Levoatriocardinal Vein With Partial Anomalous Venous Return and a Bidirectional Shunt

A 52-year-old woman with a history of systemic lupus erythematosus presented to our institution with nonhealing ulcers on her left lower extremity and toes. She had no cardiac symptoms, with a normal ECG and chest radiograph (Figures 1 and 2). As part of her evaluation she underwent a transesophageal echocardiogram to look for endocarditis, which demonstrated a right-to-left shunt with Valsalva that appeared to originate from the vicinity of the lateral aspect of the left atrium (Movie I in the online-only Data Supplement). There was also a vascular structure seen adjacent to the aorta that typically would represent a remnant of the cardinal vein, such as a persistent left superior vena cava. There were no findings of endocarditis.Figure 1. ECG with normal sinus rhythm.Figure 2. Chest radiograph demonstrates normal heart size and pulmonary vascularity.A magnetic resonance angiogram was performed to further evaluate the origin of the right-to-left shunt and demonstrated a levoatriocardinal vein that drained the left upper lobe …