title: Right-to-left anatomic shunt associated with a persistent left superior vena cava: the importance of injection site in demonstrating the shunt.
abstract: Anatomic right-to-left shunt causes hypoxemia that can pose a diagnostic challenge to clinicians. Among the many possible causes of right-to-left shunt, persistent left-sided superior vena cava (PLSVC) with an "unroofed" coronary sinus represents an uncommon congenital anomaly in which detection by saline-contrast echocardiogram (bubble echo) or contrast-enhanced CT scan requires injection of contrast in the left arm. We present the case of an elderly man with hypoxemia on the basis of a right-to-left shunt accompanying a PLSVC with unroofed coronary sinus in whom the shunt escaped initial detection following a bubble echo with contrast injected into the right arm. This case reminds pulmonary clinicians, who are frequently called on to assess the cause of hypoxemia, that specifying a contrast injection into the left arm is required in the pursuit of this specific shunt-producing anomaly.
authors: Pulmonary, Critical Care and Sleep Medicine Division, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors: Nandhitha N
authors: NN
authors: Thaiyananthan
authors: Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors: Frank J
authors: FJ
authors: Jacono
authors: Cleveland Louis Stokes Veterans Affairs Medical Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors: Sanjay R
authors: SR
authors: Patel
authors: Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors: Jeffrey A
authors: JA
authors: Kern
authors: Lerner College of Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH. Electronic address: stollej@ccf.org.
authors: James K
authors: JK
authors: Stoller
mesh_terms: D000015:Abnormalities, Multiple / Q000000981:diagnostic imaging* / Q000503:physiopathology; D000369:Aged, 80 and over; D000792:Angiography; D003287:Contrast Media / Q000494:pharmacology*; D003330:Coronary Vessel Anomalies / Q000000981:diagnostic imaging* / Q000503:physiopathology; D018450:Disease Progression; D004452:Echocardiography / Q000379:methods; D017809:Fatal Outcome; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D000860:Hypoxia / Q000175:diagnosis / Q000209:etiology; D008297:Male; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000628:therapy; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed; D014683:Vena Cava, Superior / Q000002:abnormalities*
chemical_list: D003287:Contrast Media