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A 33-year-old woman with a history of brain abscess 4 years earlier was admitted with an infected cranial bone flap requiring surgical debridement. Four days postoperatively she was found collapsed, presumed secondary to a seizure. She was resuscitated but developed severe aspiration pneumonia. Systemic pressures were recorded from a left internal jugular line, and a chest x ray (panel A) suggested that it had passed via a persistent left superior vena cava (SVC) into the left atrium and ventricle and into the ascending aorta. The diagnosis was confirmed by echocardiography: intravenous agitated saline contrast from the left arm showed immediate opacification of the left heart (panel B). She died from multiorgan failure 24 h later. Postmortem examination confirmed this isolated anomaly.
Right to left shunts predispose to cerebral abscess. A left SVC draining directly to the left atrium is a rare cause of right to left shunt (<5:100 000 of the general population).
This case highlights two very important clinical issues. Firstly, a brain abscess in the absence of an obvious precipitating cause should prompt a search for a right to left shunt with saline contrast echocardiography. Secondly, saline contrast studies should be performed from the left and not the right arm, to prevent overlooking a persistent left SVC to left atrium communication.
This article has been adapted from Hirth A, Disney P, Thorne S. Brain abscess associated with an unusual cause of right to left shunt Heart 2007;93:34
Competing interests: None.
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