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Angiographic anatomy of the coronary sinus and its tributaries
M Gilard1, J Mansourati, Y Etienne
1Department of Cardiology, Brest University Hospital, Brest, France. Jacques.Boschat@univ-brest.fr
Insights
Left ventricular pacing improves heart failure but requires detailed cardiac vein anatomy. Coronary venography in 100 patients revealed key vein dimensions and variations, crucial for successful lead placement.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Electrophysiology
Background:
- Permanent left ventricular pacing is a recognized treatment for severe heart failure, enhancing hemodynamic and clinical outcomes.
- Successful left ventricular lead implantation relies on accessing tributaries of the coronary sinus (CS).
- Detailed anatomical descriptions of cardiac veins for pacing purposes are limited.
Purpose of the Study:
- To anatomically characterize the coronary sinus and its tributaries for endovenous left ventricular lead implantation.
- To identify anatomical factors influencing the success rate of left ventricular lead placement.
Main Methods:
- Coronary venography was performed simultaneously with coronary angiography in 100 consecutive patients.
- Contrast material was injected into the left coronary artery to visualize cardiac veins.
- Three observers analyzed vein number, dimension, angulation, and position using multiple radiographic views.
Main Results:
- The middle cardiac vein (mean diameter 2.62 mm) and great cardiac vein (mean diameter 3.55 mm) were consistently identified.
- Left posterior vein(s) (LPV) showed variability in number (0-3), size, and angulation (mean diameter 2.25 mm).
- Absence or small diameter (<2 mm) and unfavorable angulation of LPV can impede endovenous lead insertion.
Conclusions:
- Angiographic assessment of CS tributaries' dimensions, tortuosity, number, and angulation predicts successful lead insertion in approximately 85% of cases.
- Current pacing lead technology is suitable for most anatomies, but limitations exist.
- Development of novel, specialized pacing leads is necessary to improve implantation success rates in challenging venous anatomies.
Unlabelled:
Permanent left ventricular pacing has been shown to improve the hemodynamic and clinical status of patients with severe heart failure. To pace the left ventricle, the electrode is implanted in tributaries of the coronary sinus (CS). However, the anatomy of cardiac veins with this purpose in mind has not been described in detail.
Methods:
One hundred consecutive patients admitted for coronary angiography had a simultaneous coronary venography performed after the injection of 8 to 10 mL of contrast material into the left coronary artery. Cardiac veins were analyzed in antero-posterior, left anterior oblique 60 degrees, and right anterior oblique 30 degrees views by three different observers. The number, dimension, angulation, and position of the coronary sinus and of its tributaries were studied.
Results:
Two veins are consistently present: the middle cardiac vein (mean diameter 2.62 +/- 1.26 mm) and the great cardiac vein (mean diameter 3.55 +/- 1.24 mm). The left posterior vein(s) (LPV) (mean diameter 2.25 +/- 1.2 mm) is (are) variable in number (ranging from 0 to 3), size, and angulation. The absence of LPV limits the ability to pace the left ventricle endovenously. The diameter of the vein (< 2 mm) and its angulation may also complicate the insertion of the lead.
Conclusion:
Angiographic analysis of dimensions, tortuosity, number, and angulation of venous tributaries of the CS seems to allow the insertion of commercially available pacing leads in approximately 85% of cases. An increase in this percentage hinges on the development of new, dedicated leads.