV. The IVC a and v waves were coincident with the TV closure and opening, and therefore, considered as moments of maximal presystolic and systolic filling of the IVC. The JP a wave inscribed before, whereas the v wave did so after the same IVC waves, respectively. The IVC a wave was due to the atrial contraction and influenced by the cardiac rhythm. The emptying index (EI) was calculated from the diameters in a and b as a - b/a X %, whereas the collapsability index (CI) was calculated from the expiratory and inspiratory diameters as Ex - In/Ex X %, obtaining a good correlation with the right atrial mean pressure. Finally, the percentage systolic pulsation (SP) was calculated from the diameters in b and v as b - v/b X %. The indices of function of the IVC have been very useful in the evaluation of patients with raised heart pressure, tricuspid regurgitation, and pericardial effusion. From the present investigation it results that the IVC wall motion, more so than the JP waves, is an expression of right atrial and ventricular events, and that the above indices are an expression of the atrial and ventricular function in relation to the hemodynamic situation.     

Superior vena cava syndrome secondary to saphenous venous graft aneurysm with right atrial fistula.

Mega-aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare complications of bypass surgery. We report the development of superior vena cava syndrome secondary to an SVG mega-aneurysm with concomitant fistulous communication to the right atrium. Successful treatment was achieved by coil embolization and chronic anticoagulation.     

Incompetence of the internal jugular venous valve: spectrum of echo-Doppler appearances

The echocardiographic literature contains very scant reference to incompetence of the valve in the internal jugular vein. However, we found frequent Doppler evidence of such incompetence, especially in patients with congestive failure. This incompetence manifests as a variety of color Doppler and pulsed Doppler patterns, illustrated here in 3 patients.     

Duplex sonographic detection of internal jugular venous thrombosis after removal of central venous catheters

Venous thrombosis is a very common complication of central venous catheters inserted via the jugular or subclavian vein. The aim of this prospective study is to test the suitability of duplex sonography in detecting thrombi in the internal jugular vein after catheter removal and to analyze the number and extent of such thrombus formations. The study group comprised 64 consecutive patients with an average age of 59 ± 16 years admitted to an internal intensive care unit. In 54 cases the catheters were removed under sonographic control. In 10 cases duplex sonography was carried out within 24 h after removal of the catheters. The data of 63 patients were evaluated. In 40 patients (63.5%), thrombi of varying extent were present in the jugular vein. No significant correlations were found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization (therapeutic vs. low-dose). Local inflammation signs and local hematoma showed a significantly higher incidence (p < 0.01) in patients with thrombus formation. Duplex sonography lends itself as a valuable diagnostic tool in the diagnosis of thrombus formation in the internal jugular vein after removal of central venous catheters. Sonographic examinations should be carried out in all long-stay patients at an intensive care unit, in whom central venous catheters are inserted repeatedly via the internal jugular vein.     

Unusual collateral vessel from right subclavian vein to left atrium,a rare complication of superior vena cava obstruction

The most commonly reported collateral systems in the setting of superior vena cava obstruction are azygos venous system, vertebral venous system, external and internal thoracic venous system based on McLntire and Sykes classification. A 49‐year‐old female with renal disease complained dyspnea on exertion. Transesophageal echocardiography showed significant mitral annular calcification, large multi‐lobulated mass at posterior aspect of RA, and complete obstruction of superior vena cava by thrombus formation. Computed tomography angiography showed a collateral vein to the left atrium (LA) roof. This case report is the first one which shows development of collateral vein from right subclavian to LA.     

Usefulness of interatrial conduction time to distinguish between focal atrial tachyarrhythmias originating from the superior vena cava and the right superior pulmonary vein

Objective: Differentiation of the tachycardia originating from the superior vena cava (SVC) or the right superior pulmonary vein (RSPV) is limited by the similar surface P‐wave morphology and intraatrial activation pattern during tachycardia. We sought to find a simple method to distinguish between the two tachycardias by analyzing the interatrial conduction time. Methods: Sixteen consecutive patients consisting of 8 with SVC tachycardia and the other 8 with RSPV tachycardia were studied. The interatrial conduction time from the high right atrium (HRA) to the distal coronary sinus (DCS) and the intraatrial conduction time from the HRA to the atrial electrogram at the His bundle region (HIS) were measured during the sinus beat (SR) and during the tachycardia‐triggering ectopic atrial premature beat (APB). The differences of interatrial (Δ[HRA‐DCS]_SR‐APB) and intraatrial (Δ[HRA‐HIS]_SR‐APB) conduction time between SR and APB were then obtained. Results: The mean Δ[HRA‐DCS]_SR‐APB was 1.0 ± 5.2 ms (95% confident interval [CI]–3.3–5.3 ms) in SVC tachycardia and 38.5 ± 8.8 ms (95% CI 31.1–45.9 ms) in RSPV tachycardia. The mean Δ[HRA‐HIS]_SR‐APB was 1.5 ± 5.3 ms (95% CI –2.9–5.9 ms) in SVC tachycardia and 19.9 ± 12.0 ms (95% CI 9.9–29.9 ms) in RSPV tachycardia. The difference of Δ[HRA‐DCS]_SR‐APB between SVC and RSPV tachycardias was wider than that of Δ[HRA‐HIS]_SR‐APB (37.5 ± 9.3 ms vs. 18.4 ± 15.4 ms, P < 0.01). Conclusions: The wide difference of the interatrial conduction time Δ[HRA‐DCS]_SR‐APB between SVC and RSPV tachycardias is a useful parameter to distinguish the two tachycardias and may avoid unnecessary atrial transseptal puncture.     

Abnormal drainage of inferior vena cava to left atrium together with a partial abnormal pulmonary venous drainage to right atrium in the presence of atrial septal defect

The direct abnormal drainage of the inferior vena cava (IVC), while rare, is well‐recognized anomaly of systemic venous drainage. It has been reported both in isolation and in association with other cardiac defects. This is a case of an abnormal drainage of IVC into left atrium (LA) together with partial abnormal pulmonary venous drainage to the right atrium (RA) and atrium septal defect (ASD).     

Circadian blood pressure pattern and right ventricular and right atrial mechanics: A two- and three-dimensional echocardiographic study

The purpose of this investigation was to evaluate right ventricular (RV) and right atrial (RA) function and mechanics in untreated hypertensive patients with different blood pressure (BP) patterns by using two-dimensional (2DE) speckle tracking analyses and three-dimensional echocardiography (3DE). This cross-sectional study included 174 recently diagnosed hypertensive patients. All patients underwent a 24-hour ambulatory BP monitoring and complete 2DE and 3DE examination, including 2DE speckle tracking analysis. Our results showed that 2DE RV global longitudinal strain was significantly lower in the non-dippers. Similar results were obtained for 2DE RV systolic and early diastolic strain rate. The RA longitudinal strain, as well as RA systolic and early diastolic strain rate, was decreased in non-dippers. Our results revealed that 3DE RV end-diastolic and end-systolic volumes were increased, whereas 3DE RV ejection fraction was reduced in non-dipper hypertensive patients. Similar results were obtained for RA volumes and RA ejection fraction estimated by 2DE. Independent predictors of 3DE RV ejection fraction, 2DE RV and RA global longitudinal strain were left ventricular mass index and RV wall thickness. An additional independent predictor of the RV longitudinal strain was 3DE RV ejection fraction, and for RA longitudinal strain, an additional independent predictor was tricuspid E/é ratio. Two-DE speckle tracking evaluation and 3DE examination revealed that the RV and RA function and mechanics were more deteriorated in the non-dipper patients than in dipper untreated hypertensive patients.     

为左上腔静脉永存合并右上腔静脉缺如患者植入起搏导线

目的 对左上腔静脉永存合并右上腔静脉缺如患者的心室起搏导线植入方法作初步探讨,方法 为3例病态窦房结综合征,2例三度房室阻滞患者植入VVI起搏系统,导线经左上腔静脉、冠状静脉窦、右心房、三尖瓣口而固定于右心室心尖部（4例）或至心大静脉远段（1例）,靠近心外膜左缘。结果 5例患者的导线均成功放置分别随访3个月-7年,起搏功能良好。结论 对左上腔静脉存伴右上腔静脉缺如患者植入心脏起搏系统,通过适当地操作,一般可将导线定侠于右心室心尖部;而经冠状静脉窦作左心室心外膜起搏亦是可以选择的。     

Electrophysiologic characteristics of atrial tachycardia originating from the right pulmonary veins or posterior right atrium: double potentials obtained from the posterior wall of the right atrium can be useful to predict foci of atrial tachycardia in right pulmonary veins or posterior right atrium

INTRODUCTION: The right pulmonary veins (RPVs) and posterior wall of the right atrium (PRA) are anatomically located adjacent to each other. The aim of this study was to demonstrate the electrophysiologic characteristics of atrial tachycardia (AT) originating from the PRA or RPVs. METHODS AND RESULTS: A total of 26 consecutive patients with AT originating from the RPVs or PRA underwent detailed atrial endocardial mapping and successful radiofrequency catheter ablation. Eight foci were found in the PRA and 18 foci in the RPVs. Analysis of P wave configuration showed that lead V1 was the most helpful in distinguishing the AT foci between these two sites. In all cases, double potential (DP) configurations were recorded from several electrodes of a multielectrode catheter placed in the PRA, and the first DP component (FP) was the earliest potential recorded from the right atrium during the tachycardia. The amplitude of the FP was higher than that of the second DP component (SP) for AT foci originating in the PRA, whereas the reverse occurred for those in the RPV. The activation sequence of the FP was from superior to inferior for the AT foci in the superior RPV, whereas the reverse occurred for the AT foci in the inferior RPV. CONCLUSION: P wave configuration in lead V1 is helpful in distinguishing AT foci between those originating in the PRA and RPVs. The DPs obtained from the PRA can be useful in predicting whether AT foci originate from the PRA or RPVs.     

Persistent Left Superior Vena Cava and Absent Right Superior Vena Cava: Not Only an Anatomic Variant

Introduction:

A 71 year old asymptomatic woman came for an echocardiogram because of a left bundle branch block. A much dilated coronary sinus (CS) with an entering large vessel was found along with a mild left ventricular systolic dysfunction. Cardiac Magnetic Resonance (CMR) showed a persistent left superior vena cava (PLSVC), and an absent right superior vena cava (ARSVC). PLSVC drained into the dilated CS. No other cardiac abnormalities were found. Any late Gadolinium enhancement was also not seen. PLSVC and ARSVC are associated with sinus node and conduction tissue maldevelopment and atrial arrhythmias, and thus clinical follow up is indicated.

Conclusion:

CMR is a useful addition to echocardiogram to search for further cardiac abnormalities, and outline the anatomy with precision in doubtful cases.     

Diagnostic utility of ultrasonography in hepatic venous outflow tract obstruction in a tropical country

The present study was undertaken to define the role of ultrasonography (US) in screening and diagnosis of hepatic venous outflow tract obstruction. Forty-five consecutive patients clinically suspected to have hepatic venous outflow tract obstruction were included in the study for screening by US and for assessment of patency or block in the hepatic vein (HV) and/or inferior vena cava (IVC). Four patients were excluded from the study. Eleven patients had a diagnosis other than hepatic venous outflow tract obstruction and all these patients were found to have patent HV and IVC. Thirty patients were finally diagnosed to have hepatic venous outflow tract obstruction. Using US, as a screening test 27 (90%) out of 30 such cases were correctly identified as cases of hepatic venous outflow tract obstruction and in these cases the site of block in hepatic venous outflow tract (major HV and/or IVC) was correctly diagnosed in 90% of the cases. Our results indicate that US is a sensitive and accurate test and should be the initial investigation for screening and identifying the site of obstruction in patients with hepatic venous outflow tract obstruction.