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Updated: Sep 24, 2025
Anatomical Reconstructions of the Human Cardiac Venous System using Contrast-computed Tomography of Perfusion-fixed Specimens
Published on: April 18, 2013
Anatomical variations in coronary venous drainage: Challenges and solutions in delivering cardiac resynchronization
Zaki Akhtar1,2, Manav Sohal1, Christos Kontogiannis1
1Department of Cardiology, St George's University Hospital, London, UK.
Aims:
To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties.
Methods:
From four implanting institutes, data of all CRT implants between October 2008 and October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted 'normal' anatomy. Patient demographics, procedural detail, and subsequent left ventricle (LV) lead pacing indices were collected.
Results:
From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2 ± 10.6 years in age with an LV ejection fraction of 34 ± 10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), five of which had coronary sinus ostium atresia (CSOA) including two with an "unroofed" coronary sinus (CS); one patient had a unique anomalous origin of the CS and one patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including one case of endocardial LV implant. Pacing follow-up over 37.64 ± 37.6 months demonstrated LV lead threshold between 0.62 and 2.9 volts (pulsewidth 0.4-1.5 ms) in all cases; five patients died within 2.92 ± 1.6 years of a successful implant.
Conclusion:
CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required.
Insights
Cardiac resynchronization therapy (CRT) implants are feasible despite abnormal coronary venous anatomy. Specialized techniques and alternative venous access routes can overcome these challenges for successful left ventricle lead placement.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Cardiac resynchronization therapy (CRT) is a treatment for heart failure.
- Successful CRT requires optimal left ventricle (LV) lead placement, often via the coronary sinus.
- Anatomical variations in the coronary venous system can complicate CRT procedures.
Purpose of the Study:
- To investigate coronary venous system abnormalities in CRT candidates.
- To describe methods for overcoming difficulties in CRT implantation due to venous anomalies.
Main Methods:
- Screened 3548 CRT implants (Oct 2008-Oct 2020) for abnormal cardiac venous anatomy.
- Collected patient demographics, procedural details, and LV lead pacing indices.
- Identified 15 patients (0.42%) with venous abnormalities, including persistent left superior vena cava and coronary sinus ostium atresia.
Main Results:
- 15 patients (0.42%) had abnormal venous anatomy, including persistent left superior vena cava and coronary sinus ostium atresia.
- Successful percutaneous implantation was achieved in 14 patients, often requiring repeat attempts and general anesthesia.
- Alternative venous access routes and techniques were employed for successful LV lead placement.
Conclusions:
- Percutaneous CRT implantation is achievable even with significant coronary venous abnormalities.
- Alternative venous access strategies are crucial for successful implantation in these complex cases.
- Careful pre-procedural planning and adaptable techniques are essential for CRT in patients with venous anomalies.
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