Coronary Sinus AnatomyCoronary Sinus Anatomy

ffor Electrophysiologistsor ElectrophysiologistsMazda Motallebi, MD, FACC, FHRS, CCDSMazda Motallebi, MD, FACC, FHRS, CCDS

Cardiac Electrophysiology Service Cardiac Electrophysiology Service Caremore Caremore Health Health PlanPlanLos Angeles, California Los Angeles, California

DisclosureDisclosure

Consultant, clinical instructor and speaker for Biotronik.Consultant, clinical instructor and speaker for Biotronik.

Consultant and clinical instructor for St. Jude Medical. Consultant and clinical instructor for St. Jude Medical.

Consultant and speaker for BiosenseConsultant and speaker for Biosense--Webster.Webster.

Why Coronary Sinus? Why Coronary Sinus? CRTCRT

CCoronary sinus ablation (AVNRT, WPW, A fib, oronary sinus ablation (AVNRT, WPW, A fib, AT)AT)

Outflow tract Tachycardia Ablation Outflow tract Tachycardia Ablation (Great (Great Cardiac Cardiac Vein & Anterior InterVein & Anterior Inter--ventricular ventricular Vein)Vein)

Ablation & Ablation & Ethanol Ethanol Injection in Vein of Marshall Injection in Vein of Marshall (A fib)(A fib)

Left atrium pacing & BiLeft atrium pacing & Bi--atrial pacing (Vein of atrial pacing (Vein of Marshall)Marshall)

Defibrillation (CS Coil) Defibrillation (CS Coil)

It is considered It is considered the the 5th Cardiac Chamber with 5th Cardiac Chamber with muscular & contractile properties muscular & contractile properties , located in left , located in left posterior AV groove.posterior AV groove.

The CS begins proximally at the right atrial orifice The CS begins proximally at the right atrial orifice and ends distally at the valve of Vieussen (junction and ends distally at the valve of Vieussen (junction of of CS CS & GCV).& GCV).

CS length 3CS length 3--5 cm5 cm

Coronary Coronary Sinus Sinus

Vieussen

The wall of the CS is made up of striated muscle The wall of the CS is made up of striated muscle

Always has connection Always has connection to left atrial to left atrial myocardiummyocardium

In Many hearts CS musculature has connection In Many hearts CS musculature has connection to both atrial to both atrial myocardium (besides Bachmannmyocardium (besides Bachmann s bundle , CS is another electric s bundle , CS is another electric connection between atria)connection between atria)

Rarely , if there is a Rarely , if there is a connection with LV Myocardium : connection with LV Myocardium : Epicardial Bypass Epicardial Bypass tract tract

First order tributaries originatingFirst order tributaries originatingfrom from the main the main coronary sinus coronary sinus

Great cardiac Great cardiac veinvein

Middle cardiac vein Middle cardiac vein

Small cardiac veinSmall cardiac vein

Posterior cardiac veinPosterior cardiac vein

First order Tributaries of CSFirst order Tributaries of CS

Ant Int

er -ventr

icular

Vein

LAD

Great Cardiac Veinin AV groove

Cx

ANTERIOR

Segmental Approach to CRT&

Fluoroscopic Anatomy

Case Case

Courtesy of Jag Singh MD , Harvard Medical School, MGH, Boston, MA.

RAO

Case Case LAO

AApical pical lead lead locations locations are are associated with associated with worse outcome worse outcome (irrespective (irrespective of of

QRS morphology ,QRS morphology ,electrical activation electrical activation sequence sequence and type of the vein)and type of the vein)

Courtesy of Jag Singh MD , Harvard Medical School

Worsening of CHF & Widening of QRS Worsening of CHF & Widening of QRS after BIV Implant after BIV Implant

Lateral Chest X ray

An

t Inter-ven

tricular vein

Basal PosterBasal Poster--Lateral BranchLateral Branch

RV-LV leads separation

Anterior LV stimulation Hemodynamic worsening in 33%

Circulation. 2001;104:3026-3029

Females Respond to CRT BetterFemales Respond to CRT Better

2nd order Lateral tributary vein take off at Basal Level in women & at Mid Level in men.

BASAL BETTER THAN MID!

FEMALEMALE

Telescopic techniqueTelescopic technique

Frequency of veins Frequency of veins Great cardiac vein 100%Great cardiac vein 100%

MCV 100%MCV 100%

Posterior/ PostPosterior/ Post--lateral vein 75% lateral vein 75%

Lateral vein 85%Lateral vein 85%

Ant InterAnt Inter--Vent Vein 60% Vent Vein 60%

15% of hearts have only 2 branches between 15% of hearts have only 2 branches between AIVC & MCVAIVC & MCV

-number of branches-distance to the coronary sinus, -branching angle,-arc length, tortuosity,-ostial diameter -minimum diameter

29% of specimens do not have a venous branch overlying the postero-lateral segment of the LV large enough to fit a 5 F pacing lead.

OPTIMAL for Cannulation: OPTIMAL for Cannulation:

TTake off angle ake off angle of the branch of the branch > 90 degree > 90 degree

Diameter Diameter greater than 2 greater than 2 mmmm

SUBSUB--OPTIMAL for OPTIMAL for Cannulation: Cannulation:

Take off angle 60Take off angle 60-- 90 degree 90 degree

Diameter 1.5 to 2 mm Diameter 1.5 to 2 mm

DIFFICULT DIFFICULT for Cannulation for Cannulation

Acute take off angle (lower than 60 degree)Acute take off angle (lower than 60 degree)

Diameter less than 1.5 mmDiameter less than 1.5 mm

Diameter & Take Off AngleDiameter & Take Off Angleof the Branchof the Branch

Anterolateral , lateral, posteroAnterolateral , lateral, postero--lateral lateral and posterior branches coronary sinus and posterior branches coronary sinus found be: found be:

Optimal Optimal 45%45% SubSub--optimal 35%optimal 35% Difficult or Impossible 20%Difficult or Impossible 20%

55% were Difficult or Sub55% were Difficult or Sub--optimal (Skills & optimal (Skills & Tools)Tools)

Based on Above criteriaBased on Above criteria

Posterior Posterior && PosteroPostero--lateral veinslateral veins

More likely to have acute take off (35% vs 23%) More likely to have acute take off (35% vs 23%)

Lateral marginal veins: Lateral marginal veins:

More likely to have tortuosity More likely to have tortuosity in their in their course course

(28% vs 15%) (28% vs 15%)

Definition of Tortuosity: Having Definition of Tortuosity: Having at least one complete U at least one complete U in the course of the vein . in the course of the vein .

Comparing Lateral versus Comparing Lateral versus PostPost--lateral Brancheslateral Branches

Data suggest Data suggest that there is a paucity of CS that there is a paucity of CS tributaries tributaries in areas in areas of previous infarction. of previous infarction.

Posterior Posterior veins tended to veins tended to be less be less prevalent in prevalent in patients with a history of inferior patients with a history of inferior MI.MI.

Lateral Lateral veins were less often seen in patients veins were less often seen in patients with a with a history of history of lateral MI.lateral MI.

Myocardial Infarction and Myocardial Infarction and CS TributariesCS Tributaries

Coronary sinus drains to right atrium at posteroCoronary sinus drains to right atrium at postero--inferior inferior aspect on Interaspect on Inter--atrial septum; Posterior to Tricuspid leaflet atrial septum; Posterior to Tricuspid leaflet and Anterior to Eusthacian valve / ridge. and Anterior to Eusthacian valve / ridge.

Coronary Sinus Ostium

The average diameter of CS The average diameter of CS ostium isostium is99--10 mm (Even a 10 mm (Even a large Pressure Product Safe Sheath, external diameter 11 large Pressure Product Safe Sheath, external diameter 11 FFrench)rench)

Hemodynamic Factors:Hemodynamic Factors:

CS diameter correlates positively with CS diameter correlates positively with LV diameter, LV diameter, LVEDP LVEDP and and RA Pressure RA Pressure (Do not make the patient (Do not make the patient dry before a BIV proceduredry before a BIV procedure))

AVNRT patients have CS ostium and proximal CS are 44% AVNRT patients have CS ostium and proximal CS are 44% larger than control group ( Windsock shape rather than larger than control group ( Windsock shape rather than tubular shape) tubular shape)

Coronary Sinus Ostium

The The Thebesian valves are present in 67% of the Thebesian valves are present in 67% of the hearts. hearts.

Thebesian valve is mainly located at superior & Thebesian valve is mainly located at superior & posterior aspect of the ostium.posterior aspect of the ostium.

Therefore cannulation of CS fromTherefore cannulation of CS from

anterior aspect (RV) is easier. anterior aspect (RV) is easier.

CS Ostium Valve (Thebesian Valve)

Absence of Thebesian valveAbsence of Thebesian valve

33% of hearts33% of hearts

Optimal for implantOptimal for implant

Crescent shape ThebesianCrescent shape Thebesian

31%31%

Optimal for implant Optimal for implant

Semilunar Thebesian valve29% of heartsSub-optimal for implant

Fenestrated Thebesian valve 4% of heartsTechnically difficult (worst)

Band shape Band shape Thebesian valveThebesian valve

3% 3% of heartsof hearts

Technically difficult Technically difficult

Valve Valve of of VieussensVieussens

Valve of Vieussens

Present in 75% of heartsPresent in 75% of hearts

Usually Usually one one leafletleaflet

8% 8% is wellis well--developed and developed and

technically difficult to crosstechnically difficult to cross..

Cannulation with Hydrophilic Cannulation with Hydrophilic wire & Braided Inner Catheterwire & Braided Inner Catheter

Crossing the valve with wireCrossing the valve with wire

and Anchoring Balloon technique and Anchoring Balloon technique

Valve of Valve of VieussensVieussens

EEmbryological mbryological remnant of the left remnant of the left SVCSVC

Start at the GCV & CS JunctionStart at the GCV & CS Junction

Coursing superior & laterally behind posterior wall of Coursing superior & laterally behind posterior wall of left atrium toward LIPV left atrium toward LIPV

Then between Then between the anterior surface of the leftthe anterior surface of the left--sided sided pulmonary pulmonary veins and veins and the posterior surface of the the posterior surface of the Base Base of the of the LAA LAA reaching the superior reaching the superior pulmonary pulmonary venoveno--atrial atrial junction.junction.

Left Atrial Oblique VeinLeft Atrial Oblique Vein(Vein (Vein of of Marshall)Marshall)

Vein of Vein of Marshall Marshall

VV

From CS ostium to VOM From CS ostium to VOM 30 mm (3030 mm (30--50mm)50mm)

VOM diameter1.2 mm

RFARFARFA on the Ridge with higher power .

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VOM could VOM could be be identified in identified in 87%of 87%of the the hearts.hearts.

The The Vieussens Vieussens valve is valve is present in present in 75% of the 75% of the heartshearts

They are closely They are closely associated.associated.

VOM is more proximal VOM is more proximal than Vieussens than Vieussens valve valve (relative (relative to the to the Cs Cs ostium)ostium)

Rate of phrenic stimulation in BIV reported 1% to 12%Rate of phrenic stimulation in BIV reported 1% to 12%

Phrenic nerve Phrenic nerve typically typically courses over courses over the the BasalBasalregion region of of the the aanterior internterior inter--ventricular vein ventricular vein (most often overlap (most often overlap 7373%)%)

the the MidMid region region of the of the left marginal vein left marginal vein (overlapping left (overlapping left lateral veins in 53%)lateral veins in 53%)

The The AApicalpical region region of the of the middle cardiac middle cardiac veins veins & & Posterior cardiac veinPosterior cardiac vein( overlap in 26%)( overlap in 26%)

Closet distance with left marginal & middle Cardiac Closet distance with left marginal & middle Cardiac Vein (3.6 mm)Vein (3.6 mm)

PPhrenic Nerve & CS Tributarieshrenic Nerve & CS Tributaries

Posterior Vertical Take Off & Sharp Sigmoid Curve of CS

PrePre--implant knowledge of CS anatomy could be extremely implant knowledge of CS anatomy could be extremely helpful (particularly if prior procedure failed). Consider CT shelpful (particularly if prior procedure failed). Consider CT scan can or MRI after a failed case. or MRI after a failed case.

DO NOT use preDO NOT use pre--shaped sheath.shaped sheath.

Use a straight catheter and shape it to accommodate the Use a straight catheter and shape it to accommodate the sigmoid curve.sigmoid curve.

Inner Catheter (AL2 or AL3) could be helpful.Inner Catheter (AL2 or AL3) could be helpful.

Right Right sided sided approach might provide better access.approach might provide better access.

Posterior Vertical Posterior Vertical Take Off & Take Off & Sharp Sharp Sigmoid Sigmoid Curve Curve of of CS CS

Prior to AV Groove Prior to AV Groove

Rotational Rotational Angiography Angiography

Advanced Advanced Image Fusion to Overlay Coronary Image Fusion to Overlay Coronary Sinus Anatomy Sinus Anatomy with Realwith Real--Time Fluoroscopy to Facilitate Time Fluoroscopy to Facilitate Left Ventricular Left Ventricular Lead Lead

Implantation in Implantation in CRTCRT

1) Real time 2) Reduced X ray time & IV Contrast1) Real time 2) Reduced X ray time & IV Contrast3) 88% of patients had prior failed lead placement with (100% su3) 88% of patients had prior failed lead placement with (100% success after this technique )ccess after this technique )

4) Consider MRI or CT scan in failed procedures, congenital hea4) Consider MRI or CT scan in failed procedures, congenital heart disease, mitral valve surgery rt disease, mitral valve surgery

PACE Feb 2011; 34:226234)

MRI or CT Scan inMRI or CT Scan inSuspected Congenital Anomaly or Humongous CS Suspected Congenital Anomaly or Humongous CS

Balloon Occlusion Venography is Impossible

What is the Technical Problem? What is the Technical Problem?

1) 1) Could be an isolated Could be an isolated incidental incidental findingfinding

2) Associated with Congenital Heart Disease2) Associated with Congenital Heart Disease

3) WPW: Epicardial postero3) WPW: Epicardial postero--septal accessory septal accessory pathway with true negative Delta wave in Lead IIpathway with true negative Delta wave in Lead II

The muscle layers are The muscle layers are often connected often connected with the left with the left atrial or left ventricle myocardium (when is atrial or left ventricle myocardium (when is connected with both makes the Epicardial AP)connected with both makes the Epicardial AP)

Diverticulum of Coronary Sinus Diverticulum of Coronary Sinus or Middle Cardiac Veinor Middle Cardiac Vein