Abstract
Anatomy
Coronary venous sinus is the major portal for cardiac venous drainage and plays a crucial role in electrophysiological procedures like left ventricular pacing.
Pathology
Although congenital anomalies of the coronary sinus are rare, we present a unique case of interrupted coronary sinus. The proximal segment drained normally into the right atrium, while the distal segment drained into a common channel that connected to the left subclavian vein via a persistent left superior vena cava.
Imaging Correlation
This anomaly was initially suspected during Levo-phase coronary sinus angiography and further confirmed by computed tomography and direct coronary sinus angiography.
Treatment
The patient successfully underwent implantation of a cardiac resynchronization therapydevice with right atrial and ventricular leads placed via normal superior vena cava, and the left ventricular lead placed via the persistent left superior vena cava.
Take-Home Message
Understanding coronary sinus anomalies is essential for successful interventions, highlighting the importance of proper evaluation and knowledge in this field.
Key words: bradycardia, cardiac resynchronization therapy, cardiomyopathy, coronary vessel anomaly
Graphical Abstract
Anatomy
Coronary venous sinus is the major conduit of the heart for drainage of venous blood.1 As it wraps around the heart along with its various branches, it gives access to the various parts of the left atrium and left ventricle for various interventional procedures like placement of left ventricular lead for left ventricle stimulation for the purpose of cardiac resynchronization. Coronary venous sinus is formed as a continuation of anterior cardia and great cardiac vein as it wraps around the left atrioventricular grove. In its course, it receives various branches like vein of marshal, posterior/posterior-lateral veins, and middle cardia vein (Figure 1).2,3 Although, variations in coronary venous anatomy are frequently seen, prevalence of coronary venous sinus anomalies is low. Knowledge of the various coronary venous anomalies is of paramount importance for success of the procedure and safety of the patient involving coronary venous sinus interventions.
Take-Home Messages
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Understanding and knowledge of various coronary sinus anomalies is important for favorable outcomes of the various procedures involving coronary sinus.
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Complete preprocedural workup of such patients is crucial.
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There is a relatively small PLSVC with flow reversal in these cases, and conventional left axillary and subclavian vein angiography will not show its presence.
Figure 1.
Normal Coronary Venous Sinus Anatomy4
Pathology
The present case probably demonstrates the first case of interrupted coronary venous sinus anatomy and implantation of a cardiac resynchronization therapy device in such anatomy in the published literature. Levo-phase venography of the coronary sinus showed interruption of the coronary venous sinus in the middle (Video 1). The proximal part of the Coronary venous sinus was joined by the middle cardiac vein and was draining into the right atrium, while the distal part was joined by anterior and posterolateral veins and was draining into a common channel, which in turn drained into the left subclavian vein via a persistent left subclavian vena cava (PLSVC). It is important to note here that the flow in the PLSVC in this case was retrograde from the heart to the left subclavian vein, which is against the conventional antegrade flow from left subclavian vein to coronary sinus and right atrium usually seen in the case of PLSVC.5 For this reason, no PLSVC was demonstrated on left axillary and subclavian vein angiography (Video 2).
Imaging Correlation
Computer tomography confirmed the aforementioned findings. In addition, it demonstrated the presence of collaterals between the interrupted parts of the coronary venous sinus (Video 3). Direct coronary venous sinus angiography further demonstrated the presence of interrupted coronary venous sinus with the proximal part draining into the right atrium, and the distal part draining into the left subclavian vein via the PLSVC. It further clearly demonstrated the presence of multiple collaterals between the two parts of the coronary venous sinus (Figure 2, Video 4).
Figure 2.
Direct Coronary Venous Sinus Angiography of the Patient
Coronary venous sinus angiography showing interrupted coronary venous sinus, collaterals, and persistent left superior vena cava. CS = coronary sinus; PLSVC = persistent left superior vena cava.
Treatment
The patient successfully underwent the cardiac resynchronization therapy pacing device therapy. The right atrial and ventricular lead was placed via the superior vena cava route, while the left ventricular lead was placed via the PLSVC route into the posterior lateral vein (Video 5).
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors would like to thank the staff of cathlab SKIMS for their contribution in this study.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Levo phase coronary venous sinus angiography.
Levo-phase coronary venous angiography showing interrupted coronary venous sinus.
Fluoroscopic venography of the axillary/subclavian vein.
Axillary/subclavian vein angiography shows normal venous drainage. No persistent left superior vena cava detected.
CECT coronary venography.
Computed tomography coronary venography showing interrupted coronary venous sinus and persistent left subclavian vein.
Direct coronary venous sinus angiography.
Coronary venous angiography showing the presence of persistent left superior vena cava draining into the left subclavian vein.
Fluoroscopy of the implanted CRT pacing system.
Fluoroscopy showing completion of cardiac resynchronization therapy procedure with a left ventricular lead placed via the persistent left superior vena cava (PLSVC), and right atrial and right ventricular leads via the normal superior vena cava. PLSVC-persistent left superior vena cava.
References
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Associated Data
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Supplementary Materials
Levo phase coronary venous sinus angiography.
Levo-phase coronary venous angiography showing interrupted coronary venous sinus.
Fluoroscopic venography of the axillary/subclavian vein.
Axillary/subclavian vein angiography shows normal venous drainage. No persistent left superior vena cava detected.
CECT coronary venography.
Computed tomography coronary venography showing interrupted coronary venous sinus and persistent left subclavian vein.
Direct coronary venous sinus angiography.
Coronary venous angiography showing the presence of persistent left superior vena cava draining into the left subclavian vein.
Fluoroscopy of the implanted CRT pacing system.
Fluoroscopy showing completion of cardiac resynchronization therapy procedure with a left ventricular lead placed via the persistent left superior vena cava (PLSVC), and right atrial and right ventricular leads via the normal superior vena cava. PLSVC-persistent left superior vena cava.