Surgical management of multiple coronary artery to coronary sinus fistulas with giant left circumflex artery and multivalvular infective endocarditis.

Coronary artery fistula (CAF) is characterized as a congenital or acquired abnormal communication between a coronary artery and any of the four chambers of the heart (coronary-cameral fistula) or great vessels (coronary arteriovenous fistula) bypassing the capillaries within myocardium. CAF is a rare disease, challenging to diagnose and treat depending on the anatomical location and type of the fistula and accompanying diseases. This study aims to report a case with multiple coronary artery to coronary sinus (CS) fistulas with giant left circumflex artery and multivalvular infective endocarditis.

Coronary sinus reducer for the treatment of refractory angina (ORBITA-COSMIC): a randomised, placebo-controlled trial.

BACKGROUND: The coronary sinus reducer (CSR) is proposed to reduce angina in patients with stable coronary artery disease by improving myocardial perfusion. We aimed to measure its efficacy, compared with placebo, on myocardial ischaemia reduction and symptom improvement. METHODS: ORBITA-COSMIC was a double-blind, randomised, placebo-controlled trial conducted at six UK hospitals. Patients aged 18 years or older with angina, stable coronary artery disease, ischaemia, and no further options for treatment were eligible. All patients completed a quantitative adenosine-stress perfusion cardiac magnetic resonance scan, symptom and quality-of-life questionnaires, and a treadmill exercise test before entering a 2-week symptom assessment phase, in which patients reported their angina symptoms using a smartphone application (ORBITA-app). Patients were randomly assigned (1:1) to receive either CSR or placebo. Both participants and investigators were masked to study assignment. After the CSR implantation or placebo procedure, patients entered a 6-month blinded follow-up phase in which they reported their daily symptoms in the ORBITA-app. At 6 months, all assessments were repeated. The primary outcome was myocardial blood flow in segments designated ischaemic at enrolment during the adenosine-stress perfusion cardiac magnetic resonance scan. The primary symptom outcome was the number of daily angina episodes. Analysis was done by intention-to-treat and followed Bayesian methodology. The study is registered with ClinicalTrials.gov, NCT04892537, and completed. FINDINGS: Between May 26, 2021, and June 28, 2023, 61 patients were enrolled, of whom 51 (44 [86%] male; seven [14%] female) were randomly assigned to either the CSR group (n=25) or the placebo group (n=26). Of these, 50 patients were included in the intention-to-treat analysis (24 in the CSR group and 26 in the placebo group). 454 (57%) of 800 imaged cardiac segments were ischaemic at enrolment, with a median stress myocardial blood flow of 1·08 mL/min per g (IQR 0·77-1·41). Myocardial blood flow in ischaemic segments did not improve with CSR compared with placebo (difference 0·06 mL/min per g [95% CrI -0·09 to 0·20]; Pr(Benefit)=78·8%). The number of daily angina episodes was reduced with CSR compared with placebo (OR 1·40 [95% CrI 1·08 to 1·83]; Pr(Benefit)=99·4%). There were two CSR embolisation events in the CSR group, and no acute coronary syndrome events or deaths in either group. INTERPRETATION: ORBITA-COSMIC found no evidence that the CSR improved transmural myocardial perfusion, but the CSR did improve angina compared with placebo. These findings provide evidence for the use of CSR as a further antianginal option for patients with stable coronary artery disease. FUNDING: Medical Research Council, Imperial College Healthcare Charity, National Institute for Health and Care Research Imperial Biomedical Research Centre, St Mary's Coronary Flow Trust, British Heart Foundation.

A rare case of isolated persistent left superior vena cava diagnosed by echocardiography.

BACKGROUND: The persistent left superior vena cava (PLSVC) is an infrequent vascular variant. PLSVC with absent right superior vena cava, also known as isolated PLSVC, is an exceptionally rare entity. In this case we present a patient with isolated PLSVC draining to coronary sinus, diagnosed incidentally during echocardiography. CASE PRESENTATION: A 35-year-old man underwent a transthoracic echocardiography which showed an enormously dilated coronary sinus. Hand-agitated saline was injected via peripheral intravenous cannulas. The contrast appeared firstly in the coronary sinus before it opacified the right atrium. Since this was also visible by the right antecubital saline injection, it indicated an extremely rare case of PLSVC with the absence of right superior vena cava which was confirmed by cardiac magnetic resonance. CONCLUSIONS: The finding of a distinctively dilated coronary sinus in echocardiography led us to further investigation using agitated saline that revealed an infrequent anomaly termed isolated PLSVC. The in-depth diagnosis of this vascular variant is crucial considering that it may lead to important clinical implications, such as difficulties with central venous access, especially in the current era of a rapid development of cardiac device therapies.

Left coronary sinus of valsalva aneurysm dissecting into interventricular septum: a case report.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is an extremely rare condition, and its rupture causes acute symptoms such as chest pain and dyspnea. Ruptured SVA is frequently associated with other congenital defects. CASE PRESENTATION: A 37-year-old male presented with SVA originating from the left coronary sinus that ruptured into the interventricular septum. SVA was diagnosed by echocardiography, cardiac computed tomography and magnetic resonance imaging, and confirmed during the operation. CONCLUSIONS: SVA is a rare cardiac abnormality which can lead to severe clinical symptoms upon rupture. Immediate surgery is necessary to repair the ruptured SVA.

Anatomical Study of the Cardiac Veins and their Tributaries in Bovines (Bos indicus) in Comparison with Humans and Other Animal Species / Estudio Anatómico de las Venas Cardiacas y sus Tributarias en Bovinos (Bos indicus) en Comparación con Humanos y Otras Especies Animales

SUMMARY: In bovines, anatomical observations of the coronary vascular tree describe qualitative characteristics. The objective of this study was to morphometrically characterize the coronary veins and their tributaries in cattle. An arcuate application with 2.0 silk was performed around the ostium of the coronary sinus of 28 bovine hearts and a number 14 catheter was placed, through which semi- synthetic polyester resin and mineral blue color was perfused. In 22 hearts (78.6 %) the great cardiac vein was originated at the cardiac apex. The configuration of the arteriovenous trigone was mainly closed inferior and superior types (50 %). The caliber of the great cardiac vein at the level of the atrioventricular sulcus was 6.7 +/- 1.2 mm. The origin of the left marginal vein was observed in the lower third of the left cardiac margin (53.6 %), its distal caliber was 4.1 +/- 0.8 mm and its drainage was at the level of the great cardiac vein. The middle cardiac vein originated from the cardiac apex in 78.6 % of the samples, emptied mainly into the coronary sinus (82.1 %) and its distal caliber was 4.7 +/- 0.9 mm. Anastomoses occurred in 28.6 % of the hearts, being found in most cases between the middle cardiac vein and the great cardiac vein (50 %), which was significant compared to other anastomoses (p<0.001). The length of the coronary sinus was 42.2 +/- 5.1 mm, its distal caliber was 13.8 +/- 2 mm, and its shape was cylindrical. Myocardial bridges were found in 3 hearts (10.7 %) mainly in the lower third of the middle cardiac vein (66.6 %). Most of the main coronary veins drained into the coronary sinus, with some cases with atypical outlets and the presence of a high percentage of anastomosis that serves to improve cardiac venous drainage in case of venous compression or obstruction.

En bovinos, las observaciones anatómicas de árbol vascular coronario describen características cualitativas. El objetivo de este estudio fue caracterizar morfométricamente las venas coronarias y sus tributarias en bovinos. Se realizó una aplicatura arciforme con seda 2.0 alrededor del ostium del seno coronario de 28 corazones de bovino y se colocó un catéter número 14, a través del cual se perfundió resina de poliéster semisintética y color azul mineral. La vena cardiaca magna se originó en 22 corazones (78,6 %) en el ápex cardiaco. La configuración del trígono arteriovenoso fue principalmente cerrado inferior y superior (50 %). El calibre de la vena cardiaca magna a nivel del surco atrioventricular fue 6,7 +/- 1,2 mm. El origen de la vena marginal izquierda se observó en el tercio inferior del margen izquierdo cardiaco (53,6 %), su calibre distal fue 4,1 +/- 0,8 mm y su desembocadura fue a nivel de la vena cardiaca magna. La vena cardiaca media se originó en el ápex cardiaco en el 78,6 % de las muestras, desembocó principalmente en el seno coronario (82.1 %) y su calibre distal fue 4,7 +/- 0,9 mm. Se presentó anastomosis en el 28,6 % de los corazones, encontrándose en la mayoría de los casos entre la vena cardiaca media y la vena cardiaca magna (50 %), lo cual fue significativo en comparación con otras anastomosis (p<0,001). La longitud del seno coronario fue 42,2 +/- 5,1 mm, su calibre distal fue 13,8 +/- 2 mm y su forma fue cilíndrica. Se encontró puentes miocárdicos en 3 corazones (10,7 %) y en el tercio inferior de la vena cardiaca media (66,6 %). La mayoría de las venas coronarias principales desembocan en el seno coronario, con algunos casos con desembocaduras atípicas y la presencia de un alto porcentaje de anastomosis que sirve para mejorar el drenaje venoso cardiaco en caso de compresión u obstrucción venosa.

Myocardial Blood Flow Determination From Contrast-Free Magnetic Resonance Imaging Quantification of Coronary Sinus Flow.

BACKGROUND: Determination of myocardial blood flow (MBF) with MRI is usually performed with dynamic contrast enhanced imaging (MBFDCE ). MBF can also be determined from coronary sinus blood flow (MBFCS ), which has the advantage of being a noncontrast technique. However, comparative studies of MBFDCE and MBFCS in large cohorts are lacking. PURPOSE: To compare MBFCS and MBFDCE in a large cohort. STUDY TYPE: Prospective, sequence-comparison study. POPULATION: 147 patients with type 2 diabetes mellitus (age: 56+/-12 years; 106 male; diabetes duration: 12.9+/-8.1 years), and 25 age-matched controls. FIELD STRENGTH/SEQUENCES: 1.5 Tesla scanner. Saturation recovery sequence for MBFDCE vs. phase-contrast gradient-echo pulse sequence (free-breathing) for MBFCS . ASSESSMENT: MBFDCE and MBFCS were determined at rest and during coronary dilatation achieved by administration of adenosine at 140 µg/kg/min. Myocardial perfusion reserve (MPR) was calculated as the stress/rest ratio of MBF values. Coronary sinus flow was determined twice in the same imaging session for repeatability assessment. STATISTICAL TESTS: Agreement between MBFDCE and MBFCS was assessed with Bland and Altman's technique. Repeatability was determined from single-rater random intraclass and repeatability coefficients. RESULTS: Rest and stress flows, including both MBFDCE and MBFCS values, ranged from 33 to 146 mL/min/100 g and 92 to 501 mL/min/100 g, respectively. Intraclass and repeatability coefficients for MBFCS were 0.95 (CI 0.90; 0.95) and 5 mL/min/100 g. In Bland-Altman analysis, mean bias at rest was -1.1 mL/min/100 g (CI -3.1; 0.9) with limits of agreement of -27 and 24.8 mL/min/100 g. Mean bias at stress was 6.3 mL/min/100 g (CI -1.1; 14.1) with limits of agreement of -86.9 and 99.9. Mean bias of MPR was 0.11 (CI: -0.02; 0.23) with limits of agreement of -1.43 and 1.64. CONCLUSION: MBF may be determined from coronary sinus blood flow, with acceptable bias, but relatively large limits of agreement, against the reference of MBFDCE . LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2.

Interrupted inferior vena cava draining into the coronary sinus associated with circumflex artery to coronary sinus fistula.

In an adult patient, coronary artery fistula involving the circumflex artery (CX) connected to the coronary sinus caused aneurysm of the left main and CX associated with ectasia of the intermediate branch. The patient had posterolateral infarction with severe ischemic mitral regurgitation and moderate tricuspid regurgitation. A rare venous return anomaly was also present. The inferior vena cava, which was interrupted at the level of the liver, continued with the hemiazygos to drain into a persistent left superior vena cava, which in turn drained into the coronary sinus. Surgery included CX closure and mitral and tricuspid repair. The strategy had to be adapted to the anatomy. The fistula was dissected and snared for cardioplegia delivery, and venous return was achieved by cannulation of the superior vena cava and femoral vein. The procedure was uneventful, and 4 years later the patient is asymptomatic.

Coronary sinus ablations in pediatric patients with supraventricular arrhythmias.

BACKGROUND: Intracoronary sinus ablations have been performed for various arrhythmical substrates. The aim of this study is to report our experience on pediatric patients of the safety and efficacy of ablations in the coronary sinus. METHODS: This is a retrospective study of all patients who underwent ablations in the coronary sinus from October 2013 to October 2021 at a single center. Clinical presentation, type of arrhythmia causing tachycardia, ablation procedure, and outcome were recorded. RESULTS: A total of 27 patients were included in the study. Nineteen (69%) of those followed up received a diagnosis of Wolff-Parkinson-White syndrome (WPW), 4 (15%) were cases of supraventricular tachycardia with concealed accessory pathway (AP), 2 (8%) were cases of focal atrial tachycardia, and 2 (8%) were cases of permanent junctional reciprocating tachycardia. Negative delta wave was noteworthy especially in lead II in 11/19 (58%) cases and coronary sinus diverticulum was detected in the WPW cases. Of those with manifest AP (19 cases), 15 (79%) had a high-risk AP and the AP in all WPW cases was adenosine unresponsive. Radiofrequency (RF) catheter ablation was performed in 25/27 (93%) cases during the procedure, and 16/25 (64%) of these were irrigated RF catheters. No complications were observed in the follow-up, including coronary artery injury. CONCLUSIONS: Catheter ablation of supraventricular tachyarrhythmias can be accomplished effectively and potentially safely within the coronary sinus. Coronary sinus diverticula should be suspected in patients with manifest posteroseptal APs who have a previous failed ablation and typical electrocardiographic signs.

Management of anomalous origin of right coronary artery from left coronary sinus.

Aberrant origin of coronary artery is a rare congenital anomaly associated with increased risk of myocardial ischemia and sudden death, with the highest risk lesions being those arising from the opposite sinus of Valsalva. We report a case with an aberrant right coronary artery arising superior to the left coronary cusp, with a slit-like ostium, having an inter-arterial and intramural course through the aortic root, that underwent repositioning of the right coronary artery. We believe such cases warrant surgical correction and reimplantation is a safe, effective and reproducible technique.

Contrast removal from coronary sinus for prevention of contrast-induced nephropathy: a review.

The occurrence of contrast-induced-nephropathy (CIN) is related to the amount of contrast administration. Any removal of contrast from systemic circulation before reaching the kidneys might be beneficial using a device that removes contrast from a coronary sinus (CS). This manuscript aims to review the available literature regarding contrast removal from CS during coronary angiography or intervention for the prevention of CIN.

Surgical repair of an unroofed coronary sinus in a dog.

A 5-year-old, 7.9 kg castrated male Miniature Dachsund presented with heart enlargement on radiography. The dog was asymptomatic. Echocardiography revealed a tubular structure running along the posterior wall of the left atrium and connecting to the right atrium on the caudal side of the left atrium and annulus, which was presumed to be a dilated coronary sinus. After confirming a shunt between the left atrium and coronary sinus by cardiovascular catheterization, an unroofed coronary sinus was diagnosed. Open-heart surgery using cardiopulmonary bypass was performed through left atriotomy. The defect between the left atrium and the coronary sinus was closed by suturing. The cardiac enlargement improved after surgery. The dog was still alive 1227 days after surgery without clinical signs.

Anomalous circumflex artery: a benign variant generating a malignant potential after valve surgery.

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery.

Unroofing of an anomalous right coronary artery originating from the left coronary sinus.

Coronary abnormalities, including the anomalous aortic origin of a coronary artery, coronary fistula and myocardial bridge, are among the most common congenital cardiovascular anomalies. A left coronary artery arising from the right cusp is less common than the right coronary artery arising from the left cusp but is more often found in autopsy series of sudden cardiac deaths. A slit-like/fish-mouth-shaped orifice, acute angle take-off, intramural course, interarterial course and hypoplasia of the proximal coronary artery have all been proposed as reasons for symptoms, ischaemia and sudden cardiac death. Surgical intervention is recommended for those patients with signs or symptoms of myocardial ischaemia. Intervention in asymptomatic patients with an interarterial/intramural left coronary artery from the right sinus of Valsalva is recommended due to the higher calculated risk of sudden cardiac death. In asymptomatic patients with an intramural right coronary artery from the left sinus of Valsalva, provocative testing is recommended. The slit-like orifice is more commonly seen in an anomalous right coronary artery arising from the left sinus, and we believe it is the major factor responsible for myocardial ischaemia. Our unroofing technique focuses on: (i) transecting the endothelial tissue flap to create a neo-ostium; (ii) limiting the flap resection to the intramural portion to avoid extra-aortic incision; and (iii) marsupialization of a neo-ostium with interrupted sutures to reapproximate the endothelium and prevent aortic dissection.

Echocardiographic imaging of a bifurcated double barrel coronary sinus.

BACKGROUND: The coronary sinus (CS) is the terminal collecting vessel of the myocardial venous network, which returns deoxygenated blood used by the heart to the right atrium. The advent of high-fidelity imaging via CT and transesophageal echocardiography (TEE) has further defined the anatomy of the CS and its multiple tributaries. Understanding this anatomy is crucial for cardiac surgical cases that require the cannulation of the coronary sinus to deliver retrograde cardioplegia. However, anatomical variants of the CS may frustrate surgical retrograde catheter placement, in turn increasing the risk of CS injury or leading to inadequate cardioplegia delivery. Here, we present an especially unique CS presentation, a bifurcated, double-barrel CS, which was discovered via intraoperative TEE imaging that revealed a CS with two smaller lumens instead of the singular large os. CASE PRESENTATION: A 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant. CONCLUSIONS: Discovery of this patient's double-barrel CS during the pre-bypass TEE was incidental, showing that such anatomical variants may be completely asymptomatic and benign in the non-operative setting. However, the delivery of cardioplegia proved challenging for this patient, highlighting some degree of risk with certain cardiac interventions. This case demonstrates the utility of intraoperative TEE to quickly ascertain unforeseen anatomical variants of the CS which could compromise the safety of cardiac surgery cases.

Retrograde carbon dioxide coronary sinus venography.

It is potentially harmful to perform coronary sinus (CS) angiography in patients with severe contrast allergy or severe renal dysfunction due to the risk of contrast-induced nephropathy (CIN). However, angiography is a well-established method to guide LV-lead position during cardiac resynchronization therapy-implantation. These two case reports describe the first successful applications of carbon dioxide CS angiography in patients requiring cardiac resynchronization therapy.

Coronary Sinus Defect, Premature Restriction of Foramen Ovale and Cysto-Colic Peritoneal Band.

Background: Unroofed coronary sinus is a congenital cardiac anomaly usually associated with persistent left superior vena cava. Premature restriction or closure of foramen ovale is described in association with hypoplastic left heart syndrome. Abdominal peritoneal bands when present manifest clinically. Case report: A 27 years, gravida 2, presented with intrauterine fetal death at 24 weeks gestation due to fetal congestive cardiac failure, cardiomegaly and hydrops. Perinatal autopsy showed absent coronary sinus with cardiac veins draining directly into the heart. There was no persistent left superior vena cava. The foramen ovale was restricted prematurely. The ductus arteriosus was present and non-restrictive. Abdomen showed a cysto-colic peritoneal band. Conclusion: This is the first report showing a triad of (1) complete absence of coronary sinus without left superior vena cava (type-II); (2) premature restriction of foramen ovale without hypoplastic left heart; and (3) a cysto-colic peritoneal band between the gall bladder and colon.

Retrograde fast pathway cryoablation inside the coronary sinus for slow-fast atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava.

INTRODUCTION: Persistent left superior vena cava (PLSVC) is accompanied by enlarged coronary sinus (CS) and deformation of the triangle of Koch. This makes anatomical evaluation of the atrioventricular (AV) nodal pathways difficult. METHODS: We attempted cryoablation of retrograde fast pathway located in the enlarged CS roof of PLSVC for slow-fast AV nodal reentrant tachycardia (AVNRT) induced by inadvertent antegrade fast pathway elimination during ablation of left atrial tachycardia. RESULTS: Slow-fast AVNRT was successfully eliminated without AV block progression. CONCLUSIONS: This is the first case of successful retrograde fast pathway ablation of the CS ostial roof for slow-fast AVNRT with PLSVC.