European Journal of Echocardiography 2004 5(1):93-96; doi:10.1016/S1525-2167(03)00049-0
© 2004 by European Society of Cardiology
Copyright © 2003, The European Society of Cardiology
Visualization of a coronary sinus valve using intracardiac echocardiography
M.F. Scholten*,
T. Szili-Torok,
A.S. Thornton,
J.R.T.C. Roelandt and
L.J. Jordaens
Department of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands
Received 18 March 2003; received in revised form 9 May 2003; accepted after revision 28 May 2003.
* Corresponding author. Department of Clinical Electrophysiology, Thoraxcentre, Erasmus MC, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Tel.: +31-10-4633991; fax: +31-10-4634420. m.f.scholten{at}erasmusmc.nl
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Abstract
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Cannulation of the coronary sinus (CS) is sometimes difficult
due to the presence of anatomical anomalies. Fluoroscopy is
of limited value in visualizing these variations. This case
is the first to demonstrate how intracardiac echocardiography
(ICE) allows visualization of a valve, which is one of the causes
of problematic cannulation of the CS. Based on information obtained
by ICE an appropriate catheter could be selected.
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1. Introduction
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The coronary sinus (CS) is of special interest to the electrophysiologist
and pacemaker-implanting physician. In electrophysiology (EP)
studies left sided atrio-ventricular recording is routinely
done indirectly from within the CS. The left atrium or the left
ventricle can also be paced via the CS.
1,2 The CS can be cannulated
from the jugular, subclavian or femoral vein and the insertion
of electrode catheters is a routine task for experienced physicians
in most of the patients.
3,4 Occasionally, however, cannulation
of the CS or its tributaries can be extremely difficult because
of anatomical variation in its origin or course and more rarely
the presence of valves. This may result in prolonged procedure
and fluoroscopy times and even failure of the procedure. The
aim of this report is to demonstrate the usefulness of advanced
imaging techniques such as intracardiac echocardiography (ICE)
in identification of the anatomical variations in such patients
and how this may result in a successful procedure.
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2. Case study
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A 56-year-old man, with a 10-year history of recurrent episodes
of palpitations, was referred for EP study and ablation. The
patient had a history of hypertension and diabetes and had undergone
kidney transplantation. He was treated with several anti-arrhythmic
drugs, without reduction in symptoms. An ECG recorded during
palpitations showed a fast regular narrow QRS complex tachycardia,
without visible retrograde P-waves, suggesting the presence
of AV nodal reentrant tachycardia (AVNRT). An EP study was performed
in a nonsedated state. Initially, two diagnostic electrode catheters
were introduced into the high right atrium and onto the anterior
tricuspid annulus in order to record stable atrial and His-potentials.
A pacing electrode was introduced into the right ventricle.
A 5 F decapolar electrode catheter (Supreme CS, Daig Corp, St
Jude Medical Inc, Minnetonka, MN, USA) was inserted through
the left subclavian vein and an attempt was made to advance
it into the CS. The middle cardiac vein was easily cannulated
several times but the distal CS could not be reached. After
several failed attempts a steerable diagnostic catheter (Dynamic
XT, Bard Electrophysiology, Billerica, MA, USA) was further
used to cannulate the CS but without any success. An 8 French
intracardiac echo catheter (ICE 9900, Boston Scientific Inc,
San Jose, CA, USA) was then inserted through the left femoral
vein using a 60 cm long vascular sheath (Boston 5662, Boston
Scientific Inc, San Jose, CA, USA). As this ICE catheter provides
horizontal cross-sectional images, it was placed at the level
of the CS ostium. ICE showed a thin membrane located approximately
3 cm from the ostium of the CS (
Fig. 1), measured by ICE. Thereafter,
a diagnostic angiography catheter (Amplatz L1, Cordis Europe,
Roden, The Netherlands) was introduced through the right femoral
vein and positioned in the ostium of the CS and a radiographic
contrast injection was performed. Retrograde filling of the
CS was very limited (
Fig. 2), but echocardiography showed the
appearance of contrast material distal to a membranous structure
in the CS. These findings led to the hypothesis that the distal
portion of the CS could be reached using a very thin, non-conventional
electrode catheter. Therefore a 2.5 F octapolar, diagnostic
microcatheter (Pathfinder 8, Cardima Inc, Fremont, CA, USA)
was chosen and successfully introduced into the CS via the angiographic
catheter (
Fig. 3). The diagnostic EP study confirmed the absence
of accessory pathways and successful radiofrequency ablation
of the slow pathway of the AV node was then performed.
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Figure 1 Horizontal cross-sectional image as obtained with ICE. A thin membrane (arrow) is visible inside the CS approximately 3 cm from the ostium. The transducer is in the center of the image (ICE). RA: right atrium.
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3. Discussion
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The CS opens into the right atrium between the inferior vena
cava and the tricuspid valve orifice, and its ostium is guarded
by an endocardial fold. This crescent shaped valve of the CS
is also known as the Thebesian valve. The tributaries of the
CS are the great, small and middle cardiac veins, the posterior
vein of the left ventricle and the oblique vein of the left
atrium (Marshall's vein). All except the last may potentially
have valves at their orifices.
5 In the majority of individuals
the great cardiac vein has a prominent valve where the vein
turns around the obtuse margin to become the CS.
6 This valve
was first described in 1706 by the French scientist R. Vieussens
in his book "Nouvelles découvertes sur le coeur".
7 Other
single or double parietal venous valves in the CS have been
described.
8 Until recently, all anatomical variants were known
from post-mortem human studies only. Although there is anecdotal
reference to these valves when difficulties are encountered
during interventions to enter the CS, there is no study, which
provides direct evidence thereof. One of the reasons is that
fluoroscopy—which is an almost exclusive visual tool for
guiding EP procedures—does not allow visualization of
small anatomical structures. The resolution of transthoracic
echocardiography is too limited to visualize these small valves
and is cumbersome anyway during interventions. Transesophageal
echocardiography (TEE) provides better imaging for intracardiac
structure identification, but requires general anesthesia, because
TEE causes significant patient discomfort during lengthy procedures.
Recently ICE became available, providing excellent image accuracy
and direct visualization of small anatomical structures.
9,10 The case presented illustrates the limited value of fluoroscopy
in visualization of important anatomical structures during EP
procedures. Immediately after insertion of the ICE imaging tool,
the correct diagnosis was made and the appropriate catheter
was selected for the remaining part of the EP study.
In conclusion, this is the first report showing in vivo images of a valve in the CS. According to anatomical studies this valve is most likely a parietal valve. We also demonstrate that improved imaging can effectively modify the procedural strategy and therefore may improve the outcome of procedures in the CS.
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References
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- http://www.bium.univ-paris5.fr. Histoire de la Medecine et de l'art dentaire.
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- Szili-Torok T., Kimman G.P., Theuns D.A.M.J., Res T., Roelandt J.R.T., Jordaens L.J. Visualisation of intracardiac structures and radiofrequency lesions using intracardiac echocardiography. Eur J Echocardiogr (2003) 4:17–22.[CrossRef][Medline]
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Abstract
1. Introduction
