Europace Advance Access published online on April 15, 2008
Europace, doi:10.1093/europace/eun088
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CASE REPORT
Duplicated coronary sinus with a connecting branch
Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Avenue Street, Birmingham, AL 35294-0019, USA
Manuscript submitted 21 December 2007. Accepted after revision 19 March 2008.
* Corresponding author. Tel: +1 205 975 4724; fax: +1 205 975 4720. E-mail address: takumi-y{at}fb4.so-net.ne.jp
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A 48-year-old woman with class III heart failure and left bundle branch block underwent an implantation for cardiac resynchronization therapy. Right anterior oblique (RAO) view coronary sinus (CS) venography suggested the antero- and postero-lateral branches appeared to arise from the same vessel of a duplicated CS, but the antero-lateral branch arising from a different vessel was visualized via a connecting branch by the contrast injected into the vessel with the postero-lateral branch, and the distal parts of the two vessels were superimposed in the RAO view. This unusual anomaly may have the potential risk for complications such as perforations.
Implantation of a cardiac resynchronization therapy (CRT) device with a defibrillator was recommended for a 48-year-old woman with ischaemic cardiomyopathy, a left ventricular (LV) ejection fraction of 25%, New York Heart Association Class III heart failure, and left bundle branch block. She had undergone coronary bypass surgery and mitral valvoplasty. In a balloon-occluded coronary sinus (CS) venogram in the right anterior oblique (RAO) view, the antero-lateral (solid star) and postero-lateral (open star) branches appeared to arise from the same vessel in the venography, but a duplicated CS (white arrowheads) with a connecting branch was suggested in the late phase (Figure 1A and B). During the implantation of the LV lead, the antero-lateral branch was considered as a preferable choice of the target vein because the postero-lateral branch had an acute take off and small lumen. However, the guidewire could not be advanced to the target site. A balloon-occluded CS venogram was then performed in the left anterior oblique view and revealed that a branch (dotted arrows) connected the two vessels and the antero- and postero-lateral branches arose from different vessels (Figure 1D). When the balloon was deflated during the contrast injection, a simultaneous visualization of the proximal portions of the two vessels was achieved and it revealed that the two vessels had a common ostium (black arrowheads) (Figure 1E). Cannulation into the vessel with the antero-lateral branch was not feasible because of the acute take off of the vessel. Ultimately, the LV lead was successfully implanted into the postero-lateral branch (Figure 1C and F).
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The anatomy of the CS has become a subject of more interest because the implantation of the LV leads into the CS has been widely employed in the CRT. Non-invasive three-dimensional imaging, such as multislice computed tomography or magnetic resonance imaging, has revealed that the CS and its tributaries have anatomical variations.1
,2 Nevertheless, anomalies of the CS anatomy may sometimes complicate the implantation of the LV lead.3 Coronary sinus venography is very helpful to recognize the CS anatomy and to decide about the optimal strategy of the LV lead implantation. In this case, the antero- and postero-lateral branches appeared to arise from the same vessel of the duplicated CS, but a different vessel with the antero-lateral branch was visualized via a connecting branch by the contrast injected into the vessel with the postero-lateral branch, and the distal parts of the two vessels were superimposed in the RAO view. This unusual anomaly may have a potential risk of complications such as a perforation when the LV lead is forced towards the antero-lateral branch via the vessel with the postero-lateral branch. In fact, some doctors prefer single plane to simultaneous biplane angiography for an easy procedure and reduction of the X-ray exposure. In many cases, CS venography in multiple projections may not be necessary because the single projection separates the CS branches adequately. Therefore, it is important to know what CS venography findings in the single projection suggest the necessity of additional CS venography in another projection and how to perform that additional CS venography effectively. This study provided an example, illustrating this fact. Conflict of interest: T.Y. is supported by a research grant from Boston Scientific and St. Jude Medical. A.E.E., G.N.K., H.T.M., and V.J.P. have participated in catheter research funded by Biosense-Webster and Irvine Biomedical. G.N.K. has received honoraria from Medtronic, Boston Scientific, and St Jude Medical. A.E.E. has received honoraria from and served on events committees for Boston Scientific and St Jude Medical. The electrophysiology fellowship program at the University of Alabama Birmingham receives funding support from Boston Scientific and Medtronic. The other authors report no conflicts.
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[1] Jongbloed MR, Lamb HJ, Bax JJ, Schuijf JD, de Roos A, van der Wall EE, et al. Noninvasive visualization of the cardiac venous system using multislice computed tomography. J Am Coll Cardiol (2005) 45:749–53.
[2] Wijetunga M, Cuoco F, Ravi ND, Fuisz A, Strickberger SA. Characterization of the coronary sinus ostium by cardiac magnetic resonance imaging. Am J Cardiol (2006) 98:1400–2.[CrossRef][Web of Science][Medline]
[3] Tada H, Ito S, Naito S, Oshima S, Taniguchi K. Longitudinally partitioned coronary sinus: an unusual anomaly of the coronary venous system. Pacing Clin Electrophysiol (2005) 28:352–3.[CrossRef][Medline]
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