A 42-year-old male was admitted for radiofrequency ablation of atrial fibrillation (AF). He was diagnosed as AF 4 years ago and took anti-arrhythmic agent, beta blocker and anticoagulant. He had left side weakness due to cerebral infarction of right middle cerebral artery territory 3 years ago. He had a history of hypertension. His family had no history of diseases or congenital abnormality. He had no other symptoms but intermittent palpitation. His heart sound was irregular, but nothing particular was revealed on other physical and laboratory examinations. Double the shadow of thoracic aorta and widening state of superior mediastinum were shown in chest X-ray, but there were no other remarkable matters (Fig. 1). Initial electrocardiogram showed AF with moderate ventricular response (average 60-80 beats/min). On transthoracic and transesophageal echocardiography, no structural cardiac abnormalities were revealed. It seemed that hepatic vein was connected to right atrium through inferior vena cava (IVC) as usual. There was no pulmonary hypertension. We checked coronary multidirectional computed tomography (MDCT) to identify the anatomical variations of the patient's coronary vessels and heart before the ablation procedure. There was a tubular structure which was paralleling with descending thoracic aorta. It was supposed to be an IVC interruption with hemiazygos continuation (Fig. 2A). Hepatic veins were drained to right atrium. Abdomen computed tomography (CT) was performed to evaluate other combined abnormality. Multiple and round soft tissue densities were detected around the spleen, which were enhanced at the same degree of the spleen. Left-sided colon and right-sided small bowels indicated intestinal malrotation. IVC was located at the left side of aorta, and the hepatic segment of IVC was absent (Fig. 2B-D). By means of venography of IVC through right femoral vein, the interruption of the thoracic IVC with hemiazygos continuation along with aortic arch was confirmed (Fig. 3). All those findings were compatible with SAP.

A 52-year-old female was presented with a history of intermittent fever for a month. She had been DDDR-type pacemaker insertion state for last 8 months due to sick sinus syndrome. Her family history was non-specific. She had no other symptoms and signs of fever. Nothing specific was shown on her physical and laboratory examinations. Her chest X-ray showed no significant lesions, except gastric air detected under the right side of diaphragm and hepatic shadow in the left side abnormally (Fig. 4). Liver dynamic CT was checked to identify the anatomy of her abdominal organs. The symmetric liver and gallbladder with multiple sandy stones were midline. Multiple spleens and stomach were located at the right side of abdomen. Superior mesenteric vein was unusually located anterior to the superior mesenteric artery. The left-sided IVC was crossed the aorta at the level of diaphragm and drained into right atrium (Fig. 5). There was no intraabdominal lesion to develop fever. During hospitalization, methicillin resistant staphylococcus epidermidis was repeatedly incubated on blood cultures. She was referred us for an echocardiographic examination to find any evidence of infection in her heart. Echocardiogram revealed that large multiple mobile vegetations which were attached on the right ventricular pacemaker lead. The vegetations were prolapsed through the tricuspid valve, and the largest diameter of them was 20 mm. Coronary MDCT for the anatomical confirmation of vascular structure was checked before heart surgery. There was left-sided IVC, but no IVC interruption. She got surgery for removal of infected pacemaker lead and vegetation on tricuspid valve. After 4 weeks of antibiotics therapy, there was no longer pathogen growth in blood culture.