Through venous approach via right femoral vein, 7 French guiding catheter passed right atrium and innominate vein approaching to LSVC. The proximal and distal part of the LSVC were measured 9.8 and 9.6 mm, respectively by angiography (Fig. 3). The abnormal connection between LSVC and LSPV was closed

using the Amplatzer® Vascular Plug II (diameter = 12 mm; St. Jude Medical, St. Paul, MN, USA) (Fig. 4). After checked up size of PFO by sizing balloon, transcatheter PFO Inhibitors,research,lifescience,medical closure with Amplatzer® PFO occluder (diameter = 25 mm; St. Jude Medical, St. Paul, MN, USA) was also performed (Fig. 5). Follow-up echocardiogram showed complete occlusion of flow through the LSVC and PFO. Fig. 3 Angiogram. Abnormal connection of LSVC to left atrium was shown on angiogram. LSVC: left superior vena cava, LUPV: left upper pulmonary vein. Fig. 4 Abnormal drainage of left superior vena cava and left upper pulmonary vein was closed using the Amplatzer® vascular plug II. Fig. 5 Transcatheter PFO

closure with Amplatzer® PFO occluder. PFO: patent foramen ovale. Discussion Inhibitors,research,lifescience,medical In recent years, transthoracic echocardiogram (TTE) or transesophageal echocardiography in patients who have had TIA or stroke has become a routine assessment. Inhibitors,research,lifescience,medical A contrast echocardiography is usually performed by injecting microbubbles through the peripheral intravenous (IV) line, and acted the Valsalva maneuver to determine the presence of right-to-left shunting across the PFO. In our patient, the IV line was first started on the right arm and the contrast echocardiography was performed,

which proved the presence of PFO. On contrast echo conducted on Rt. Inhibitors,research,lifescience,medical arm, the enhancement was seen at not only Rt. side of heart, but also Lt. side. On careful review by an experienced doctor, small Inhibitors,research,lifescience,medical amount of direct flow into the LA was recognized. Another IV line was started on the left arm of the patient. The contrast echo was done as a same way on Lt. arm. On repeated contrast echocardiography, massive amount of microbubbles draining straight to LA was detected. Heart CT was performed to determine the precise LSVC drainage, resulting persistent LSVC persistent LSVC connection to LSPV was diagnosed. Incidence of persistent LSVC is 0.5% of the general population and increased to 4.3% in patients with congenital heart disease.6),7) Persistent LSVC draining into the coronary sinus and Histamine H2 receptor the right atrium is of no hemodynamic significance. But persistent LSVC draining directly or through an Epigenetic inhibitor unroofed coronary sinus into the left atrium represents the same risks as all other lesions with right-to-left shunt and forms a substrate for paradoxical embolism. If complications related to the right-to-left shunt occur, correction is indicated.8) In this case of our patient, relatively young age at the time of stroke development probably indicates that both PFO and persistent LSVC was the cause of paradoxical embolism.