© 2005 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
The coronary sinus conduit function: Anatomical study (relationship to adjacent structures)
aAlexandria University School of Medicine Egypt; bRoyal Brompton Hospital, Charing Cross Hospital London SW3 6NP, UK
Manuscript submitted 3 August 2004. Accepted after revision 5 May 2005.
*Corresponding author. Tel.: +44 207 351 8164; fax: +44 207 351 8634.E-mail address: m.henein{at}rbh.nthames.nhs.uk (M. Y. Henein).
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Abstract |
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 Top Abstract IntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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BACKGROUND: The mitral valve annulus (MVA) is anchored antero-medially to the aorta. Dilatation of the MVA primarily affects its postero-lateral aspect, which is related to the coronary sinus (CS). The CS and its tributaries have been used for pacing the left ventricle in patients with intractable heart failure. The aim of this study was to determine anatomical relations between the CS and its adjacent structures in 40 adult normal cadaveric heart specimens.
METHODS: In 32 specimens, longitudinal sections were made along the free circumference of the MVA in 6 separate regions, 36° between each, with the 0° marked by a line joining the centre of the CS ostium and that of the MV. In each section, the relations of the CS to the circumflex artery and the MVA were determined. CS diameter and its distance from the endocardium, just below the MVA, were also measured by a digital calliper.
RESULTS: The great cardiac vein (GCV) diameter is 5.6±1.6 mm. As it leaves the interventricular groove, it curves to the left forming the base of the triangle of "Brocq and Mouchet" with the two branches of the left coronary artery, having a triple relationship with the circumflex artery. It then continues as the CS (diameter 9.3±5.3 mm) in the inferior atrioventricular groove. The end part of the GCV crosses superficial to the left circumflex artery at the level of the left marginal vein. The shortest distance between the wall of the CS and the endocardium adjacent to the MVA at the level of the anterolateral commissure is 5.2±1.6 mm, i.e. beyond the Vieussens valve. Thus, together with the CS the great cardiac vein, form a semicircular venous channel at the postero-lateral aspect of the MVA. In 37/40 hearts, this venous channel arches upwards in its middle part to be in direct contact with the left atrium.
CONCLUSION: This study demonstrates an intimate proximity between the coronary sinus, at its beginning and end, and the mitral valve annulus. It also highlights the close relationship between the great cardiac vein, the annulus and the left ventricular free wall. Assessing the same relationship using the currently available imaging techniques should aid in the successful cannulation of the coronary sinus for various cardiological interventions.
Key Words: coronary sinus, anatomy, pacing, mitral annulus
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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The great cardiac vein leaves the anterior interventricular groove and courses postero-laterally and to the left forming the base of the "Brocq and Mouchet" triangle, then turns around the left aspect of the atrio-ventricular junction and continues in the inferior atrioventricular groove as the coronary sinus [1]
. This course forms a continuous semicircular venous channel that runs parallel to the free margin of the mitral valve annulus.
The coronary sinus (CS) has infrequently been used in electrophysiological studies for ablation of the postero-septal and left-sided accessory pathways [2]. It has also served as a conduit for the insertion of left ventricular pacemaker lead in patients with severe heart failure refractory to medical therapy [3,4]. This procedure is known for its technical limitations due to the variability of the coronary sinus course, valves and its relationship to adjacent structures. Retrograde venography via the coronary sinus is currently the standard technique for defining coronary sinus anatomy; however, it is invasive in nature and can be technically challenging. Furthermore, routine angiographic protocols do not allow simultaneous study of coronary arterial and venous systems and hence their relationship [5].
Therefore, the aim of the present work was to study the morphology and the anatomy of the coronary sinus with regard to its diameter, length, appearance and position of valves, its course in the inferior atrioventricular groove and relations to the surrounding structures mainly the left circumflex coronary artery and mitral annulus.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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Forty adult normal cadaveric heart specimens fixed in 10% formal saline were studied (31 males). The wall of the right atrium was incised along the sulcus terminalis to view the ostium of the coronary sinus. The cavity of the left atrium was opened by an incision across the two lower pulmonary veins.
In 32 specimens, longitudinal sections were made along the free circumference of the mitral valve annulus in six separate regions, 36° between each. Region 1: from 0° to 36°; Region 2: from 36° to 72°; Region 3: from 72° to 108°; Region 4: from 108° to 144°; Region 5: from 144° to 180°; Region 6: from 180° to 216° (Diagram 1). The 0° line corresponded to a line joining the centre of the coronary sinus ostium and the centre of the mitral valve annulus. In each longitudinal section, the great cardiac vein and the coronary sinus were studied in relation to the left circumflex coronary artery and mitral valve annulus. The sections were made in each region perpendicular to the plane of the valve (Diagram 1) allowing the distance between the endocardium just inferior to the mitral valve annulus and the nearest endothelial lining of the wall of the veins to be measured in the six regions (Figs. 1 and 2). In addition, the diameter of the CS was measured. All measurements were made using the Absolute Digimatic Calliper (MITUTOYO).
In the remaining eight specimens the coronary sinus was slit open in order to study its valves and the ostia of its tributaries as well as the CS length from the Vieussens valve to the CS ostium.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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Great cardiac vein and the coronary sinus
In all cases the great cardiac vein (5.6±1.6 mm in diameter) curved to the left as it left the anterior interventricular groove, to form the base of the triangle of " Brocq and Mouchet" with the two branches of the left coronary artery; the left anterior descending and the left circumflex arteries (Fig. 3). At this point, the vein was related internally to the anterolateral commissure of the mitral valve. The triangle was usually traversed by diagonal branches of the left anterior descending artery, which either passed superficial or deep to the vein. The latter part of the course of the great cardiac vein, as it left the triangle, lay in close relationship to the left circumflex artery; it passed from below upwards and to the right, then superficial to the artery. Thus the vein had a triple relation to the artery; being proximally inferior, then superficial, and finally superior to the artery (Fig. 4). In only two cases of the 40, the vein was deep to the artery throughout its course.
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After crossing the left circumflex artery, the great cardiac vein ended at the Vieussens valve and continued as the coronary sinus. The site of the valve was marked externally by a small constriction in 26 of the specimens (Fig. 3). This constriction is marked by the junction of the tributary, minute, oblique vein of the left atrium (vein of Marshall). The coronary sinus was 48.4±5.2 mm long and 9.3±5.3 mm in diameter. In 34/40 specimens the Vieussens valve was rudimentary and incomplete. In the remaining six specimens it was well developed, formed of one thin deep transparent leaflet that was attached to the ventricular wall of the coronary sinus. The leaflet was 2.6±1.9 mm wide. Just to the right of the Vieussens valve the oblique vein of the left atrium opened into the CS.
The coronary sinus ostium was guarded by the Thebesian valve, which was seen in 87.5% of the cases (35/40) as a thin semilunar fold, 1–4.1 mm long, at the antero-inferior rim of the ostium. In 4/40 (10%) specimens the valve was in the form of a narrow circular rim surrounding the whole ostium and in only one case the valve cusp showed small fenestrations. The valve was absent in one case (2.5%). When present the valve did not cover more than one third of the coronary sinus ostium. The terminal part of the coronary sinus lay in the upper part of the floor of the inferior pyramidal interatrial fossa, which is an adipose filled region at the crux of the heart containing the U-turn part of the right coronary artery, known as the "U-turn of James" and its atrioventricular branch (Diagram 1). The coronary sinus opened in the wall of the right atrium postero-superior to the commissure between the septal and the posterior leaflets of the tricuspid valve. The ostium marked the base of Koch's triangle and had a mean height of 7 mm (5–9 mm), and mean width of 12 mm (7–16 mm).
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In 80% (32/40) of specimens the coronary sinus was cylindrical in shape with the widest diameter towards its opening into the right atrium, and in 20% (8/40) it showed marked narrowing at the site of the Vieussens valve, giving a funnel shape appearance. The great cardiac vein and the coronary sinus were commonly embedded in the sub-epicardial fat of the inferior atrio-ventricular groove. The coronary sinus as it passed to the right deviated slightly superiorly to become more related to the back of the left atrium before it coursed inferiorly to open into the right atrium.
Coronary veins and the mitral annulus
Our findings show that the great cardiac vein and the coronary sinus form a semicircular venous channel that is related to the free circumference of the mitral valve annulus. To study such a relationship in detail the distance between the venous channel and the free circumference of the mitral annulus was measured at six regions, each 36° wide (Diagram 1). The CS was related to the mitral valve annulus in the first four regions whereas in the 5th and 6th regions the annulus was in direct relation with the great cardiac vein.
Three patterns identified the relationship between the veins and the annulus:
Pattern A. In 23/32 cases (71.9%), the venous channel in region 2 was widely separated from the mitral annulus compared with the two ends. The closest point was at region 6. The mean distances were 9.4 mm, 10.6 mm, 9.9 mm, 9.1 mm, 6.6 mm and 5.8 mm in regions 1, 2, 3, 4, 5 and 6, respectively. Distances at regions 1, 2, 3 and 4 were significantly longer than in regions 5 and 6 (P<0.01).
Pattern B. In 7/32 cases (21.9%), the coronary sinus was widely separated from the annulus proximally, at its ostium and became closer distally towards the great cardiac vein. The mean distances were 11.6 mm, 11.1 mm, 10.6 mm, 9.8 mm, 8.3 mm, and 7.0 mm in regions 1, 2, 3, 4, 5 and 6, respectively. Distances at regions 1, 2, 3 and 4 were significantly longer than in regions 5 and 6 (P<0.01).
Pattern C. 2/32 cases (6.2%) showed a non-consistent pattern. The mean distances were 10.8 mm, 11.1 mm, 10.9 mm, 10.9 mm, 10.0 mm, and 10.3 mm in regions 1, 2, 3, 4, 5 and 6, respectively.
The results are summarized in Diagram 2, which shows that in about 94% of specimens the nearest point between the annulus and the coronary sinus was in region 6. The shortest distance was 5.2 mm, where the great cardiac vein was related to the mitral annulus as it formed the base of the triangle of "Brocq and Mouchet". At that region the great cardiac vein was related internally to the anterolateral commissure of the mitral valve. The longest distance was 11.4 mm in region 2 (Diagram 2).
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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The mitral annulus was previously described as being D-shaped rather than circular [6]
. The straight border of which is related to the aortic valve and right and left fibrous trigones. This border is a sheet like fibrous area and not a fibrous cord as the name implies [6,7]. The rounded part of the annulus was described as a continuous fibrous cord that may show disjunctions [8]. The aim of this study was to mark the exact relationship between the coronary veins and the surrounding structures in the posterior atrio-ventricular region as well as the mitral valve annulus. |
Great cardiac vein and coronary sinus |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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The beginning of the CS is marked by either an outer constriction, the opening of the oblique vein of the left atrium or by the Vieussens valve internally, as described by Becker [10]
. Our results showed that the Thebesian valve marks the coronary sinus ostium and was found in 90% of cases but well developed in only 6 specimens. When present it covered not more than one third of the coronary sinus ostium, thus creating no significant limitation to the coronary sinus-right atrial continuity. The coronary sinus opened in the wall of the right atrium postero-superior to the commissure between the septal and posterior leaflets of the tricuspid valve. This upwards position of the coronary sinus ostium might be due to some muscular fasciculi extending from the wall of the atrium surrounding the end of the coronary sinus as cited by Chauvin et al. [9]. The shortest distance between the venous circle and the mitral annulus was 5.2 mm at the level of the anterolateral commissure of the mitral valve, where the great cardiac vein forms the base of the triangle of "Brocq and Mouchet". This reflects the site of adherence between the vein and the left ventricular free wall myocardium. Similar results have previously been reported by Yamanouchi and colleagues [11] in 66% of cases where the distance was greatest in the middle of the venous channel compared with the two ends. Their results, however, were based on only 180° of the free annular circumference. In contrast, Shinbane and colleagues [12] found that the distance was more than 10 mm based on measurements at 20 mm incremental distance from the coronary sinus ostium, having not included the great cardiac vein in the analysis. The coronary sinus coursed at the crux of the heart along the upper part of the floor of the inferior septal pyramidal space, before it opened into the right atrium. In our cases it was distant from the mitral annulus at that point by more than 9 mm. These findings were compatible with the anatomical dissection of the inferior pyramidal space by Sealy and Mikat [13], that showed a distance of 10 to 12 mm above the mitral annulus at the septal portion of the left atrium. |
Coronary sinus intervention |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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The coronary sinus has been recently serving as a conduit for catheter treatment of arrhythmias as well as left ventricular pacing. These procedures are well known for their potential technical difficulties. Coronary sinus cannulation by conventional deflectable 7-F catheter has been reported by Corcoran et al. to have been obstructed by the Vieussens valve in 46% of the cases [14]
. Our results could not support these findings having shown a well-developed Vieussens valve in only 15% of cases. Maros and colleagues' findings are supportive of ours, having found the Vieussens valve present in 78%, but well developed only in 6% of cases [15]. Although variable prevalence of the Vieussens valve has been published, in 57%, 59% and 65% of cases [1,16,17], in none of these reports has an incidence as high as 46% for the presence of a developed valve been documented. Another explanation of the technical difficulty for coronary sinus cannulation is the possible flexing of the great cardiac vein [14]. Our results may provide anatomical basis for such a suggestion. The great cardiac vein may kink at the level of being crossed by the deeply seated muscular left circumflex artery resulting in luminal obstruction. Finally, congenital coronary sinus anomalies do exist, e.g. diverticulae, stenoses, ectasia, an unroofed sinus, ostial atresia, complete absence of duplication of the coronary sinus [18–23]. Although reported, these congenital abnormalities are rare and are, therefore, unlikely to explain the relatively common technical difficulty of coronary sinus cannulation. |
Conclusion |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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Our findings delineate the anatomical course of the coronary venous circle around the mitral annulus and its relationship to the left circumflex artery. The study demonstrates the intimate proximity of the coronary sinus at its beginning and end to the mitral annulus and also highlights the close relationship between the great cardiac vein, the annulus and left ventricular free wall. The time seems ripe to reproduce such relationships by the currently available imaging techniques as a means of assessing the coronary venous system in patients before interventional procedures.
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References |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionGreat cardiac vein and...Coronary sinus interventionConclusionReferences |
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