Levo atrio-cardinal vein

Trans-catheter closure of a rare cause of pre-tricuspid left-to-right shunt: A “double” levoatriocardinal vein without left heart obstructive lesions

1. Levo-atrio-cardinal vein A pre-tricuspid shunt needs closure

2. Parasagittal magnetic resonance angiography reconstruction (A) and posterior view of three-dimensional volume rendering reconstruction (B). The anterior levoatriocardinal vein connects (*) directly the left atrium and the superior vena cava. The posterior levoatriocardinal vein (**) arises from the right upper pulmonary vein (at level of left atrium junction) draining to the superior vena cava. IVC, inferior vena cava; LA, left atrium; RA, right atrium; RPA, right pulmonary artery; RUPV, right upper pulmonary vein; SVC, superior vena cava.

3. History In 1926, McIntosh et al. described the first report about an anomalous vessel connecting the left atrium and the upper systemic vein system in a patient with cor triatriatum In 1950, Edwards and DuShane named “ levoatrio -cardinal vein” a physiological left atrial decompression through a venous connection with the left innominate vein

4. Embryologically Embryologically, the pulmonary veins develop from a capillary plexus around the embryonic foregut while the superior vena cava develops from the anterior cardinal veins. However, the capillary plexus of the embryonic esophagus builds some vascular connections with vessels of the anterior cardinal system. The fate of these vessels is the spontaneous obliteration as soon as the primitive pulmonary veins establish a connection with the left atrium.

5. Embryology However, concomitant left-sided heart obstructions may keep these vascular connections (named levoatriocardinal veins) patent with consequent decompression of the left-sided cardiac chambers. Two anatomic patterns of levoatriocardinal vein are described: a direct communication between the left atrium and the cardinal venous system (the most frequent), and a communication between a pulmonary vein and the cardinal venous system. Furthermore, a connection is feasible both with the right superior vena cava as well as with the left innominate vein. In 1995, Bernstein et al. [5] described the largest series of patients with levoatriocardinal vein and every patient showed only one levoatriocardinal vein

6. Treatment If it is associated with left sided obstructive lesion like mitral atresia ,cortriatriatum or HPLHS ,then address primary lesion first If not associated with left sided obstructive lesion ,percutaneous closure is enough to stop left to right pre tricuspid shunt

7. Reference https://doi.org/10.1016/j.jccase.2020.09.002