Congenital Anomaly Diagnosis of Typical Cardiac Chest Pain Due to Thebesian Veins Draining Into the Left Ventricular Chamber: A Case Report and Review of Literature.

Thebesian veins are microfistulae that drain the coronary arteries directly into one or more chambers of the heart. Persistence of these anomalous connections into adulthood can lead to shunting of blood away from the myocardium causing typical chest pain symptoms with electrocardiogram changes consistent with ischemia. We describe a case of a 77-year-old female who underwent ischemic evaluation for her symptoms found to have significant Thebesian veins. We also engage in a comprehensive review of the literature finding consistencies in the way these cases are presented in the literature.

Abnormally Enlarged Singular Thebesian Vein in Right Atrium.

Thebesian veins in the heart are subendocardial venoluminal channels and are usually less than 0.5 mm in diameter. The system of TV either opens a venous (venoluminal) or an arterial (arterioluminal) channel directly into the lumen of the cardiac chambers or via some intervening spaces (venosinusoidal/ arteriosinusoidal) termed as sinusoids. Enlarged thebesian veins are reported in patients with congenital heart disease and usually, multiple veins are enlarged. Very few reports of such abnormal enlargement are there in the absence of congenital heart disease, but in all such cases, they are multiple and in association with coronary artery microfistule. We report a very rare case of a singular thebesian vein in the right atrium, which was abnormally enlarged. It is important to recognize because it can be confused with other cardiac structures like coronary sinus during diagnostic or therapeutic catheterization and can lead to cardiac injury and complications if it is attempted to cannulate it or pass the guidewires.

Prominent Thebesian Veins in Association With Takotsubo Cardiomyopathy.

Thebesian veins are microvascular connections from the coronary arterial supply directly into the heart chambers. While they play an important role in providing nourishment to the myocardium by maintaining adequate perfusion, they are also responsible for a physiologic right to left shunt in the body's circulation. We present a case report of this rare anatomic finding of extensive Thebesian veins causing acute coronary syndrome and Takostubo cardiomyopathy.

Coronary-Cameral Fistula, Thebesian Veins, and Anomalous Coronary Vein on Cardiac Computed Tomography.

A 63-year-old female with a history of hypertension presented with progressively worsening shortness of breath. She underwent a cardiac catheterization and was found to have prominent Thebesian veins as well as anomalous connections between the proximal right coronary artery and the right ventricle. Cardiac computed tomography was ordered for further evaluation and showed a coronary fistula to the right ventricular outflow tract confirming the diagnosis of a coronary-cameral fistula (CCF). CCF are rare congenital anomalous communications that occur between coronary arteries and a cardiac chamber. They are usually an incidental finding and patients are rarely symptomatic. As the use of coronary computed tomography angiography is rapidly expanding, the detection of CCF will likely increase in the general population.

Prominent Thebesian veins, a rare congenital coronary anomaly presenting as acute myocardial ischemia.

Persistent Thebesian veins with the appearance of multiple coronary artery microfistulas are a rare finding and little is known about their physiologic and clinical features. In addition, few reports have demonstrated the perfusion status of patients with Thebesian veins. We report a 75-year-old woman referred for non-ST-elevation myocardial infarction due to prominent Thebesian veins who displayed a perfusion defect in cardiac magnetic resonance imaging. .

Thebesian veins as drainage to the ventricle: A case report.

A 64-year old woman was referred to the division of cardiology due to recurrent angina pectoris (CCS III). The patient's symptoms and high cardiovascular risk profile were an indication for coronary angiography. Relevant coronary heart disease was hereby ruled out; however, angiography showed a direct drainage of coronary vessels into the chambers. These Thebesian veins are of venoluminal nature in most cases and have a clinical implication in selected cases only.

Angiographically detectable Thebesian veins are a dynamic and reversible finding in the setting of congenital heart disease.

OBJECTIVE: Angiographically detectable Thebesian veins (ThVs) are a rare finding sometimes associated with coronary steal and myocardial ischemia in adults, but there are limited data regarding prominent ThVs in the setting of complex congenital heart disease (CHD). This study represents the largest series to date describing the presence and temporal changes of angiographically detectable ThVs in children with CHD. METHODS: This is a single center case series describing the clinical characteristics and coronary anatomy in children with CHD and angiographicall detectable ThVs. After identification of the index case, additional patients were identified in a prospective manner during the course of routine clinical care. We developed a qualitative scale to grade ThV burden, with changes tracked over time in the subset of patients who underwent serial cardiac catheterizations. RESULTS: A total of 10 patients are included in this report. There was a predominance of female gender (8 of 10 patients), right-dominant single ventricle physiology (7 of 10 patients), and heterotaxy syndrome (6 of 10 patients). The degree and location of epicardial coronary artery tortuosity was qualitatively related to ThV burden. The subset of patients who underwent serial cardiac catheterizations demonstrate that ThV dilation can progress or regress over time. CONCLUSIONS: Angiographically detectable Thebesian veins are a rare finding in patients with congenital heart disease and may represent global changes in the coronary circulation. This is the first report, adult or pediatric, to demonstrate that ThV dilation is a dynamic process capable of both progression and regression. The physiologic impact of these findings remains to be elucidated.

Persistent thebesian vessels involving the right and left ventricles leading to coronary steal phenomena and ischemia.

We report an extremely rare case of thebesian vein microfistulae to both ventricles. A 65-year-old woman, with no major cardiovascular risk factors, presented with multiple episodes of chest pain. The resting electrocardiogram showed T-wave inversion in leads V(1) -V(4). A Dipyridamole myocardial perfusion imaging revealed large and severe inferior defect with complete reversibility. Coronary angiography showed no coronary artery disease. On contrast injection, an exaggerated capillary blush from the distal portions of the right and left coronary artery systems was seen in both ventricles, mimicking the image of ventriculography. This appearance suggests prominent thebesian vessels, a congenital communication between the coronaries and the two ventricles. The clinical relevance of these myocardial sinusoids is still not well established. Although the majority of these fistulas are small in size and with no clinical significance, they can rarely present with chest pain, cardiac arrhythmia, syncope, myocardial infarction, and/or pulmonary hypertension. These fistulae when excessive can cause significant shunting of blood to the ventricles, leading to coronary steal phenomena and ischemia. This phenomenon is facilitated by the low resistance in these microfistulae as opposed to the higher resistance in the normal coronary circulation. Due to the diffuse nature of these microfistulae, neither surgery nor transcatheter therapy is feasible. This condition can only be managed medically; however, it should be noted that vasodilator agents, such as nitrates, can worsen the coronary steal phenomenon. Our patient was treated with ranolazine with significant improvement in her symptoms, which was not reported previously. Multiple coronary artery microfistulae could be an underestimated condition of angina in patient with normal coronaries.