SURGICAL ANATOMY OF VENOUS
SYSTEM OF HEART
By- Dr.Jyotindra Singh
TAKE HOME MESSAGE
The Developing Venous System
The Developing Venous System
Formed by vasculogenesis.
3 vital systemic venous drainage - VITELLINE/ UMBILICAL/ CARDINAL
SINUS VENOSUS - RIGHT AND LEFT HORNS - Provide bilateral
The connection of 3 veins on left side regress- CORONARY SINUS
When sinus venosus fail to regress- Persistent left superior vena cava
Remodeling of Abdominal Venous System Occurs
through Obliteration of the Left Supracardinal Vein
Failure of Left Cardinal Veins to Undergo Normal
Regression Leads to Venous Anomalies
LSVC occurs in 0.3% to 0.5%
of the normal population
In 65% of cases, left
brachiocephalic vein is also
4% of patients with CHD have
Usually drains to the coronary
TRIBUTARIES TO CORONARY SINUS
1. The Great Cardiac Vein (v. cordis magna; left coronary vein)
2. The Small Cardiac Vein (v. cordis parva; right coronary vein)
3. The Middle Cardiac Vein (v. cordis media)
.4. The Posterior Vein of the Left Ventricle (v. ventriculi sinistri)
5. The Oblique Vein of the Left Atrium(oblique vein of Marshall)
6. The Right Marginal vein
Lt. common carotid A.
Lt. subclavian A.
Superior vena cava
Right coronary artery
Left coronary artery
Great cardiac vein
(left anterior descending)
Inferior vena cava
Rt. Coronary A
GREAT CARDIAC VEIN
The GCV curves to the left as it leaves the anterior interventricular
groove, to form the base of the triangle of
‘‘ Brocq and Mouchet ”
Left anterior descending and the left circumﬂex arteries form other
GCV related internally to the anterolateral commissure of the mitral
The latter part lay in close relationship to the left circumﬂex artery
After crossing the left circumﬂex artery, the great cardiac vein ended
at the Vieussens valve and continued as the coronary sinus
GREAT CARDIAC VEIN
Patent SVGs and
a patent LIMA to
the 1st diagonal
branch of the LAD.
insertion of the
LIMA skip graft
into the Great
instead of the
GREAT CARDIAC VEIN
Introducing the cardioplegic solution via the coronary
sinus will not perfuse the entire left side of the heart.
Post operatively there will be some myocardial
dysfunction due to non perfusion of the area drained
by Great cardiac vein.
Since the opening of the great cardiac vein in the right
atrium is very close to the interatrial septum it may be
mistaken as an atrial septal defect during cardiac
Selective arterialization of coronary
CVBG – Therapeutic option in patients with diffuse coronary artery
Arterial blood can perform retrograde perfusion through it and
nourish ischemic myocardium.
It helps to ensure sufficient blood flow, reduced thrombosis and
improved graft patency.
Another reason to select middle cardiac vein for arterialization was
that left coronary artery trunk or its branches may lie on the surface of
great cardiac vein for nearly 50% patients.
It means that, when coronary atherosclerosis happens, great cardiac
vein may be oppressed by sclerotic left coronary artery trunk or its
THEBESIAN VENOUS SYSTEM
In the absence of both
LSVC and a Coronary sinus
ostium in the left
atrium, drainage occurs
through enlarged Thebesian
Also, when hypoplastic
cardiac veins fail t o join t h
e coronary sinus, they
empty individually into the
atrial chambers through
dilated Thebesian channels
TRIANGLE OF KOCH
CORONARY SINUS DILATATION
1. Cardiac arrhythmia due
to stretching of the
atrioventricular node and
bundle of His.
2. Obstruction of the left
because of partial occlusion
of the mitral valve.
The coronary sinus is defined as the blood conduit that is a continuation of the great cardiac
vein from the valve of the great cardiac vein to the ostium of the coronary sinus.
The length varies from 3 to 5.5 cm. CS lies in the sulcus between the left atrium and ventricle
Begins proximally at the right atrial orifice and ends distally at the valve of Vieussen's.
The CS receives blood from the ventricular veins during ventricular systole and empties into the
right atrium during atrial systole.
The wall of the CS is made up of striated myocardium that is continuous with the atria, forming
a myocardial sleeve around the venous system
The Thebesian valve is a crescent shaped structure often found guarding the mouth of the CS
as it opens to the right atrium.
(1) absent, 14.7%;
(2) small and crescentric,
(3) large and covering the
entire orifice of the coronary
(4) bars and bands, 5.3%;
(5) threads and networks,
(6) common Eustachian
and Thebesian valves,
(1) the provision of a relatively uniform distribution of cardioplegia
even in the presence of severe coronary artery disease
2) it is effective in the presence of aortic regurgitation
(3) Redo – CABG antegrade cardioplegia is associated with a high
risk of atheromatous embolization from patent grafts
(4) RCP may be an effective method for treating coronary air
(5) it can be given without interrupting the surgical procedure.
Coronary Sinus ANOMALIES
An Absent coronary sinus is always
associated with a persistent left
superior vena cava (PLSVC)
connecting to the left atrium.
A Hypoplastic coronary sinus
occurs when one or more of the
cardiac veins drain directly into the
Atresia or stenosis of the coronary
sinus ostium may occur alone or with
associated cardiac anomalies
Enlargement of the coronary sinus
can be divided into two groups
- with left to right shunt
- without left to right shunt
Unroofed coronary sinus anomaly
CORONARY SINUS ASD
Located – posteriorly and inferiorly in the interatrial septum.
INTERATRIAL SEPTAL TISSUE – separates AV valve
May be associated SECUNDUM ASD.
CLEFT MITRAL VALVE- confluent PRIMUM ASD
PULMONARY VEINS – enter left atrium more superiorly than
usual – when LSVC present with coronary sinus ASD.
Left to right or right to left shunt depending on relative
ventricular compliance/ right atrial pressure.
Figure 1. Transesophageal echocardiography revealed both atrial and right ventricular
enlargement (left), a defect of the partial coronary sinus (middle), and shunt of the left atrium
to the dilated coronary sinus (right) at the near longitudinal plane.
REPAIR OF CORONARY SINUS ASD
Goal – separate systemic & pulmonary return
- eliminate shunting at atrial level
Caution – close to conduction system and pulmonary veins.
ROOFING PROCEDURE - BICAVAL VENOUS CANNULATION
- STANDARD RIGHT ATRIOTOMY
IF ATRIAL SEPTUM INTACT- FOSSA OVALIS IS INCISED
UNROOFED CS- MEDIAL TO PULMONARY VEINS
PERICARDIAL PATCH USED TO COVER THE DEFECT
ATRIAL SEPTUM REPAIRED EITHER PRIMARILY OR WITH
SECOND PERICARDIAL PATCH
UNROOFED CORONARY SINUS SYNDROME
LSVC to left atrium with coronary sinus ASD
LSVC to left atrium with COMMON ATRIUM
Complete unroofing without LSVC
Partial unroofing –mid portion without LSVC
Partial unroofing –distal portion ,no LSVC
Partial unroofing –distal portion ,intact
corsinus ostium with coronary sinus ASD
PLSVC, is a result of a residual left
anterior cardinal vein.
It occurs in 0.1% to 0.3% of the
PLSVC is 3% to 8%, and up to 40%
when such patients have abnormal
A PLSVC originates from the
junction of the left innominate vein
and the left jugular vein.
More than 90% of cases of PLSVC
drain through a coronary sinus.
The rest drain into the coronary sinus
through a window into the left atrium,
directly into the left atrium or into the
left pulmonary vein .
In 60% of cases, the innominate vein
bridges the two superior venae
In the other 40%, the cavae drain the
right and left brachiocephalic regions
If there is no innominate vein the
PLSVC must persist; however, the
converse is not true.
A PLSVC with an absent right
superior vena cava is found in 14% of
Questions to be asked
Is there a right superior
Is the Innominate
Is the PLSVC associated
with any other cardiac
Where does the PLSVC
And does the surgery
involve the right atrium?
WITH OSTIAL ATRESIA
WITHOUT OSTIAL ATRESIA
- INTACT CORONARY SINUS
- UNROOFED CORONARY SINUS
- COMPLETE UNROOFING
- PARTIAL UNROOFING
LSVC with CS Ostial atresia
Grave hazard- for cardiac surgeon if not identified
Permanent/temporary occlusion or vigorous
manipulation – cause myocardial congestion/ischemia
Patency should be sought – preoperatively/intraop
LSVC TO CS WITHOUT ATRESIA
If large left innominate vein is present – tourniquet.
Small/absent innominate veinCardiac catheterisation – occlusion pressure less than
18 mm hg- temporarily occluded.
Third angled venous cannula – cannulated directly
When temporarily occlusion not advisable
Flexible venous cannula retrograde through CS
Use of cardiotomy sucker.
Single right atrial venous cannula + profound
hypothermia and total circulatory arrest
LSVC TO LA without CS
LSVC can be ligated below innominate vein.
LSVC to RIGHT ATRIUM
- direct implantation
- left atrial tubular flap creation
- right atrial tubular extension
- PTFE graft
limitation – stenosis /occlusion of rerouted LSVC
Repositioning the ATRIAL SEPTUM
-- Interatrial septum- completely excised
-- autologous pericardium/ prosthetic
Goal – systemic venous orifice lie on right side
- pulmonary venous orifice lie on left side
- optimal baffle placement
LSVC detached from heart – cardiac end oversewn
LSVC sutured to superior aspect of –
LEFT PULMONARY ARTERY
Avoids complication likebaffle leaks/baffle stenosis /atrial arrythmia
When b/l morphologically Right atria present
Lsvc enters the left sided Right atrium
Not an example of Unroofed coronary sinus.
Right isomerism – CS usually absent
Minor venous channel open directly into RA/RV
INCLUDES – LSVC to left atrium
- Absence of coronary sinus
- Low lying ASD
Simple closure – Persistent desaturation
Correction - ASD repair + ligation of LSVC
- Excision of septum primum
- Placement of intra atrial baffle
HEART LUNG TRANSPLANT
Recipient LSVC is divided near its entrance
into left atrium during recipient cardiectomy
It is sutured end to end to donor left inominate
SUPERIOR ROOFING – defect made in
Superior wall of left atrium is used to make left
atrial tunnel from LSVC orifice to interatrial
Pathogenesis - Impingement of a left superior
vena cava on the developing left atrium.
Left and right pulmonary veins may enter the
left atrium more superior than usual.
Mild to moderate narrowing- left atrium to which
pulmonary veins are attached.
Partially unroofed CS
condition can be easily overlooked
suspicious- when no asd or pulmonary vein
anomaly seen in RA with documented oxygen
Diagnosis – pass a probe in CS orifice
- View defect through separate
incision in interatrial septum
FONTAN REPAIR - When it co exists with
tricuspid atresia – marked RIGHT to left shunt
that incorporates coronary sinus into systemic
Clinical trials investigating treatment with angiogenesis factors and gene therapy have been
New devices for creating cardiac arteriovenous fistulas percutaneously have been deviced
Three different systems of percutaneous mitral annuloplasty are currently under evaluation:
the Edwards Monarc system, the Carillon Mitral Contour System and the PTMA implant
They are inserted into the coronary sinus and the great cardiac vein and all
work on the same principle: they shrink the mitral annulus, increasing leaflet coaptation and
thus reducing the regurgitation .
Take home message
Indications of selective CVBG include the patients with
tenuous right coronary artery or with diffuse lesions. It
is fit for the patients who need secondary CABG
Partially unroofed coronary sinus should not be
Close relation between LAD and GCV should
be kept in mind.