Coronary venous anatomy and anomalies

Coronary Sinus Ostial Atresia With Small Cardiac Vein Drainage Into Right Atrium: A Rare Case With an Unusual Drainage Pathway

This case report describes an 80-year-old man with a history of persistent atrial fibrillation. Echocardiography revealed a severely dilated coronary sinus without a normal opening at the coronary sinus ostium, which communicated with an unusual dilated small cardiac vein. Contrast echocardiography and coronary computed tomography angiography were then utilized for further evaluation. After multimodal imaging, this rare case was diagnosed as coronary sinus ostial atresia with an unusual small cardiac vein draining into the right atrium.

Cardiac venous system mapping for ventricular arrhythmia localization

The coronary venous system offers a route for mapping and ablation of ventricular arrhythmias with suspected epicardial or intramural origins. Coronary venous mapping helps the operator to select the best ablation approach, decide when percutaneous epicardial access may be necessary and provides an opportunity for therapeutic interventions, including radiofrequency application inside the coronary veins or ethanol infusion. In this article we review the anatomy of the coronary venous system, the scenarios in which coronary venous mapping can be helpful and the technical aspects involved in coronary venous mapping.

Clinical anatomy of the coronary venous system and relevance to retrograde cardioplegia and cardiac electrophysiological interventions

Anomalies of coronary venous system, the valve of the coronary sinus (Thebesian valve) and other cardiac malformations may make interventions through the coronary sinus difficult. These variants may pose a challenge in cannulating the coronary sinus for retrograde cardioplegia and for interventions performed through the coronary sinus by cardiac electrophysiologist/interventional cardiologist. Retrograde cardioplegia is an established method of myocardial protection with advantages, indications, and complications. A good knowledge of the anatomy of the coronary sinus and its variants is important in understanding the difficulties encountered while cannulating the coronary sinus for the delivery of retrograde cardioplegia, cardiac resynchronization therapy, treatment of arrhythmias, and percutaneous mitral valve annuloplasty.

Rare anomalous drainage of the great cardiac vein into superior vena cava

Anatomical variations in cardiac venous anatomy can occur. This case highlights an extremely rare anomaly of the great cardiac vein draining into the superior vena cava (SVC) depicted by computed tomography coronary angiography.

Small cardiac vein draining into the inferior vena cava

Cardiac venous anomalies are rare congenital anatomical anomalies, which are most commonly found on computed tomography scans as an accidental finding. We report a case of a 14-year-old child who was operated for an atrial septal defect, and during the operation, we came across an anomalous drainage of the small cardiac vein into the inferior vena cava. The child's postoperative course was uneventful.

An exceptional anomaly of the coronary venous drainage: anatomic description

BACKGROUND

Anomalies of the coronary sinus are rare in the general population but are more frequent in patients with congenital heart defects. Whatever the cardiac anatomy, the coronary sinus is invariably located in the left atrioventricular sulcus, inferior to the wall of the morphologically left atrium.

METHODS

A complete morphological examination of a fetal cardiac specimen of the M3C collection, according to segmental analysis, was performed by two observers.

RESULTS

We report here for the first time a cardiac specimen with a venous channel receiving the majority of coronary veins, located in the right atrioventricular sulcus and therefore inferior to the wall of the morphologically right atrium, in a fetal cardiac specimen with congenitally corrected transposition in situs solitus. In addition, the anatomy of the venous drainage of the heart was mirror-imaged to that observed in a normal heart and different compared to that usually observed in congenitally corrected transposition.

CONCLUSION

This very particular anatomy occurring in association with congenitally corrected transposition might be related with an additional disturbance in the laterality pathway.

Possibility to measure the volume of coronary sinus in contrast-enhanced computed tomography

Introduction

Modern imaging techniques such as computed tomography (CT) can help in the assessment of coronary sinus volume in a vitro manner, but there is no comprehensive research on this topic so far. Hence, we decided to develop a methodology for measuring the volume of the coronary sinus in multi-detector CT and to try to apply it in practice.

Material and methods

Forty-nine patients (22 men) were included in this research, with a mean age of 70.08 ± 13.6 years. Scanning with retrospective ECG-gating was performed using a Toshiba Aquilion 64 (slice: 0.5 mm; helical pitch: 12.8; rotation time: 0.4 s). 80 ± 20 cm3 of non-ionic contrast was administered to each patient. The volume of coronary sinus and other data measurements were performed using Vitrea 2 workstations. The organ volume measurement function was used to measure volume objects in CT scans. To standardise the measurements, they were all performed to the place where the vein of Marshall reaches the coronary sinus. In cases of loss of vein of Marshall, the first lateral vein was used as the junction between the coronary sinus and the great cardiac vein.

Results

The coronary sinus volume varied from 0.96 cm3 to 8.52 cm3. The average volume was 3.71 ± 1.64 cm3. There was a significant correlation between end diastolic volume and coronary sinus volume (r = 0.33, p = 0.02). In most cases the quality of visualisation was good - the average was calculated as 4.16 ± 0.87. The Thebesian valve was present in 22 cases (44.9%); however, no statistical relationship between the presence of the Thebesian valve and coronary sinus was observed.

Conclusion

It is possible to visualise and calculate the volume of the coronary sinus in cardiac CT.

Essential right heart physiology for the perioperative practitioner POQI IX: current perspectives on the right heart in the perioperative period

As patients continue to live longer from diseases that predispose them to right ventricular (RV) dysfunction or failure, many more patients will require surgery for acute or chronic health issues. Because RV dysfunction results in significant perioperative morbidity if not adequately assessed or managed, understanding appropriate assessment and treatments is important in preventing subsequent morbidity and mortality in the perioperative period. In light of the epidemiology of right heart disease, a working knowledge of right heart anatomy and physiology and an understanding of the implications of right-sided heart function for perioperative care are essential for perioperative practitioners. However, a significant knowledge gap exists concerning this topic. This manuscript is one part of a collection of papers from the PeriOperative Quality Initiative (POQI) IX Conference focusing on "Current Perspectives on the Right Heart in the Perioperative Period." This review aims to provide perioperative clinicians with an essential understanding of right heart physiology by answering five key questions on this topic and providing an explanation of seven fundamental concepts concerning right heart physiology.

Myocardial Blood Flow Determination From Contrast-Free Magnetic Resonance Imaging Quantification of Coronary Sinus Flow

BACKGROUND

Determination of myocardial blood flow (MBF) with MRI is usually performed with dynamic contrast enhanced imaging (MBFDCE ). MBF can also be determined from coronary sinus blood flow (MBFCS ), which has the advantage of being a noncontrast technique. However, comparative studies of MBFDCE and MBFCS in large cohorts are lacking.

PURPOSE

To compare MBFCS and MBFDCE in a large cohort.

STUDY TYPE

Prospective, sequence-comparison study.

POPULATION

147 patients with type 2 diabetes mellitus (age: 56+/-12 years; 106 male; diabetes duration: 12.9+/-8.1 years), and 25 age-matched controls.

FIELD STRENGTH/SEQUENCES

1.5 Tesla scanner. Saturation recovery sequence for MBFDCE vs. phase-contrast gradient-echo pulse sequence (free-breathing) for MBFCS .

ASSESSMENT

MBFDCE and MBFCS were determined at rest and during coronary dilatation achieved by administration of adenosine at 140 μg/kg/min. Myocardial perfusion reserve (MPR) was calculated as the stress/rest ratio of MBF values. Coronary sinus flow was determined twice in the same imaging session for repeatability assessment.

STATISTICAL TESTS

Agreement between MBFDCE and MBFCS was assessed with Bland and Altman's technique. Repeatability was determined from single-rater random intraclass and repeatability coefficients.

RESULTS

Rest and stress flows, including both MBFDCE and MBFCS values, ranged from 33 to 146 mL/min/100 g and 92 to 501 mL/min/100 g, respectively. Intraclass and repeatability coefficients for MBFCS were 0.95 (CI 0.90; 0.95) and 5 mL/min/100 g. In Bland-Altman analysis, mean bias at rest was -1.1 mL/min/100 g (CI -3.1; 0.9) with limits of agreement of -27 and 24.8 mL/min/100 g. Mean bias at stress was 6.3 mL/min/100 g (CI -1.1; 14.1) with limits of agreement of -86.9 and 99.9. Mean bias of MPR was 0.11 (CI: -0.02; 0.23) with limits of agreement of -1.43 and 1.64.

CONCLUSION

MBF may be determined from coronary sinus blood flow, with acceptable bias, but relatively large limits of agreement, against the reference of MBFDCE .

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Control of coronary vascular cell fate in development and regeneration

The coronary vasculature consists of a complex hierarchal network of arteries, veins, and capillaries which collectively function to perfuse the myocardium. However, the pathways controlling the temporally and spatially restricted mechanisms underlying the formation of this vascular network remain poorly understood. In recent years, the increasing use and refinement of transgenic mouse models has played an instrumental role in offering new insights into the cellular origins of the coronary vasculature, as well as identifying a continuum of transitioning cell states preceding the full maturation of the coronary vasculature. Coupled with the emergence of single cell RNA sequencing platforms, these technologies have begun to uncover the key regulatory factors mediating the convergence of distinct cellular origins to ensure the formation of a collectively functional, yet phenotypically diverse, vascular network. Furthermore, improved understanding of the key regulatory factors governing coronary vessel formation in the embryo may provide crucial clues into future therapeutic strategies to reactivate these developmentally functional mechanisms to drive the revascularisation of the ischaemic adult heart.

The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance

Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.

A novel therapy in microvascular obstruction in ST-elevation myocardial infarction: pressure-controlled intermittent coronary sinus occlusion therapy

Percutaneous coronary intervention has transformed the management of ST-elevation myocardial infarction (STEMI) due to a reduction in early mortality and need for repeat revascularization. However, the conventional revascularization strategy, combined with state-of-the-art anti-thrombotic and antiplatelet therapies, can still be associated with poor clinical outcome in some patients, because of reperfusion injury and microvascular obstruction contributing to the infarct size. To address this important therapeutic need, a broad-range of device-based treatments have been introduced. This is an overview of the pressure-controlled intermittent coronary sinus occlusion (PiCSO) device (Miracor Medical SA) which has been proposed for STEMI patients. PiCSO therapy could lead to an improved perfusion, decrease microvascular dysfunction, and thus potentially reduce infarct size.

Cor Triatriatum Dexter Associated with an Ostium Primum Atrial Defect and Left-Sided Opening of the Coronary Sinus in a Stillborn Fetus

Cor triatriatum is a very rare cardiac malformation characterized by the presence of an abnormal interatrial membrane separating either the left or right atrial chamber into two compartments. It can be associated with other cardiac defects and is often symptomatic in childhood. The signs depend on the size and position of the interatrial membrane and other associated malformations. Here we report a case of right-sided cor triatriatum associated with an ostium primum-type interatrial septum defect and left-sided opening of the coronary sinus in a fetus. The cause of intrauterine death was asphyxia due to total placental abruption.

Contrast removal from coronary sinus for prevention of contrast-induced nephropathy: a review

The occurrence of contrast-induced-nephropathy (CIN) is related to the amount of contrast administration. Any removal of contrast from systemic circulation before reaching the kidneys might be beneficial using a device that removes contrast from a coronary sinus (CS). This manuscript aims to review the available literature regarding contrast removal from CS during coronary angiography or intervention for the prevention of CIN.

Echocardiographic imaging of a bifurcated double barrel coronary sinus

BACKGROUND

The coronary sinus (CS) is the terminal collecting vessel of the myocardial venous network, which returns deoxygenated blood used by the heart to the right atrium. The advent of high-fidelity imaging via CT and transesophageal echocardiography (TEE) has further defined the anatomy of the CS and its multiple tributaries. Understanding this anatomy is crucial for cardiac surgical cases that require the cannulation of the coronary sinus to deliver retrograde cardioplegia. However, anatomical variants of the CS may frustrate surgical retrograde catheter placement, in turn increasing the risk of CS injury or leading to inadequate cardioplegia delivery. Here, we present an especially unique CS presentation, a bifurcated, double-barrel CS, which was discovered via intraoperative TEE imaging that revealed a CS with two smaller lumens instead of the singular large os.

CASE PRESENTATION

A 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.

CONCLUSIONS

Discovery of this patient's double-barrel CS during the pre-bypass TEE was incidental, showing that such anatomical variants may be completely asymptomatic and benign in the non-operative setting. However, the delivery of cardioplegia proved challenging for this patient, highlighting some degree of risk with certain cardiac interventions. This case demonstrates the utility of intraoperative TEE to quickly ascertain unforeseen anatomical variants of the CS which could compromise the safety of cardiac surgery cases.

Management of noncerebral malperfusion complicating acute type A dissection

Vital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second-look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.

Transcatheter Coronary Sinus Interventions

The coronary sinus has become a popular route for an increasing number of innovative transcatheter interventions to treat coronary and structural heart diseases. However, interventional cardiologists have limited experience with the cardiac venous system and its highly variable anatomy. In this paper, we review the anatomy of the cardiac veins as it relates to transcatheter interventions. We also provide a contemporary overview of the emerging coronary sinus-based transcatheter therapies and their growing literature.

Morphometry of the Great Cardiac Vein in Cadaveric Hearts of South Indian Origin

Introduction

In recent years, rapid developments in procedures like cardiac pacing, targeted drug therapy, and trans coronary venous ablation have necessitated a need for a detailed study of cardiac venous anatomy. Because the number, diameter, and course of the coronary veins vary, extensive information on the patient's specific anatomy is required for the best planning of the treatment. With this background, we planned the current research to analyze the anatomy of the great cardiac vein (GCV) in terms of length and diameter, provide a formula for calculating diameter using linear regression analysis and report the frequency of formation of the triangle of Brocq and Mouchet.

Methods

We conducted this cross-sectional study on fifty-two adult human cadaveric hearts of South Indian origin collected during dissection classes for undergraduate medical students. We measured the GCV's length and diameter and applied the linear regression analysis to derive a formula for estimating the diameter of the GCV. We also noted the frequency of formation of the triangle of Brocq and Mouchet and presented it as a percentage.

Results

The mean length and width of the GCV were 67.77 mm and 2.76 mm, respectively. The formula obtained after linear regression analysis for calculating the diameter of the GCV was: the diameter of GCV=0.0089 (length of GCV vein) ± 2.147. The triangle of Brocq and Mouchet with GCV as the base was present in 97% of the hearts.

Conclusion

The length and diameter of the GCV reported in the current study were considerably lesser than the reported findings in the literature. These findings suggest significant variations in the anatomy of the cardiac veins and call for further research on the anatomy of cardiac veins.

Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance

The left ventricular summit (LVS) is a triangular area located at the most superior portion of the left epicardial ventricular region, surrounded by the two branches of the left coronary artery: the left anterior interventricular artery and the left circumflex artery. The triangle is bounded by the apex, septal and mitral margins and base. This review aims to provide a systematic and comprehensive anatomical description and proper terminology in the LVS region that may facilitate exchanging information among anatomists and electrophysiologists, increasing knowledge of this cardiac region. We postulate that the most dominant septal perforator (not the first septal perforator) should characterize the LVS definition. Abundant epicardial adipose tissue overlying the LVS myocardium may affect arrhythmogenic processes and electrophysiological procedures within the LVS region. The LVS is divided into two clinically significant regions: accessible and inaccessible areas. Rich arterial and venous coronary vasculature and a relatively dense network of cardiac autonomic nerve fibers are present within the LVS boundaries. Although the approach to the LVS may be challenging, it can be executed indirectly using the surrounding structures. Delivery of the proper radiofrequency energy to the arrhythmia source, avoiding coronary artery damage at the same time, may be a challenge. Therefore, coronary angiography or cardiac computed tomography imaging is strongly recommended before any procedure within the LVS region. Further research on LVS morphology and physiology should increase the safety and effectiveness of invasive electrophysiological procedures performed within this region of the human heart.

Temporal changes of the diameter of the coronary sinus during the cardiac cycle

INTRODUCTION

Currently, there are no studies that analyse the changes in the cardiac venous system that are dependent on the phase (RR interval) of reconstruction. The aim of the study was to assess the size of the coronary sinus at two measurement sites depending on the phase of the heart cycle.

METHODS

Fifty patients were included. Cardiac computed tomography was performed in all of the patients due to a suspicion of coronary artery disease (typical indications) using a dual-source Siemens Somatom Force scanner. The "MM reading" presets were used to measure the coronary sinus ostium (measurement 1) and the coronary sinus trunk, which is close to the great cardiac vein (measurement 2) in millimetres. All of the calculations were performed on axial scans using 0%-100% and a 256 × 256 matrix.

RESULTS

The largest CS was found at the 30%, 40% and 50% RR interval-this phenomenon occurred in 37 of the 50 cases (74%). The CS was largest in the 30% phase (9/50 cases; 18%), in the 40% phase (17/50 cases; 34%) and in the 50% phase, and it was the largest in 11 of the 50 cases (22%). There were also no gender-related differences.

CONCLUSIONS

The size of the coronary sinus varies with the phase of the heart cycle. At the 40% phase, it is largest in most cases.

Rotational Atherectomy Induced Coronary Perforation of Right Coronary Artery Draining into Middle Cardiac Vein

Ellis Type III cavity spilling coronary perforation is a rare complication. We report to our knowledge, the first case of rotational atherectomy induced Type III cavity spilling coronary perforation of right posterior descending artery draining into middle cardiac vein, successfully managed by covered stent deployment. (Level of Difficulty: Advanced.)