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Europace 2004 6(5):451-452; doi:10.1016/j.eupc.2004.04.005
© 2004 by European Society of Cardiology
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IMAGES IN ELECTROPHYSIOLOGY/PACING

Anomaly of the middle cardiac vein?

Yoga Yuniadia, Ching-Tai Taib, Kwo-Chang Uengc and Shih-Ann Chenb,*

aNational Cardiovascular Center, Harapan Kita, and Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia Jakarta, Indonesia; bDivision of Cardiology, Department of Medicine, National Yang-Ming University, School of Medicine, and Taipei Veterans General Hospital Taipei, Taiwan; cDivision of Cardiology and Cardiovascular Surgery, Institute of Medicine, Chung-Shan Medical University Hospital Taichung, Taiwan

Manuscript submitted 25 September 2003. Accepted after revision 15 April 2004.

*Corresponding author. Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan. Tel.: +886-2-28757156; fax: +886-2-28735656. E-mail address: epsachen{at}ms41.hinet.net (S.-A. Chen).

Key Words: coronary sinus, middle cardiac vein, electrophysiological study, cardiac resynchronization therapy

A 69-year-old man who had suffered from frequent palpitations for 3 years was referred for radiofrequency (RF) ablation of atrial flutter and fibrillation.

At the beginning of the electrophysiology study (EPS), when the coronary sinus (CS) catheter (6F, Livewire Daig Corporation, Minnetonka) was inserted via the right internal jugular vein to the right atrium, it easily entered the CS ostium and was advanced distally following the usual angulation of CS shown by the left anterior oblique (LAO 60°) and right anterior oblique (RAO 30°) views. Slow hand injection of contrast media through the central lumen of CS catheter filled some small vein tributaries at the catheter tip, which drained to CS. The contrast neither opacified the area around the catheter nor extravasated into the surrounding tissue (panels A and B of Fig. 1). After placing the catheter in another site, contrast clearly showed the CS contour (panels C and D of Fig. 1). Two possibilities were considered; first, the CS catheter was engaged in a small branch of the middle cardiac vein, which had several functional small connections to CS. Secondly, the middle cardiac vein showed an anomaly, which was parallel to CS, and small.



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  		Figure 1
 
Knowledge of CS tributaries, their angulation and possible anomalies, is important for EPS and device implantation. This case demonstrates the very important role of CS angiogram after inserting the CS catheter. Furthermore, CS venography is compulsory for inserting a CS lead into an appropriate vein for biventricular pacing.


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