2. Imaging of the coronary venous system
has traditionally been overshadowed by
that of the coronary arteries.
2
3. Knowledge of the anatomy of the
coronary sinus (CS) and cardiac
venous drainage is important because
of its relevance in electrophysiologic
procedures and cardiac surgeries..
3
4. Several procedures make use of the
CS, such as left ventricular pacing,
mapping and ablation of arrhythmias,
retrograde cardioplegia and stem cell
therapy.
4
6. The cardiac veins can be grouped into
the following categories, according to
the region being drained:
the CS and its tributaries ,
the anterior cardiac veins,
and the thebesian veins.
6
7. Normal coronary venous anatomy on volume-rendered images from contrast material–
enhanced coronary CT angiography. (a) Anterolateral view of the heart shows the anterior
interventricular vein (AIV) coursing through the anterior interventricular sulcus parallel to the
left anterior descending artery (LAD). It continues as the great cardiac vein (GCV) in the left
atrioventicular groove along with the left circumflex artery (LCX).
7
8. Posteroinferior view of the heart shows the GCV continuing as the CS, which
finally drains into the right atrium (RA). Also shown are the posterior
interventricular vein (PIV) accompanying the posterior descending artery (PDA),
the posterior vein of the left ventricle (PVLV), and the left marginal vein (LMV)
accompanying the obtuse marginal artery (OMA). 8
9. The anterior cardiac veins are the primary
venous return for the anterior wall of the right
ventricle.
There are three or four small veins total,
which ultimately drain into the right atrium,
although the pattern of drainage is diverse.
Each vein may open directly into the right
atrium, or the veins may coalesce to form a
common venous trunk before emptying into
the right atrium 9
10. The thebesian veins (venae cordis
minimae) are a number of small veins
that drain the subendocardium. They
are composed of endothelial cells and
are continuous with the endothelial
lining of the cardiac chambers.
10
11. CS and Its Tributaries
The major tributaries of the CS include
(a) the anterior interventricular vein, (b)
the GCV, (c) the left marginal vein and
posterior vein, and (d) the middle
cardiac vein or posterior interventricular
vein
11
13. Anterior Interventricular Vein.—The
anterior interventricular vein ascends in
the anterior interventricular sulcus
parallel to the left anterior descending
coronary artery, then continues as the
GCV
13
14. Great Cardiac Vein.—The GCV is a
continuation of the anterior
interventricular vein and runs along the
left atrioventricular groove parallel to the
left circumflex coronary artery,
ultimately terminating in the CS. The
transition from the GCV to the CS is
defined by the left atrial oblique vein of
Marshall externally and the valve of
Vieussens internally
14
16. Left Marginal Vein and Posterior Vein of the Left
Ventricle.—The left marginal vein usually courses
adjacent to the obtuse marginal artery along the
lateral aspect of the left ventricle and drains into the
GCV or directly into the CS. The posterior vein drains
the diaphragmatic and lateral wall of the left ventricle
and in most cases drains into the CS; infrequently, it
can also drain into the GCV. The posterior vein of the
left ventricle may be a single large vessel or consist
of several smaller veins.
16
17. Middle Cardiac Vein or Posterior
Interventricular Vein.—The middle
cardiac vein runs in the posterior
interventricular groove, parallel to the
posterior descending coronary artery,
and drains into the inferior aspect of the
CS just proximal to its termination in the
right atrium Given its location, it is also
referred to as the posterior
interventricular vein.
17
18. Small Cardiac Vein.—When present,
the small cardiac vein runs in the right
atrioventricular groove. It drains into the
CS or directly into the right atrium.
18
23. The left horn of the sinus venosus and
adjacent left common cardinal vein
(LCC) remain in adult life as the CS.
The right horn of the sinus venosus
persists as the venous portion of the
right atrium.
23
28. The length of the CS varies from 3 to 5.5 cm and
is dependent on the site of the drainage of the
posterolateral vein. The diameter
of the CS is also variable and is dependent on the
loading conditions, presence and extent of atrial
myocardium with the coronary vein, and the
presence of underlying cardiac disease or prior
cardiac surgery.
28
29. The CS lies in the sulcus between the left
atrium and ventricle and is a continuation
of the great cardiac vein from the valve of
the great cardiac vein to the ostium of the
CS as it terminates in the right atrium.
The CS 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.
29
30. 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
30
31. The CS, like the rest of the cardiac
venous system, contains various
valves. The most common valve is
the Thebesian valve at the ostium of
the CS.
31
33. The Thebesian valve is a crescent shaped structure
often found guarding the mouth of the CS as it opens to
the right atrium. The Thebesian valve is highly variable
and occasionally may present an obstruction during
cannulation of the CS.
The CS also contains the valve of Vieussen’s that
often marks the end of the vein. These venous valves
are also frequently found at the entrance of the
ventricular veins into the great cardiac vein.
The right ventricular venous system drains directly into
the right ventricle through the Thebesian venous
network
33
34. The CS ostium is 5–15 mm in diameter
and is located on the posterior
interatrial septum anterior to the
Eustachian ridge and valve and
posterior to the tricuspid annulus.
The ostium is often covered, to a
variable extent, by the Thebesian valve.
The valve usually covers the superior
and posterior surfaces of the ostium,
but may be covered completely with
formation of fenestrations. 34
43. Methods and results: The CS-angiographic features and
incidence of structural anomalies were prospectively
studied in 56 patients undergoing AP radiofrequency
ablation.
Retrograde CS angiography was successfully performed
in 46/56 pt (82%), (33 males/13 females). The CS
angiographic findings of the 46 patients were compared to
the AP localization established by electrophysiological
mapping and to the successful ablation sites.
CS anomalies were identified in 17 (37%) patients and
included the following: CS diverticulum (seven patients),
funnel shaped ostium (three patients), CS aneurysm (two
patients), subthebasian pouch (one patient), sharp
angulation (one patient), and bulbous malformation (one
patient). 43
54. Perhaps more importantly accurate radiographic anatomy is needed
with standardized fluoroscopic views [right and left anterior oblique
(LAO) projections] to guide placement of leads and sheath of catheter
cannulation of the main body of this vein.
In the LAO projection, when cannulating the CS, the lead catheter will
be seen to move leftward after entry.
In the RAO projection, catheter or lead movement towards the sternum
(anterior) signifies cannulation of ventricular vein where as posterior
deflection or orientation suggests that an atrial vein has been entered.
54
61. Barcelo et al. pointed out that the coronary sinus is
not a simple vein. Their finding confirms that
observation by showing the dynamic variation of the
coronary sinus lumen, probably as part of a
physiologic phase: the draining and conducting of
blood.
An exaggerated response to this mechanism could
potentially modify cyclic coronary circulation and
perfusion, causing slow flow phenomena or other
pathophysiologic changes in patients with normal
coronary arteries or with other pathology, such as
abnormal relaxation of the ventricular wall. 61
81. If corkscrew tortuosities and acute take-off angles of
the only acceptable posterolateral target veins make
intubation fail, a coronary wire can be used to place a
Multifunctional Probing catheter (manufactured by
Boston Scientific) into the proximal vein segment
81
86. The modified bicaval view is the preferred
“working view” for engaging the CS ostium. A
standard bicaval view displays the SVC and IVC; a
modified bicaval view displays the SVC and CS. A
narrow range of depth, multiplane angle, and left/right
turning may be required to produce satisfactory
images, making this view potentially difficult to
acquire. Practice in a variety of patients is
recommended prior to the time when the view will be
needed to guide placement. Conditions that distort
anatomy, including aortic root dilation and cardiac
remodeling, add to the difficulty in acquiring this
view.
86
87. MMeessssaaggee
CS showing the dynamic variation of the lumen,
probably as part of a physiologic phase: the draining
and conducting of blood.
CS anomalies are common.
It can be important to identify some anatomic
variations, even though they are clinically occult, to
ensure appropriate preprocedural planning. Both CT
and magnetic resonance imaging provide excellent
noninvasive depiction of the anatomy and anomalies
of the CS.
87
