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A 20-year-old man presented at the emergency department because of presyncope. Physical examination revealed a cardiac murmur located at the second left intercostal space, and therefore, a transthoracic echocardiography (TTE) was performed.

A tunnel-like structure was detected at the dorsal wall of the left atrium (LA) superior to the posterior mitral valve leaflet (Panel A: conventional TTE, Panel B: three-dimensional TTE). A transoesophageal echocardiography (TEE) was performed to further elucidate the possible cardiac reasons for the presyncope (e.g. thrombi, atrial septal defect) and to investigate the object in the LA more detail. In the TEE, the tubular structure running through the LA could be confirmed (Panels C and D). After administering contrast agent (CA) (Echovist®) through the left basilar vein, the tube was contrasted from distal and drained the CA into the right atrium (Panel E). This raised the suspicion of a persistent left superior vena cava (PLSVC). As some bubbles passed to the LA, a persistent foramen ovale was also diagnosed. To ensure the diagnosis and to rule out other congenital anomalies of the thoracic vessels, cardiac magnetic resonance imaging was performed, which confirmed the diagnosis of PLSVC (Panel F). Covered by a membrane of pericardium/myocardium, the PLSVC took its course through the LA, leading to the coronary sinus. As partial compression was evident during diastole, some blood was drained via collaterals to the spinal veins.

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