CASE ANECDOTES, COMMENTS AND OPINIONS

Persistent left superior vena cava (PLSVC) is a congenital anomaly resulting from the failed regression of the left anterior cardinal vein and the left horn of the venous sinus. Its prevalence is 0.4% in the general population and as high as 13% in patients with congenital heart disease. 1 It is a benign anatomic anomaly but must be addressed during certain cardiac procedures. It is especially challenging in orthotopic heart transplantation (OHT), as either a surgical redirection or preservation of the PLSVC drainage is required. We present a surgical technique of rerouting the PLSVC to the right atrial appendage with bicaval OHT. A 64-year-old woman with non-ischemic cardiomyopathy with a history of mitral valve replacement underwent OHT. The presence of a PLSVC was diagnosed at the previous operation. The PLSVC drained into the coronary sinus, and there was an absence of the bridging vein connecting the right and left superior vena cava (SVC). After a median resternotomy, cardiopulmonary bypass was established with bicaval venous drainage from the right SVC and the inferior vena cava (IVC) and arterial return to the proximal aortic arch. After the aorta was clamped, the right atrium was opened, and pump suction with a pericardial sump (DLP 20Fr; Medtronic, Minneapolis, MN) was utilized in the coronary sinus for venous drainage of the PLSVC. The aorta, main pulmonary artery, right SVC and IVC were transected. The heart was excised at the left atrium leaving enough of a cuff to encompass the pulmonary veins. The PLSVC and coronary sinus were isolated from the atrioventricular groove as a long tubular conduit. Care was taken not to injure the PLSVC–coronary sinus conduit, and therefore part of the left atrial wall was left attached as part of the conduit (Figure 1A and B). It was neither necessary nor possible to ligate branches of the coronary veins draining into the coronary sinus during this dissection. The PLSVC was fully mobilized at the pericardial reflection to avoid possible kinking. A routine heart implantation was performed with the bicaval anastomosis technique. The