Angiographic anatomy of the coronary sinus and its tributaries

Vein of Marshall Ethanol Infusion for AF Ablation; A Review

The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall 'ethanolisation' to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique.

Coronary Sinus Defect, Premature Restriction of Foramen Ovale and Cysto-Colic Peritoneal Band

Background: Unroofed coronary sinus is a congenital cardiac anomaly usually associated with persistent left superior vena cava. Premature restriction or closure of foramen ovale is described in association with hypoplastic left heart syndrome. Abdominal peritoneal bands when present manifest clinically. Case report: A 27 years, gravida 2, presented with intrauterine fetal death at 24 weeks gestation due to fetal congestive cardiac failure, cardiomegaly and hydrops. Perinatal autopsy showed absent coronary sinus with cardiac veins draining directly into the heart. There was no persistent left superior vena cava. The foramen ovale was restricted prematurely. The ductus arteriosus was present and non-restrictive. Abdomen showed a cysto-colic peritoneal band. Conclusion: This is the first report showing a triad of (1) complete absence of coronary sinus without left superior vena cava (type-II); (2) premature restriction of foramen ovale without hypoplastic left heart; and (3) a cysto-colic peritoneal band between the gall bladder and colon.

Acute ST-Segment Elevation Myocardial Infarction as a Rare Postoperative Complication of Biventricular Implantable Cardioverter-Defibrillator Placement

We present a rare case of an 84-year-old woman who suffered an acute ST-segment elevation myocardial infarction as a postoperative complication of biventricular implantable cardioverter-defibrillator placement, caused by the left ventricular lead impinging onto the second obtuse marginal artery. (Level of Difficulty: Intermediate.)

Neuropeptide-Y Levels in ST-Segment-Elevation Myocardial Infarction: Relationship With Coronary Microvascular Function, Heart Failure, and Mortality

Background

The sympathetic cotransmitter, neuropeptide Y (NPY), is released into the coronary sinus during ST‐segment–elevation myocardial infarction and can constrict the coronary microvasculature. We sought to establish whether peripheral venous (PV) NPY levels, which are easy to obtain and measure, are associated with microvascular obstruction, myocardial recovery, and prognosis.

Methods and Results

NPY levels were measured immediately after primary percutaneous coronary intervention and compared with angiographic and cardiovascular magnetic resonance indexes of microvascular function. Patients were prospectively followed up for 6.4 (interquartile range, 4.1–8.0) years. PV (n=163) and coronary sinus (n=68) NPY levels were significantly correlated (r=0.92; P<0.001) and associated with multiple coronary and imaging parameters of microvascular function and infarct size (such as coronary flow reserve, acute myocardial edema, left ventricular ejection fraction, and late gadolinium enhancement 6 months later). We therefore assessed the prognostic value of PV NPY during follow‐up, where 34 patients (20.7%) developed heart failure or died. Kaplan‐Meier survival analysis demonstrated that high PV NPY levels (>21.4 pg/mL by binary recursive partitioning) were associated with increased incidence of heart failure and mortality (hazard ratio, 3.49 [95% CI, 1.65–7.4]; P<0.001). This relationship was maintained after adjustment for age, cardiovascular risk factors, and previous myocardial infarction.

Conclusions

Both PV and coronary sinus NPY levels correlate with microvascular function and infarct size after ST‐segment–elevation myocardial infarction. PV NPY levels are associated with the subsequent development of heart failure or mortality and may therefore be a useful prognostic marker. Further research is required to validate these findings.

Study of coronary sinus anatomy during levophase of coronary angiography

BACKGROUND

Coronary sinus (CS) imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular (LV) pacing during cardiac resynchronization therapy (CRT). Retrograde venogram is the current standard for imaging CS and its tributaries.

AIM

To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.

METHODS

In this prospective observational study, 164 patients undergoing routine coronary angiography for various indications (Chronic stable angina-44.5%, acute coronary syndrome- 39.5%, Dilated cardiomyopathy-11%, atypical chest pain-5%) were included. Venous phase (levophase) of left coronary injection was recorded in left anterior oblique - cranial and right anterior oblique -cranial views. Visibility of coronary veins, width and shape of CS ostium, angulations of proximal CS with body of CS were noted. Presence, size, take-off angle and tortuosity of posterolateral vein (PLV), anterior interventricular veins (AIV) and middle cardiac vein (MCV) were also noted.

RESULTS

During levophase, visibility grade (Muhlenbruch grade) for coronary veins was 3 in 74% and 2 in 26% of cases. Visibility of CS did not correlate with body mass index. The diameter of CS ostium was < 10 mm, 10-15 mm and > 15 mm in 48%, 42% and 10% of patients respectively. Proximal CS was tubular in 136 (83%) patients and funnel-shaped in 28 (17%) patients. Sharp take-off angulation between ostium and body of CS was seen in 16 (10%) patients. Two or more PLV were present in 8 patients while PLV was absent in 52 (32%) patients. Angle of take-off of PLV with body of CS was favourable (0°-45°) in 65 (40%) patients. The angle was 45°-90° in 36 patients and difficult take-off angle (> 90°) was seen in 8 patients. Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases. There was no tortuosity in 79 cases, a single bend in 29 cases and more than 2 bends in 4 cases. Thirty nine (24%) patients had other veins supplying posterior/Lateral wall of LV. There was a single vein supplying lateral/posterior wall in 31 (19%) patients. Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV.

CONCLUSION

Levophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.

Retrograde venography and three-dimensional mapping of a great cardiac vein with separate drainage into the high right atrium in a patient with Wolf-Parkinson-White syndrome

A 13-year-old boy presenting with palpitations was diagnosed with Wolf-Parkinson-White syndrome. We elected to bring him to the electrophysiology lab for evaluation of the accessory pathway and potential ablation. Structural assessment of the coronary sinus with electro-anatomical mapping and retrograde venography led to the discovery of a great cardiac vein having a separate insertion from the coronary sinus into the high right atrium. The accessory pathway was localized to the left lateral portion of the mitral annulus and treated successfully with radiofrequency ablation. Such venous anatomical variant has been seldom reported, and its association with an accessory pathway is described here for the first time. Its recognition can have important implications when performing procedures that require access into the coronary venous system.

Blood gas analysis of the coronary sinus in patients with heart failure

The difference in cardiac oxygen consumption between individuals with normal cardiac function and those with heart failure (HF), and the association between cardiac oxygen consumption and cardiac ejection fraction (EF) are poorly understood. By establishing a control group composed of individuals with normal cardiac function, the present study aimed to determine the difference in cardiac oxygen consumption between individuals with normal and abnormal cardiac function, as well as the association between cardiac oxygen consumption and cardiac EF. A total of 34 patients with normal cardiac function were enrolled in the control group and 44 patients with HF were enrolled in the experimental group. Blood samples from the aortic root, femoral vein and coronary sinus (CS) were collected from each patient. All the blood samples were subjected to blood gas analysis. The partial pressure of oxygen and oxygen saturation obtained from the peripheral vein and CS of patients with HF were lower than those in patients with normal cardiac function. In each patient with HF, the association between cardiac oxygen consumption and cardiac EF was analyzed using multi-linear correlation and regression analyses. Cardiac oxygen consumption negatively correlated with cardiac EF (R=-0.336, P=0.026). Furthermore, linear regression analysis suggested that cardiac EF had a significant effect on cardiac oxygen consumption (y = 82.906-0.483×, P=0.026). In conclusion, myocardial oxygen consumption is greater in individuals with HF compared to those with normal cardiac function. The cardiac EF affects myocardial oxygen consumption in patients with HF.

Planning and guidance of cardiac resynchronization therapy-lead implantation by evaluating coronary venous anatomy assessed with multidetector computed tomography

OBJECTIVES

We sought to evaluate the utility of multidetector computed tomography (MDCT) in preoperative planning of cardiac resynchronization therapy (CRT) device implantation.

BACKGROUND

Variation in coronary venous anatomy can affect optimal lead placement and may warrant preimplantation visualization prior to CRT lead placement.

METHODS

Prospective randomized enrollment of 29 patients (17 males; mean age at implant 66.7 ± 12.8 years) was undertaken. Patients were randomized to preimplantation MDCT (GE^® 64-detector Lightspeed, n = 16) or no MDCT. Implantation was planned based on three-dimensional coronary venous reconstruction as visualized in the CT group. Measurement of coronary sinus (CS) angulation, CS ostial (os) diameter, right atrial (RA) width, volume, and height was undertaken prior to implant. Intraoperative CS lead implantation times (introduction, cannulation, and left ventricular [LV] lead positioning), procedure time, fluoroscopy time, and venogram contrast volume were measured to determine if there was a difference between patients who underwent preimplant CT scan and those who did not.

RESULTS

CS os diameter (mean = 13.8 ± 2.9 cm) was inversely correlated with total fluoroscopy time (r = −0.57, P = .008), and total procedure time, but this correlation was not statistically significant (r = −0.36, P = 0.12). RA width (mean = 52.8 ± 9.9 cm) was associated with a shorter total procedure time (r = −0.44, P = .047) and LV lead positioning time (r = −0.33, P = .012). There were no statistically significant differences between the CT group and the non-CT group with respect to total intraoperative and fluoroscopy times or venogram contrast volumes. Total procedure time was longer in the CT group but the difference was not statistically significant (94 ± 27.2 vs. 74.7 ± 26.6; P = .065).

CONCLUSION

Noninvasive visualization of the coronary venous anatomy before CRT implantation can be used as a guide for lead placement. While no significant differences were noted between the two groups with respect to intraoperative variables, CS os diameter and RA width inversely correlated to a shorter procedure time and LV lead positioning time, respectively. Further clinical trials regarding the utility of MDCT to visualize coronary venous anatomy prior to CRT implantation for procedural planning and lead placement guidance are warranted.

Normal anatomy and variants of the venous cardiac system in MDCT coronary angiography

Three separate venous systems drain the blood returning from the heart walls. These veins are characterised by remarkable variability in terms of frequency, size and course. The knowledge of cardiac venous anatomy is of primary importance during interventional cardiac procedures that require catheterisation of cardiac veins. Some anatomical variants may hinder or contraindicate access to target veins. Coronary angiography (CA) with multidetector computed tomography (MDCT-CA) and multiplanar reformations (MPR), maximum intensity projection (MIP) and 3D reconstructions provides noninvasive visualisation of normal cardiac veins and anatomical variants. The purpose of this pictorial review is to describe by MDCT-CA the anatomy and main variants of the cardiac venous system.

Human coronary venous anatomy: implications for interventions

The coronary venous system is a highly variable network of veins that drain the deoxygenated blood from the myocardium. The system is made up of the greater cardiac system, which carries the majority of the deoxygenated blood to the right atrium, and the smaller cardiac system, which drains the blood directly into the heart chambers. The coronary veins are currently being used for several biomedical applications, including but not limited to cardiac resynchronization therapy, ablation therapy, defibrillation, perfusion therapy, and annuloplasty. Knowledge of the details of the coronary venous anatomy is essential for optimal development and delivery of treatments using this vasculature. This article is part of a JCTR special issue on Cardiac Anatomy.

Imaging of the coronary sinus: normal anatomy and congenital abnormalities

Knowledge of the anatomy of the coronary sinus (CS) and cardiac venous drainage is important because of its relevance in electrophysiologic procedures and cardiac surgeries. Several procedures make use of the CS, such as left ventricular pacing, mapping and ablation of arrhythmias, retrograde cardioplegia, targeted drug delivery, and stem cell therapy. As a result, it is more important for physicians interpreting the results of computed tomographic (CT) examinations dedicated to the heart or including the heart to be able to identify normal variants and congenital anomalies and to understand their clinical importance. Abnormalities of the CS range from anatomic morphologic variations to hemodynamically significant anomalies such as an unroofed CS, anomalous pulmonary venous connection to the CS, and coronary artery-CS fistula. It can be important to identify some anatomic variations, even though they are clinically occult, to ensure appropriate preprocedural planning. Both CT and magnetic resonance imaging provide excellent noninvasive depiction of the anatomy and anomalies of the CS. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.324105220/-/DC1.

Variance in coronary venous anatomy: a critical determinant in optimal candidate selection for cardiac resynchronization therapy

BACKGROUND

Knowledge of coronary sinus (CS) anatomy and its variations is one of the important factors determining the final position of left ventricle pacing lead during cardiac resynchronization therapy.

METHODS

Coronary venous system anatomy, including number, diameter, and opening angles of tributaries, was studied in 50 normal formalin-fixed adult cadaveric hearts.

RESULTS

Thebesian valve (TV) and Vieussens valve were present in 64% and 60% cases, respectively. CS ostium coverage of ≥75% by TV was seen in 25% (8/32) cases. Number of prominent tributaries lying between anterior interventricular vein and middle cardiac vein varied from 1-4. In 28% of hearts, only one prominent tributary was present. Midlateral vein (average diameter 1.75 ± 0.66 mm) with an average distance of 43.5 ± 12.2 mm from coronary ostium was present in 58% (29/50) hearts, of which it formed an acute angle with CS axis in four (13.39%) cases. Posterolateral vein (average diameter 1.62 ± 0.45 mm) with an average distance of 33.4 ± 11.7 mm from coronary ostium was found in 72% (36/50) cases and formed an acute angle with CS in three (8.33%) cases.

CONCLUSIONS

Restrictive TV covering ≥75% CS ostium (25% cases), presence of single prominent tributary (28% cases), and formation of acute angle of tributary with CS axis (1/4 cases with anterolateral vein, 4/29 cases with midlateral vein, 3/36 cases with posterolateral vein, and 3/28 cases with posterior veins of the left ventricle) can impede successful cannulation of CS.

Prospective versus retrospective ECG-gating for 64-detector computed tomography of the coronary venous system in pigs

BACKGROUND

Multidetector computed tomography (MDCT) provides a non-invasive anatomic description of the coronary veins that may be useful in patients candidates to cardiac resynchronization. Prospective gating reduces radiation exposure but its impact on image quality is unknown is this setting.

AIMS

This study compared image quality and reliability of MDCT angiography of the coronary veins between prospective and retrospective gating.

METHODS

Seven anaesthetized pigs underwent 64-detector row MDCT with prospective and retrospective ECG-gating. MDCT scans were evaluated for visibility of the veins, estimated radiation dose and vein characteristics. Inter- and intra-observer reproducibility was calculated.

RESULTS

Visibility grades of all veins were significantly decreased in prospective (0.82 ± 0.6) compared to retrospective gating (1.68 ± 0.9; P<0.001), the lateral vein being missed in two cases when using prospective vs. retrospective gating. The maximal vein length was significantly increased when using retrospective gating (P=0.015). Inter-observer but not intra-observer reproducibility was dependent on the gating technique for the maximal length and contrast-to-noise ratio (P=0.003 for both). Heart rate was 82 ± 13 bpm and 86 ± 11 bpm during retrospective and prospective ECG-gating (P=ns) despite full dose of atenolol titration.

CONCLUSION

Retrospective gating seems to be superior to prospective gating MDCT to describe the coronary venous system but the conclusions of our study should be confined to high heart rate condition.

Anatomy of the coronary sinus and epicardial coronary venous system in 620 hearts: an electrophysiology perspective

INTRODUCTION

Cannulation of the coronary sinus (CS) is a prerequisite for left ventricular (LV) pacing and certain ablation procedures. The detailed regional anatomy for the coronary veins and potential anatomic causes for difficulty with these procedures has not been established.

METHODS AND RESULTS

Therefore, we performed macroscopic measurements in 620 autopsied hearts (mean age 60 ± 23 years, 44% female). The CS was preserved for analysis in 96%. Sixty-three percent had a Thebesian valve that covered the posterior aspect of the CS ostium with extension to the superior (50%) and inferior aspects (18%) and was obstructive with fenestrations in 3 specimens. Partial or near occlusive valves were present occasionally at the ostium of the great cardiac vein (Vieussens; 8%) and middle cardiac vein (5%). Ninety-three percent had left atrial branches, and 41% had at least one branch with lumen > 3 French. For CRT lead placement, the mid-lateral LV was accessible from the middle cardiac vein (20%), the left posterior vein (92%) or the anterior interventricular vein (86%). Among specimens where the left phrenic nerve was preserved it crossed the LV mid-lateral wall in 45%.

CONCLUSIONS

Epicardial coronary vein anatomy is variable, and the mid-lateral LV wall can potentially be accessed through various tributaries of the epicardial veins. The orientation of the Thebesian valve favors cannulation of the CS from an anterior (ventricular) and inferior approach. Anterobasal, mid-lateral, and inferior apical LV coronary veins lie in proximity to the course of the phrenic nerve.

Robotic-Assisted or Minithoracotomy Incision for Left Ventricular Lead Placement a Single-Surgeon, Single-Center Experience

Objective

Left ventricular (LV) resynchronization with epicardial lead placement after failed coronary sinus cannulation can be achieved with minimally invasive robotic-assisted (RA) or minithoracotomy (MT) incisions. We evaluated early outcomes and costs after RA and MT epicardial LV lead implantation at our academic center.

Methods

From 2005 to 2010, 24 patients underwent minimally invasive RA or MT epicardial LV lead placement for resynchronization. Patient characteristics, electrophysiologic features, outcomes, and costs were analyzed.

Results

Ten patients underwent RA and 14 underwent MT minimally invasive LV lead placement, with no 30-day mortality in either group. Younger patients underwent RA epicardial lead placement (63.8 ± 15.4 vs 75.6 ± 10.0 years; P = 0.03). In addition, although both groups had comparable body surface areas, RA patients had significantly higher body mass index versus MT patients (44.4 ± 17.5 vs 26.9 ± 7.1 kg/m2, respectively; P = 0.003). Premorbid risk and cardiovascular profiles were similar across groups. Importantly, pacing threshold, impedance, and postoperative QRS interval were equivalent between groups. Significantly, both operating room and mechanical ventilation durations were higher with RA epicardial placement (P < 0.001). Despite equivalent outcomes, incision-to-closure interval was 48 minutes shorter with MT (P = 0.002). Absolute differences in direct costs between groups were negligible. Despite these differences, resource utilization and lengths of stay were equivalent.

Conclusions

Epicardial LV lead placement is efficacious with either approach. Early outcomes and mortality are equivalent. Greater tactile feedback during operation and equivalent short-term outcomes suggest that MT minimally invasive LV lead placement is the more favorable approach for epicardial resynchronization.

Contemporary and future trends in cardiac resynchronization therapy to enhance response

The rationale for cardiac resynchronization therapy (CRT), expectations in terms of patient benefit, patient selection for CRT, selection of a CRT pacemaker (CRT-P) vs CRT plus implantable cardioverter-defibrillator (CRT-D) platform, and studies evaluating device programming to enhance benefit from CRT are reviewed. The notion of an "optimal" left ventricular (LV) pacing site, the rationale for identifying and avoiding LV pacing in regions of scar, the use of anatomic, hemodynamic, and electrical parameters to identify an optimal LV pacing site, and the potential utility of multisite LV pacing to enhance benefit from CRT are discussed. Finally, the advantages and disadvantages of the various methods for LV lead delivery are reviewed.

The risks and benefits of transseptal endocardial pacing. Curr Opin Cardiol. 2012;27:19-23. [PMID: 22139700 DOI: 10.1097/hco.0b013e32834dc3d4]

PURPOSE OF REVIEW

Transseptal endocardial left-ventricular pacing has a number of potential advantages over left-ventricular epicardial pacing from the coronary sinus, for implantation of cardiac resynchronization therapy (CRT) devices. In this study we review the risks and potential benefits.

RECENT FINDINGS

Permanent transseptal endocardial pacing has been shown to be clinically feasible. Different methods have been described, including a superior, inferior or mixed approach. Endocardial pacing has a number of potential advantages over conventional left-ventricular pacing from the coronary sinus. It may be possible to achieve more effective CRT through optimizing the left-ventricular lead position, which is possible because of the greater choice of stimulation site. Endocardial rather than epicardial stimulation may result in more rapid ventricular activation and may be less arrhythmogenic. Disadvantages of this approach include the risk of thromboembolism and the potential for interaction with the mitral valve.

SUMMARY

Transseptal endocardial left-ventricular pacing shows promise for use in cardiac resynchronization therapy. The safety and effectiveness of this technique should now be tested in larger clinical trials.

Lead positioning strategies to enhance response to cardiac resynchronization therapy

Left ventricular lead position is one of the main determinants of CRT response. There are several approaches in LV lead positioning that include favoring an optimal anatomical position or targeting either the segment with maximal mechanical dyssynchrony or a region with maximal electrical delay. The conventional LV lead implantation faces several technical difficulties that may prevent the obtaining of a stable position and good performance of the LV lead without phrenic nerve stimulation. In addition, implant of the LV pacing lead in areas with myocardial scar may result in less than optimal cardiac resynchronization. Several strategies have been proposed to overcome all these obstacles including multimodality cardiac imaging to help in preprocedural or intraprocedural identification of the latest activated areas of the LV and the potential anatomical constraints. In selected patients, the surgical implant may be a solution to overcome these constraints. In the future, LV endocardial or epicardial multisite pacing may deliver an enhanced response to CRT.

Retrograde buddy wire technique for coronary sinus lead placement--an approach to overcome coronary vein angulation

Implantation of a left ventricular pacing lead via the coronary sinus to deliver cardiac resynchronization therapy has become standard therapy for patients with New York Heart Association (NYHA) Class III or IV heart failure and significant intraventricular conduction delay. Biventricular pacing has been shown to provide both symptomatic and mortality benefit in appropriately selected patients. There is significant variability in the anatomy of the coronary sinus and the epicardial coronary venous system. Although a suitable candidate vein may be identified during coronary venography, efforts toward successful guidewire placement or lead placement may be hampered by anatomic obstacles. In this case report, we provide a solution to overcome severe tortuosity encountered at the vein-coronary sinus junction and angulation of the proximal vein. The use of a second coronary sinus sheath and a retrogradely placed guidewire may overcome this anatomic obstacle of vessel tortuosity, when placement by other means has proven unsuccessful.

Assessment of coronary veins in patients with isolated coronary artery ectasia by antegrade coronary venous angiography

BACKGROUND

Coronary artery ectasia (CAE) is characterized by an abnormal dilatation of the coronary arteries. The most common cause of CAE is atherosclerosis but other possible etiologies include congenital abnormalities and inflammatory and connective tissue disease. Earlier studies have documented the association of CAE with the presence of aneurysms in other vascular beds. However, cardiac venous system in patients with isolated CAE has not been studied earlier. In this study, we aimed to assess coronary venous vessels by antegrade coronary venous angiography in patients with isolated CAE.

METHODS

Twenty-four patients with isolated CAE without significant stenosis and 21 age-matched and sex-matched controls without CAE were included in this study. The anatomy of the coronary venous system was imaged in a left anterior oblique view at an angle of 45° by antegrade coronary angiography.

RESULTS

Patients with isolated CAE had significantly larger coronary veins compared with control individuals with angiographically normal coronary arteries (coronary sinus ostium: 10.1 ± 1.0 vs. 8.5 ± 2.2 mm, respectively, P=0.003; coronary sinus mid level: 7.9 ± 1.4 vs. 6.5 ± 1.6, respectively, P=0.003; great cardiac vein: 5.6 ± 1.0 vs. 4.3 ± 0.8, respectively, P=0.001; middle cardiac vein: 3.9 ± 1.3 vs. 3.7 ± 1.4, respectively, P=0.52; posterior or lateral vein: 3.2 ± 1.1 vs. 2.4 ± 0.7, respectively, P=0.016).

CONCLUSION

We have shown for the first time a significant dilatation in the coronary veins in patients with isolated CAE, suggesting the presence of a more extensive vascular destruction in the coronary circulation.

Echocardiographic identification of the oblique vein of the left atrium: its relationship to the persistent left superior caval vein

Thus far, little has been written concerning echocardiographic identification of the oblique vein of the left atrium, or Marshall's vein. There is much discussion, nonetheless, on the potential significance of the vein, or its ligamentous remnant, as an arrhythmic substrate. We describe here four patients in whom transthoracic echocardiography revealed a venous structure protruding within the cavity of the left atrium. We discuss the possibility that these structures represent Marshall's vein, albeit probably as part of a persistent left superior caval vein.

Delivery of gene and cellular therapies for heart disease

Although there has been considerable interest in the utilization of gene and cellular therapy for heart disease in recent years, there remain critical questions prior to widespread promotion of therapy, and key among these issues is the delivery method used for both gene therapy and cellular therapy. Much of the failure of gene and cellular therapy can be explained by the biological therapy itself; however, certainly there is a critical role played by the delivery technique, in particular, those that have been adapted from routine clinical use such as intravenous and intracoronary injection. Development of novel techniques to deliver gene and cellular therapy has ensued with some preclinical and even clinical success, though questions regarding safety, invasiveness, and repeatability remain. Here, we review techniques for gene and cellular therapy delivery, both existing and adapted techniques, and novel techniques that have emerged recently at promoting improved efficacy of therapy without the cost of systemic distribution. We also highlight key issues that need to be addressed to improve the chances of success of delivery techniques to enhance therapeutic benefit.

A user-friendly method of cardiac venous system visualization in 64-slice computed tomography

BACKGROUND

Previsualization of the cardiac venous system is very important for some techniques, for example, cardiac resynchronization therapy (CRT). The aim of this study was to propose a new, user-friendly method of cardiac venous system visualization in 64-slice computed tomography (CT).

METHODS

In 112 patients (66 M) aged 58 +/- 11 standard deviation, a 64-slice CT with a retrospective electrocardiogram gating was performed due to a suspicion of ischemic heart disease. Special attention was paid to the requirements for image reconstruction useful for CRT.

RESULTS

In 74% of the patients, it was possible to obtain similar images to those during the CRT implantation procedure within anterior-posterior, left anterior oblique, and right anterior oblique views. The coronary sinus was clearly visible in all cases, the ostium measured 12.9 +/- 5.9 mm, and the angle of entrance 99 +/- 12 degrees. In all patients it was possible to demonstrate more than one vein; in 95%, at least one vein was clearly visible in the target area. Among the target veins, the posterolateral vein was visible most frequently (78%) in the cases as well as the lateral vein (78%).

CONCLUSION

The proposed scheme in 64-slice computed tomography enables images to be generated similar to the intraoperative fluoroscopy, which can be useful in techniques where previsualization of the cardiac venous system is recommended.

Trans-Coronary-Venous Interventions

The coronary venous system is routinely targeted during electrophysiological measurements or cardiac resynchronization therapy. However, several novel interventional techniques require coronary venous catheterization and visualization as well as transvenous delivery of devices and/or therapeutic agents. Recent reports suggest the possibility of a transvenous approach for the interventional treatment of refractory angina and mitral valve regurgitation. In addition, the coronary venous system has been used as a route for the delivery of stem cells in patients with left ventricular dysfunction due to ischemic heart disease. We review the potential value of using a coronary venous approach in association with recent therapeutic developments in the interventional treatment of structural and ischemic heart disease. We will also discuss techniques related to coronary venous catheterization.

Collateral approach for biventricular pacing of coronary sinus ostium obstruction

A 71-year-old man with dilated cardiomyopathy and complete atrioventricular block underwent cardiac resynchronization therapy (CRT) due to chronic heart failure that was not improved by conventional medical treatment. But we found the coronary vein ostium was completely obstructed by coronary venography. The contrast medium flowed out from the right atrium via a collateral pathway. Thus a left ventricular lead was placed via a collateral pathway and was successfully implanted without complications. The postoperative threshold was 2.7 V at 0.4 ms. The subjective symptom improved after CRT. The safety of this procedure was not clear.

Visualization of the cardiac venous system using cardiac magnetic resonance

We sought to investigate the value of cardiac magnetic resonance to depict cardiac venous anatomy. For cardiac resynchronization therapy the lead for the left ventricle is usually placed by transvenous approach into a tributary of the coronary sinus (CS). Knowledge of the anatomy and variations of the cardiac venous system may facilitate the positioning of the left ventricle lead. The cardiac magnetic resonance examinations of 23 subjects (16 volunteers and 7 patients) were retrospectively analyzed. All examinations were performed using navigator-gated whole-heart steady-state free precession coronary artery imaging after administration of intravascular contrast agents (gadofosveset in volunteers; Gadomer-17 in patients). The cardiac venous system was visualized in all subjects. The most frequent anatomical variant observed (in 12 subjects [52%]) was a connection of the small cardiac vein to the CS at the crux cordis. In 10 subjects (44%) the small veins entered the right atrium independently from the CS, and the posterior interventricular vein was connected to the CS at the crux cordis. Only one subject had a disconnection between the CS and posterior interventricular vein, which entered into the right atrium independently. The mean distance of the posterior vein of the left ventricle and the left marginal vein to the ostium of the CS was 15.2+/-4.7 mm and 49.7+/-14.1 mm, respectively. In conclusion, the anatomy of the cardiac venous system and its anatomical variability can be described using cardiac magnetic resonance. Its preimplantation visualization may help to facilitate the implant procedure and to reduce fluoroscopy time.

Usefulness of high-speed rotational coronary venous angiography during cardiac resynchronization therapy

Standard coronary venous angiography (SCVA) provides a static, fixed projection of the coronary venous (CV) tree. High-speed rotational coronary venous angiography (RCVA) is a novel method of mapping CV anatomy using dynamic, multiangle visualization. The purpose of this study was to assess the value of RCVA during cardiac resynchronization therapy. Digitally acquired rotational CV angiograms from 49 patients (mean age 69 +/- 11 years) who underwent left ventricular lead implantation were analyzed. RCVA, which uses rapid isocentric rotation over a 110 degrees arc, acquiring 120 frames/angiogram, was compared with SCVA, defined as 2 static orthogonal views: right anterior oblique 45 degrees and left anterior oblique 45 degrees . RCVA demonstrated that the posterior vein-to-coronary sinus (CS) angle and the left marginal vein-to-CS angle were misclassified in 5 and 11 patients, respectively, using SCVA. RCVA identified a greater number of second-order tributaries with diameters >1.5 mm than SCVA. The CV branch selected for lead placement was initially identified in 100% of patients using RCVA but in only 74% of patients using SCVA. RCVA showed that the best angiographic view for visualizing the CS and its tributaries differed significantly among different areas of the CV tree and among patients. The area of the CV tree that showed less variability was the CS ostium, which had a fairly constant relation with the spine in shallow right anterior oblique and left anterior oblique projections. In conclusion, RCVA provided a more precise map of CV anatomy and the spatial relation of venous branches. It allowed the identification of fluoroscopic views that could facilitate cannulation of the CS. The final x-ray view displaying the appropriate CV branch for left ventricular lead implantation was often different from the conventional left anterior oblique and right anterior oblique views. RCVA identified the target branch for lead implantation more often than SCVA.

Variability of coronary venous anatomy in patients undergoing cardiac resynchronization therapy: a high-speed rotational venography study

BACKGROUND

Imaging the coronary venous (CV) tree to delineate the coronary sinus and its tributaries can facilitate electrophysiological procedures, such as cardiac resynchronization therapy (CRT) and catheter ablation. Venography also allows visualization of the left atrial (LA) veins, which may be a potential conduit for ablative or pacing strategies given their proximity to foci that can trigger atrial fibrillation.

OBJECTIVE

The aim of this study was to provide a detailed description of CV anatomy using rotational venography in patients undergoing CRT.

METHODS

Coronary sinus (CS) size and the presence, size, and angulation of its tributaries were determined from the analysis of rotational CV angiograms from 51 patients (age 68 +/- 11 years; n = 12 women) undergoing CRT.

RESULTS

The CS, posterior veins, and lateral veins were identified in 100%, 76%, and 91% of patients. Lateral veins were less prevalent in patients with a history of lateral myocardial infarction than in patients without such a history (33% vs. 96%; P = .014). The diameters of the CS and its tributaries were fairly variable (7.3-18.9 mm for CS, 1.3-10.5 mm for CS tributaries). The CS was larger in men than in women and in cases of ischemic than in cases of nonischemic cardiomyopathy (all P <.05). The vein of Marshall, the most constant LA vein, was identified in 37 patients; its diameter is 1.7 +/- 0.5 mm, and its takeoff angle is 154 degrees +/- 15 degrees , making the vein potentially accessible for cannulation.

CONCLUSIONS

Differences in CV anatomy that are related to either gender or coronary artery disease could have important practical implications during the left ventricular lead implantation. The anatomical features of the vein of Marshall make it a feasible potential conduit for epicardial LA pacing.

Implantation of cardiac resynchronization therapy systems in the CARE-HF trial: procedural success rate and safety

AIMS

To assess procedural characteristics and adjudicated procedure-related (<or=30 days) major adverse events among patients who underwent cardiac resynchronization therapy (CRT) implantation in the CARE-HF study. The CARE-HF study shows that CRT improves symptoms and reduces morbidity and mortality in New York Heart Association (NYHA) class III/IV chronic heart failure (CHF) patients. However, safe and proper implantation of pacing systems remains key to effective CRT delivery.

METHODS AND RESULTS

Generalized linear modeling was used to examine the relationships between first implant success/failure and: NYHA class; beta-adrenergic blocker use; underlying ischemic vs. non-ischemic heart disease; history of coronary artery bypass graft or valve surgery; left ventricular (LV) end-diastolic volume<or=vs. >300 cm(3); and, influence of the participating study-centres. Implantation was attempted in 404/409 patients assigned to CRT, and in 65/404 patients assigned to medical therapy. Among these 469 patients, 450 (95.9%) received a successfully implanted and activated device. Complications occurred within 24 h in 47 patients (10.0%), mainly lead dislodgments (n = 10, 2.1%) and coronary sinus dissection/perforation (n = 10, 2.1%), and between 24 h and 30 days in 26 patients (5.5%), mainly lead dislodgment (n = 13, 2.8%). Mean LV lead stimulation threshold was significantly higher than at the right atrium or right ventricle, though remained stable, delivering effective, and reliable CRT. Implanting experience was the only predictor of procedural outcome.

CONCLUSION

Transvenous CRT system implantation, using a CS lead designed for long-term LV pacing, was safe and reliable. As implanting centres become more experienced, this success rate is expected to increase further.

Efficacy of Coronary Venoplasty for Left Ventricular Lead Implantation

BACKGROUND

Optimal target vein selection for the pacing lead results in a better outcome, but left ventricular (LV) variability limits this selection. The aim of the present study was to investigate the efficacy of coronary venoplasty for insertion of a LV lead.

METHODS AND RESULTS

Transvenous LV lead placement was attempted in 208 consecutive patients from November 2002 to January 2007, with success in 206 patients (99%). Retrospective analysis of the cardiac resynchronization therapy system implantation showed that 4 of the 206 patients (1.9%) required coronary venoplasty for insertion of the pacing lead implant. Using coronary balloon angioplasty catheters of 2.5 mm (2 patients), 3.0 mm (1 patient) and 4.0 mm (1 patient), each target vein was dilated. Of 4 patients, stenoses in 3 were dilated by balloon angioplasty only. However, focal stenosis of 1 patient was not able to be dilated due to severe stenosis. Therefore, part of the lesion was sharpened by rotational atherectomy and the stenosis was successfully dilated. The LV pacing lead could then be inserted and no complications occurred.

CONCLUSION

Venoplasty for stenosis was effective in allowing deployment of a LV lead into a target vein in some patients. The safety and complications of the procedure remain unclear.

Importance of Anterograde Visualization of the Coronary Venous Network by Selective Left Coronary Angiography Prior To Resynchronization

BACKGROUND

Understanding of coronary anatomy is essential to the advancement of cardiac resynchronization therapy (CRT) techniques. We determined whether the difficulties associated with catheterization of the coronary sinus (CS) and its lateral branches could be overcome by a preliminary angiographical study of the coronary venous system carried out during a pre-operative coronary angiography with examination of venous return.

METHODS AND RESULTS

All patients were scheduled for an exploratory angiography procedure and indicated for CRT. Group A patients were implanted with a CRT device after a right arterial angiographical procedure while group B patients had a selective left angiogram including examination of venous return. Data analyzed in group B were: position of CS ostium, number and distribution of lateral branches, and ability to preselect a marginal vein suitable for catheterization. Subsequent device implantation was guided by these parameters. A total of 96 and 89 patients were included in groups A and B, respectively. Implantation success rates were not different (98% and 100%, respectively), but CS catheterization time was reduced in group B (6 minutes vs 4 minutes; P < 10(-6)) as well as total time required to position the left ventricular lead (25 minutes vs 15 minutes; P < 10(-6)), fluoroscopy exposure (7 minutes vs 5 minutes; P < 10(-6)), and volume of contrast medium required (45 mL vs 15 mL; P < 10(-6)).

CONCLUSION

A coronary angiographical study, including examination of the coronary venous return prior to implantation of a CRT device, can simplify the device implant and allows patient-specific preselection of appropriate tools for the procedure.