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Background: Multiple levels of inter-atrial shunting can rarely present late in life with dyspnea and embolic stroke from effects of bidirectional shunting.

Case: A 55-year-old male with history of a patent foramen ovale, atrial fibrillation and embolic stroke presented with worsening fatigue and dyspnea at rest. Echocardiogram showed mildly reduced ventricular function with severe right heart dilation. On transesophageal echo, the coronary sinus (CS) was severely dilated with a persistent left superior vena cava (LSVC). A stress test showed no perfusion defects. CT angiography showed an absence of right SVC and a single LSVC connecting to the CS. There was partial anomalous pulmonary venous connection of the left upper pulmonary vein to the LSVC. The left lower pulmonary veins connected to the left atrium (LA) but largely drained indirectly to the right atrium via a defect at the LSVC-CS junction. The right pulmonary veins returned normally to the LA.

Decision‐making: Catheterization revealed pulmonary overcirculation with pulmonary to systemic flow ratio [Qp:Qs] of 2:1. Surgery was preferred over percutaneous intervention for the repair of atrial septal defects and redirection of left upper pulmonary venous return to the left atrial appendage. The patient improved significantly following surgery.

Conclusion: Multimodality imaging can help accurately diagnose venous anomalies and create three-dimensional models instrumental in procedural/surgical planning.




Presented at American College of Cardiology’s 70th Annual Scientific Session, May 15-17, 2021, in Atlanta, Georgia.

Not-so-apparent Mixing Lesions: Late Presentation Of Cardioembolic Stroke

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