The Anatomy of The Coronary Sinus
The Anatomy of The Coronary Sinus
The Anatomy of The Coronary Sinus
doi:10.1093/europace/eup270
Cardiac electrophysiologists use of the coronary sinus (CS) to map and ablate accessory pathways and implant left ventricular leads has
emphasized the need for understanding CS anatomy. In this review, we briefly examine the developmental and radiological anatomy of
the CS and discuss in detail the gross anatomy of this cardiac vein. We highlight the correlations of the acquired anatomical knowledge rel-
evant to clinical electrophysiology practice.
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Keywords Coronary sinus Cardiac veins
* Corresponding author. Tel: 1 507 255 2440, Fax: 1 507 255 2550, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: [email protected].
v16 A. Habib et al.
toward this vein. Because of the unique anatomy of this vein (being
perpendicular to the main access of the CS) cannulation is not
straightforward. The operator typically uses counterclockwise
torque to cannulate the CS. Once the CS has been cannulated,
clockwise torque needs to be applied to turn the sheath or
guiding catheter towards a ventricular vein. Often the posterior
vein will be cannulated in this rotation and can be used. If,
however, because of phrenic nerve stimulation or absence of
good pacing thresholds within the vein, the guiding sheath or cath-
eter can be withdrawn from this vein whereas continuing to apply
clockwise torque. The MCV can then be cannulated just before the
sheath or catheter slips out of the CS. Once entered the pacing
lead can then be placed in this vein and carefully manoeuvred to
the left ventricular free wall.12,14,16 Figure 8 Epicardial fat is seen close to the ostium of the CS,
The venous drainage of the lateral wall of the ventricle is variable particularly in the right anterior oblique (RAO) view (left
and typically gives multiple options for the implanter.33,34 panel). A lead or catheter placed in the CS will be seen proceed-
ing towards the left in the LAO view (right panel). In the RAO
Because of the posterior and posterior lateral veins can form
view the ventricular veins are seen anteriorly and the atrial
various angles with the main body of the CS inexperienced oper-
veins posteriorly. Note the position of the bundle of His
ators may not realize that this vein has been cannulated and
(coloured in green).
unnecessarily withdraw the catheter or guiding sheath. When
doubt exists as a result of prior knowledge of the anatomy of
this region venography or ultrasound imaging is required. Some- on the right. In addition, this venous system provides drainage to
times a common ostium for the posterior and MCV occurs and the right appendage as well as a significant portion of the muscular
may need specific cannulation either for placement of pacing ventricular septum.
leads or ablation of posterior epicardial accessory pathways.
References
1. Alonso C, Leclercq C, dAllonnes FR, Pavin D, Victor F, Mabo P et al. Six year
experience of transvenous left ventricular lead implantation for permanent biven-
tricular pacing in patients with advanced heart failure: technical aspects. Heart
2001;86:405 10.
2. Gerber TC, Kantor B, Keelan PC, Hayes DL, Schwartz RS, Holmes DR. The coron-
ary venous System: an alternate portal to the myocardium for diagnostic and thera-
peutic procedures in invasive cardiology. Curr Interv Cardiol Rep 2000;2:27 37.
3. Grzybiak M. Morphology of the CS and contemporary cardiac electrophysiology.
Folia Morphol (Warsz) 1996;55:272 3.
4. Abraham W, Leon A, Hannon C, Prather W, Fieberg A. Results of the InSync III
Marquis clinical trial. Heart Rhythm 2005;2:S65 (Abstract).
5. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E et al. Cardiac
Figure 9 Reconstructed computed tomography image showing
resynchronization in chronic heart failure. N Engl J Med 2002;346:1845 53.
the coronary veins. Note the complex origin of the MCV close to 6. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.
the ostium of the CS. In this patient there is a paucity of venous The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): ration-
drainage of the posterolateral wall. ale, design and end-points. Eur J Heart Fail 2001;3:481 9.
7. Asirvatham S, Packer DL Evidence of electrical conduction within the CS muscu-
lature by non-contact mapping. Circulation 1999;100 (Abstract).
8. Gilard M, Mansourati J, Etienne Y, Larlet JM, Truong B, Boschat J et al. Angio-
Perhaps more importantly accurate radiographic anatomy is graphic anatomy of the CS and its tributaries. Pacing Clin Electrophysiol 1998;21:
needed with standardized fluoroscopic views [right and left 2280 4.
9. Giudici M, Winston S, Kappler J, Shinn T, Singer I, Scheiner A et al. Mapping the
anterior oblique (LAO) projections] to guide placement of leads CS and great cardiac vein. Pacing Clin Electrophysiol 2002;25:414 9.
and sheath of catheter cannulation of the main body of this vein. 10. DCruz IA, Shala MB, Johns C. Echocardiography of the CS in adults. Clin Cardiol
In the LAO projection, when cannulating the CS, the lead catheter 2000;23:149 54.
11. Ortale JR, Gabriel EA, Iost C, Marquez CQ. The anatomy of the CS and its tribu-
will be seen to move leftward after entry.14,33,34 In the RAO pro- taries. Surg Radiol Anat 2001;23:1521.
jection, catheter or lead movement towards the sternum 12. Schaffler GJ, Groell R, Peichel KH, Rienmuller R. Imaging the coronary venous
(anterior) signifies cannulation of ventricular vein where as pos- drainage system using electron-beam CT. Surg Radiol Anat 2000;22:359.
13. Cendrowska-Pinkosz M, Urbanowicz Z. Analysis of the course and the ostium of
terior deflection or orientation suggests that an atrial vein has the oblique vein of the left atrium. Folia Morphol (Warsz) 2000;59:163 6.
been entered. 14. Asirvatham S. Anatomy of the CS. In: Cheuk-Man Y (ed). Cardiac Resynchronization
Multi-slice CT is used increasingly as a non-invasive alternative Therapy. Oxford: Blackwell Publishing; 2006. p. 211 38.
15. Moore K, Persaud T. Before We are Born: Essentials of Embryology and Birth Defects.
for preoperative evaluation of the coronary arteries and cardiac 7th ed. Philadelphia: Saunders Elsevier; 2003.
veins (Figure 9). On CT scans, the CS appears to average 30 mm 16. von Ludinghausen M. Clinical anatomy of cardiac veins, Vv. cardiacae. Surg Radiol
in length (2140 mm) with an average diameter of 9 mm Anat 1987;9:159 68.
17. Ludinghausen M, Ohmachi N, Boot C. Myocardial coverage of the CS and related
(4 14 mm).12 The CS is clearly visible with contrast material and veins. Clin Anat 1992;5:1 15.
is identified by its characteristic vertical segment superiorly that 18. Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J et al.
then forms a bend or a turn to join a horizontal segment CS-ventricular accessory connections producing posteroseptal and left posterior
accessory pathways: incidence and electrophysiological identification. Circulation
inferiorly. The horizontal segment corresponds with the right 2002;106:1362 7.
atrial termination of the CS whereas the vertical segment, due to 19. Dobosz PM, Kolesnik A, Aleksandrowicz R, Ciszek B. Anatomy of the valve of the
its perpendicular orientation to the CT cross-sectional slice, may coronary (Thebesian valve). Clin Anat 1995;8:438 9.
20. Duda B, Grzybiak M. Variability of valve configuration in the lumen of the CS in
be observed as a round density on some scans. The bend or the adult human hearts. Folia Morphol (Warsz) 2000;59:207 9.
turn of the sinus, due to its oblique orientation, is seen as an 21. Gami A, Edwards W, Lachman N, Friedman P, Talreja D, Munger T et al. Electro-
oval density.36 physiological anatomy of typical atrial flutter: the posterior boundary and causes
for difficulty with ablation. J Cardiac Electrophysiol 2009; Epub ahead of print.
22. Aronson RS, Cranefield PF, Wit AL. The effects of caffeine and ryanodine on the
electrical activity of the canine CS. J Physiol 1985;368:593 610.
Summary 23. Olgin JE, Jayachandran JV, Engesstein E, Groh W, Zipes DP. Atrial macroreentry
involving the myocardium of the CS: a unique mechanism for atypical flutter.
Accurate knowledge of the coronary venous anatomy is essential J Cardiovasc Electrophysiol 1998;9:1094 9.
for electrophysiologists performing left ventricular pacing pro- 24. Takatsuki S, Mitamura H, Ieda M, Ogawa S. Accessory pathway associated with an
cedures or radiofrequency ablation. Although many variations anomalous coronary vein in a patient with Wolff ParkinsonWhite syndrome.
J Cardiovasc Electrophysiol 2001;12:1080 2.
occur constant features include a large anterior interventricular 25. Volkmer M, Antz M, Hebe J, Kuck KH. Focal atrial tachycardia originating from the
vein that continues in the left atrial ventricular groove as the musculature of the CS. J Cardiovasc Electrophysiol 2002;13:68 71.
Cardiac venous system v21
26. Hill AJ, Ahlberg SE, Wilkoff BL, Iaizzo PA. Dynamic obstruction to CS access: the 31. Duda B, Grzybiak M. Main tributaries of the CS in the adult human heart. Folia
Thebesian valve. Heart Rhythm 2006;3:1240 1. Morphol (Warsz) 1998;57:363 9.
27. Anh DJ, Eversull CS, Chen HA, Mofrad P, Mourlas NJ, Mead RH et al. Character- 32. Jongbloed MR, Lamb HJ, Bax JJ, Schuijf JD, de Roos A, van der Wall EE et al. Non-
ization of human CS valves by direct visualization during biventricular pacemaker invasive visualization of the cardiac venous system using multislice computed tom-
implantation. Pacing Clin Electrophysiol 2008;31:7882. ography. J Am Coll Cardiol 2005;45:749 53.
28. Webb JG, Harnek J, Munt BI, Kimblad PO, Chandavimol M, Thompson CR et al. 33. Ruengsakulrach P, Buxton BF. Anatomic and hemodynamic considerations influ-
Percutaneous transvenous mitral annuloplasty: initial human experience with encing the efficiency of retrograde cardioplegia. Ann Thorac Surg 2001;71:
device implantation in the CS. Circulation 2006;113:851 5. 1389 95.
29. Hwang C, Wu TJ, Doshi RN, Peter CT, Chen PS. Vein of Marshall cannulation for 34. Sethna DH, Moffitt EA. An appreciation of the coronary circulation. Anesth Analg
the analysis of electrical activity in patients with focal atrial fibrillation. Circulation 1986;65:294 305.
2000;101:1503 5. 35. von Ludinghausen M, Ohmachi N, Besch S, Mettenleiter A. Atrial veins of the
30. Kim DT, Lai AC, Hwang C, Fan LT, Karagueuzian HS, Chen PS et al. The ligament human heart. Clin Anat 1995;8:16989.
of Marshall: a structural analysis in human hearts with implications for atrial 36. Micklos TJ, Proto AV. CT demonstration of the CS. J Comput Assist Tomogr 1985;9:
arrhythmias. J Am Coll Cardiol 2000;36:1324 7. 60 4.