Various Routes of Septal Propagation in Common Atrial Flutter

Introduction: Although in the treatment of common atrial flutter, the isthmus between the tricuspid valve annulus and the eustachian ridge is often chosen as the site for conduction block by radiofrequency ablation, the precise path of the flutter circuit remains unknown. We therefore investigated the propagation of the atrial flutter wave front around the coronary sinus ostium and how its path is altered by application of radiofrequency current. Methods and Results: To assess activation pattern, activation in the region surrounding the coronary sinus ostium was mapped using a deflectable decapolar catheter under basal conditions and while applying radiofrequency current to the septal isthmus, between the tricuspid valve annulus and the eustachian ridge. In five of eleven patients studied, the eustachian ridge side, below the coronary sinus ostium, was activated earlier, and the flutter wave exited from either the tricuspid valve annulus side or the eustachian ridge side, above the coronary sinus ostium. In four patients, a partial line of block created by applying radiofrequency current between the tricuspid valve annulus and the coronary sinus ostium or between the coronary sinus ostium and the eustachian ridge led to a shift in the direction of propagation of the flutter wave front from anterior to posterior or from posterior to anterior of the coronary sinus ostium, and prolongation of the cycle length. Conclusion: Application of radiofrequency current to the septal isthmus, between the tricuspid valve annulus and the eustachian ridge, can shift both the anterior and posterior propagation of flutter around the coronary sinus ostium.     

A Quantitative Fluoroscopic Comparison of the Coronary Sinus Ostium in Patients With and Without AV Nodal Reentrant Tachycardia

Coronary Sinus Ostium. Introduction : The purpose of this study was to perform a quantitative fluoroscopic analysis of the coronary sinus ostium and its relationship to the His bundle in patients with and without AV nodal reentrant tachycardia. Sites of slow pathway ablation are often near the coronary sinus ostium, which can be located within a few millimeters of the His bundle. Whether such close proximity of the coronary sinus ostium to the His bundle is unique to patients with AV nodal reentrant tachycardia is unknown.
Methods and Results : Fifty consecutive patients (mean age 39 ± 14 years) with no structural heart disease underwent electrophysiologic testing and radiofrequency ablation. The study group consisted of 28 patients with inducible AV nodal reentrant tachycardia or dual AV nodal physiology and 22 patients in the control group. A coronary sinus venogram was performed in each patient. The coronary sinus ostium was similar in size in the study group (11.4 ± 4.5 mm) and in the control group (10.5 ± 3.6 mm, P = 0.2). The coronary sinus ostium was funnel shaped in half of the study patients and in half of the control patients (P = 1.0). The mean distance from the upper lip of the coronary sinus ostium to the tip of the His bundle catheter was 9.7 ± 5.5 mm in the study group and 10.4 ± 5.1 mm in the control group (P = 0.7). The mean distance from the lower lip of the coronary sinus ostium to the tip of the His-bundle catheter in the study group was 20.1 ± 6.1 mm and 19.5 ± 5.6 mm in the control group (P =0.7).
Conclusion : This study demonstrates a wide range of normal coronary sinus ostium diameters, morphology, and anatomic relationships with surrounding structures, with no demonstrable correlation to the presence or absence of dual AV node physiology or AV nodal reentrant tachycardia.     

Transcatheter treatment of acquired coronary sinus ostium atresia in a child with complex congenital heart disease

Congenital coronary sinus ostium atresia is a rare condition that is typically considered benign, as long as there is adequate drainage via another route. However, in children with single ventricle congenital heart disease, adequate drainage may not be assured after complex surgical interventions, putting them at risk for myocardial injury. We present a patient with complex single ventricle congenital heart disease who developed acquired coronary sinus ostium atresia after surgical intervention that was treated by a transcatheter approach to prevent the sequelae of coronary sinus hypertension.     

The location of the coronary sinus orifice in endocardial cushion defects

Forty-six human hearts with an ECD malformation were studied, particularly examining the anatomical location of the coronary sinus ostium. The sinus opened in the right atrium in 22 cases, and in the left side in 18 cases. Six cases showed no definite coronary sinus ostium.In most cases with a left-side ostium, the posteroinferior position of the atrial septum was absent. The failure of the union of the posteroinferior primum septum with the left atriovenous fold is considered to result in left-side coronary sinus orifices. The mean frontal electrical axis of ECG's showed no relationship with the location of the coronary sinus orifice.     

房室结折返性心动过速与冠状静脉窦关系的初步研究

为探讨房室结双径路导致折返性心动过速的发病机制，以更准确的选择消融靶点和减少并发症。对经电生理检查诊断的３３例室上性心动过速（ＳＶＴ）病人进行冠状静脉窦（ＣＳ）造影的对比研究。分为两组，其中房室结折返性心动过速（ＡＶＮＲＴ）组１７例，对照组（为其他室上性心动过速）１６例。两组病人均经ＣＳ造影，观察ＣＳ形态、走行及分支情况，测量ＣＳ口（ＣＳＯ）大小、窦体直径、长度及窦口上缘与Ｈｉｓ束之间的距离。结果发现ＡＶＮＲＴ组ＣＳ近端形态多呈漏斗状，占８２．４％，而对照组漏斗状仅占２５．０％，其余多呈管状（Ｐ＜０．０１）。ＡＶＮＲＴ组ＣＳＯ明显扩张，两组ＣＳＯ直径分别为１６．４±４．７和１０．２±３．９ｍｍ（Ｐ＜０．０１）。ＡＶＮＲＴ组窦口上缘到Ｈｉｓ束的距离明显较对照组近（８．０３±６．１２ｍｍｖｓ２１．３±６．４８ｍｍ），Ｐ＜０．００１。结果提示：ＡＶＮＲＴ患者的ＣＳＯ扩张对局部心房肌的压迫和牵拉，使ＣＳＯ周围的心房肌各向异性程度增高，可能是导致各向异性折返的病理机制。由于ＣＳＯ扩张使ＣＳＯ上缘距Ｈｉｓ束距离变近，给射频消融（ＲＦＣＡ）造成困难和危险，对此类ＡＶＮＲＴ病人行ＲＦＣＡ应谨慎从事。     

Origin of all major coronary arteries from left sinus of Valsalva as a common coronary trunk: single coronary artery--a case report

Coronary anomalies are divergent and can occur in up to 1% to 2% of patients. The most common of these anomalies is separate ostia of the left anterior descending and left circumflex arteries, followed by origin of the circumflex coronary artery from the right coronary artery and the left coronary artery from the right sinus of Valsalva, either as a separate ostium or as a part of single coronary artery. Anomalous origin of right coronary artery from the left sinus of Valsalva with a separate ostium or from the left main coronary artery is very rare. These coronary anomalies may be incidentally diagnosed on routine angiography or may present with myocardial ischemia, infarction, or sudden death. A case is described in which all 3 coronary arteries were originating from the left sinus of Valsalva as a common trunk (single coronary artery), which trifurcated to left anterior descending, left circumflex, and right coronary artery.     

犬冠状窦肌组织在左右心房间电传导中的作用

目的 探讨犬冠状窦肌组织在左右心房间电传导中的作用.方法 16只犬离体心脏在Langendorff灌流下通过冠状窦口电极、冠状窦远端电极和左房侧壁电极进行程控刺激,观察左右心房间电传导.结果 冠状窦口S1S1刺激可记录到冠状窦双电位,传至远端的时间为(44±21)ms,4例S1S2刺激使左房传导顺序改变.冠状窦远端S1S1刺激仅3例诱发电传导,传导时间为(41±15)ms,1例S1S2刺激使左房传导顺序改变.左房侧壁S1S1刺激电活动由冠状窦中部向两端传导.冠状窦口、冠状窦远端、左房侧壁S1S2刺激有效不应期分别为(122±19)ms、(114±12)ms(n=3)和(107±17)ms(P>0.05),进入有效不应期前左房侧壁刺激的电传导阻滞率为0,冠状窦口刺激电传导阻滞率为25%.结论 冠状窦内存在一条左右心房间的特殊的传导束,可能是一定条件下诱发并维持房性心律失常的心房间传导通路之一.     

Right coronary artery coronary sinus fistula with coronary sinus ostium stenosis

Coronary artery fistula (CAF) is a rare anomaly of the coronary artery. The draining site of a right coronary artery (RCA) fistula may usually be the right ventricle, right atrium, or pulmonary artery. Here, we present a patient with right coronary artery to coronary sinus fistula (RCACSF) complicated by aneurysmal dilatation of the coronary sinus (CS) and stenosis of CS ostium.     

A case of atrioventricular nodal reentrant tachycardia with atresia of the coronary sinus ostium

We report a case of atrioventricular nodal reentrant tachycardia coexistent with atresia of the coronary sinus ostium. Radiofrequency current application between the supposed coronary sinus ostium and the tricuspid valve was effective at eliminating the tachycardia. A coronary venogram obtained by left coronary arteriography was useful for guiding the mapping catheter to the successful ablation site.     

Stenting of anomalous left main coronary artery arising from the right sinus of Valsalva: a case report

Anomalous origin of left and right coronary arteries from a single coronary ostium in the right sinus of Valsalva is rare. Accordingly, few reports have described percutaneous coronary interventions in this anomaly. We report a case of a 75-year-old woman with a severe lesion in the anomalous left main coronary artery arising from a single ostium in the right sinus of Valsalva. The patient was successfully treated with direct stenting.     

Coronary sinus blood flow determination by the thermodilution technique: influence of catheter position and respiration

By measuring the coronary sinus blood flow using the thermodilution technique the influence of "thermodilution catheter" withdrawal from the great cardiac vein to the ostium of the coronary sinus was investigated in 41 patients. In addition, the influence of normal and forced respiration on coronary sinus blood flow was measured in 16 of the patients. Mean great cardiac vein flow was measured to 54 +/- 25 ml X min-1. Catheter withdrawal revealed coronary sinus blood flows of 80 +/- 32, 103 +/- 35, 145 +/- 39 and 213 +/- 61 ml X min-1 when the catheter was moved by steps of 1 cm towards the coronary sinus ostium. The coronary sinus blood flow changed between 116 +/- 34 ml X min-1 and 128 +/- 41 ml X min-1 on expiration or inspiration during normal respiration, respectively, when the catheter was placed in a mid-coronary sinus position. Forced respiration changed the coronary sinus blood flow from 98 +/- 41 ml X min-1 during expiration to 196 +/- 76 ml X min-1 during inspiration. The data show that coronary sinus blood flow changes from 23 to 68 ml X min-1 per cm catheter movement, the nearer the ostium the greater the change. Therefore comparison of coronary sinus blood flow between groups of patients would be a comparison between different catheter positions. Normal respiration moves, as judged by the coronary sinus blood flow, the thermodilution catheter by less than 0.5 cm while forced respiration moves the catheter up to 2 cm within the coronary sinus.     

Congenital coronary sinus stenosis

Congenital coronary sinus (CS) stenosis is a rare malformation. We present five patients with congenital coronary sinus stenosis (CSS) and identified another nine cases reported in the literature between 1980 and 2016. Congenital CSS may be associated with an unroofed CS, a coronary artery–coronary sinus fistula, or other cardiac anomalies. Congenital CSS may be detected by echocardiography, multidetector row computed tomography, and intra‐operative evaluation. Congenital CSS can occur at the ostium, lumen, and origin of the CS. Congenital CSS imaging features, treatment, and outcomes are summarized herein.     

犬冠状静脉窦肌肉组织电生理特性的研究

目的探讨冠状静脉窦肌肉组织和细胞的电生理特性。方法采用标准玻璃微电极技术同时记录犬冠状静脉窦肌肉结构和冠状静脉窦口(CSO)外右房组织的心肌细胞动作电位,并对比观察异丙肾上腺素灌流和电刺激条件下,冠状静脉窦内、外心肌组织中细胞电活动特点。结果冠状静脉窦内细胞和CSO外右房肌细胞动作电位符合快反应细胞特点,两者动作电位指标无显著性差异(P>0.05),但冠状静脉窦内细胞平台期明显。异丙肾上腺素灌流后,24条(24/30)冠状静脉窦组织块产生自发电活动,15条组织块的最早兴奋点很快迁移至冠状静脉窦内肌肉结构,且伴有频率的增快(310±30msvs385±11ms)。在CSO离断冠状静脉窦与心房肌后给予异丙肾上腺素,仅冠状静脉窦外右房组织能够产生自发电活动。在电刺激和异丙肾上腺素同时作用下,冠状静脉窦内心肌细胞可产生持续性电活动。结论冠状静脉窦内、外的心肌细胞发生自发电活动的机制不同。     

Anatomic relations of the Marshall vein: importance for catheterization of the coronary sinus in ablation procedures.

AIMS: Our objective was to study the anatomic relations of the human left atrial oblique vein (Marshall vein), particularly of its ostium opening into the coronary sinus, in order to guide ablation procedures related to that vein. METHODS AND RESULTS: The study was carried out in 23 heart-specimens (mean weight 446 +/- 204 g) of individuals whose mean ages were 43 +/- 21 years, 20 males. The coronary sinus was opened longitudinally, exposing the ostium of the tributary veins; the Vieussens valve was looked for, as well as its relationship to the left atrial oblique vein. The diameters of the left atrial oblique vein and the coronary sinus ostia were measured and the distance between them was determined. The left atrial oblique vein could be identified in 20 (87%) of the hearts, while the Vieussens valve was present in 17 (74%) of the specimens (in 16 of which the left atrial oblique vein was identified). In such condition, the vein was adjacent to the Vieussens valve and proximally positioned relative to the coronary sinus ostium in most of them (14/16 cases). The mean diameters of the left atrial oblique vein and of the coronary sinus ostia were, respectively, 1.23 +/- 0.38 and 8.22 +/- 1.88 mm. The mean distance between both ostia was 30.9 +/- 10.2 mm. CONCLUSION: When present, the left atrial oblique vein can be easily recognized, adjacent to the Vieussens valve. The mean distance between the coronary sinus opening and left atrial oblique vein ostium was around 30 mm, independently of the heart weight and the presence of cardiomegaly.     

Does A-H interval accurately represent intranodal conduction time during ectopic rhythms?

In order to determine whether the A-H interval of the His bundle electrogram accurately represents the AV nodal conduction time under various conditions, His bundle and coronary sinus electrograms were recorded in isolated perfused rabbit hearts, with atrial stimulation from eight different sites. The S-A (stimulus to the A wave) interval was significantly longer, whereas the A-H interval was shorter on stimulations from the coronary sinus and the left atrium than on sinus nodal stimulation. Stimulations from the fossa ovalis and right atrial appendage did not significantly alter the A-H interval. The effective and functional refractory periods of the AV node were almost identical with stimulations from the sinus node, low right atrial appendage, low left atrial appendage or the ostium of coronary sinus. Mapping of the excitation process with microelectrodes revealed that the activation times in low interatrial septal fibers bordering the His bundle [abbreviated as AP(III)] was closest to the A wave as compared with the activation in the ostium of the coronary sinus [AP(I)] or near the AN region [AP(II)] on stimulation from both sinus nodal and coronary sinus regions. On sinus nodal stimulation, AP(III) preceded AP(I) and AP(II) but lagged behind the A wave by 6 msec, whereas AP(III) preceded the A wave by 5 msec on coronary sinus stimulation. Thus, the A-H interval may not always accurately represent the intranodal conduction time, as relative timing of atrial activation responsible for the A wave and that of invasion of the AV node by the atrial wavefront can be grossly altered by different atrial excitation patterns.     

Atresia of coronary sinus ostium with coronary venous flow to left atrium

The rare cardiac anomaly of atresia of the coronary sinus ostium with a large communication between the coronary sinus and the left atrium was discovered during a mitral valve replacement operation in a 44-year-old woman.     

Acute coronary syndrome due to high aortocoronary junction of the right coronary artery: the value of multislice CT

High aortocoronary junction of the right coronary artery (RCA) above the sinus of Valsalva is not rare. There is controversy whether it is a benign finding or a life threatening condition. A 47-year-old male, who had recurrent acute coronary syndrome underwent coronary arteriogram twice showing only an aberrant origin of the RCA ostium from the left coronary cuspid. Sixty-four cut multislice computed tomogram (MSCT) of the coronary arteries showed the RCA ostium taking off above the right sinus of Valsalva. The RCA then shifted leftward and coursed between the great vessels. Compression of its proximal segment as it passed between the aorta and pulmonary artery explained the recurrent coronary attack. High take-off of the RCA ostium above its cuspid should be considered a risk factor for acute coronary attack under certain conditions. MSCT is valuable in providing better spatial images compared to the more invasive conventional coronary arteriography.     

The functional anatomy of the human coronary sinus

The human coronary sinus is an important part of the cardiac venous system that serves as an anatomic landmark as well as a conduit for diagnostic and therapeutic procedures. We studied 50 human coronary sinuses of hearts of normal and increased cardiac weight in order to ascertain various functional anatomic features of the coronary sinus and differences between hearts of normal and increased weight. In the hearts of normal weight (195 to 300 gm) the Thebesian valve covered the ostium of the coronary sinus an average of 41%, with complete coverage in 20%. The valve of Vieussens covered the origin of the coronary sinus an average of 59%. The average volume of the coronary sinus was 1.26 +/- 0.45 cc. In hearts of increased weight (365 to 675 gm), the Thebesian valve covered the ostium an average of 26% and the valve of Vieussens covered the origin of the coronary sinus an average of 56.5%. The average volume of the coronary sinus was increased to 1.76 +/- 0.73 cc (p less than 0.005). Thus knowledge of these functional anatomic features and the differences in hearts of increased cardiac weight allows for better utilization of the human coronary sinus for diagnostic and therapeutic purposes.     

Direct in vivo visualization of right cardiac anatomy by fibreoptic endoscopy: observation of radiofrequency-induced acute lesions around the ostium of the coronary sinus

Current mapping techniques used during electrophysiologicalstudy involve catheter placement under fiuoroscopic guidanceand are associated with prolonged radiation exposure. We consideredthat direct visualization of right heart anatomy by means offibreoptic endoscopy could be useful in accurately localizingand guiding the ablation of arrhythmogenic substrates. Our goal was to evaluate the ability of this device to safelyand accurately visualize the ostium of the coronary sinus andits vicinity as well as radiofrequency-induced acute lesions.Anaesthetized dogs (n=4) were studied. Multipolar electrodecatheters and a 3·6 mm diameter fibreoptic endoscopewith a latex balloon covering the distal tip were inserted intothe right atrium. The blood pressure, and surface and intracardiacelectrocardiograms were recorded simultaneously. Radio frequencyenergy was delivered Just inside the coronary sinus ostium orin its vicinity. The acute lesions were carefully observed byendoscopy. Postmortem examination was then performed. With a balloon volume of 7–10 ml, the visual field was15–20 mm in diameter. The blood pressure was generallystable. The ostium of the coronary sinus and its vicinity wereclearly and accurately identified, and catheter placement inthe coronary sinus and its vicinity could be achieved underdirect vision in all four dogs. Additionally, the process bywhich acute lesions were created by radiofrequency was alsodirectly visualized in great detail. There was a good concordancebetween endoscopically observed images and postmortem findings,and there was a strong correlation between delivered energyand the volume of the radiofrequency-induced lesions (r=0·895). Thus, balloon-tipped fibreoptic endoscopy could visualize thearea around the ostium of the coronary sinus and radiofrequency-inducedlesions with no or minimal haemodynamic compromise.     

射频消融心房扑动拖带刺激的电生理特征

探讨射频消融心房扑动 (简称房扑 )拖带刺激的电生理特征 ,更好的理解房扑机制 ,以期提高消融成功率、减少复发率。 5例阵发性典型房扑患者 ,诱发房扑后 ,在高位、低位右房 ,冠状窦口 (CSO)及右房下部的峡部分别进行拖带刺激 ,分析心房激动顺序 ,然后进行三尖瓣环至下腔静脉之间的线性消融。 5例房扑折返环均为逆钟向旋转 ,峡部 ,高位、低位右房及CSO呈现隐匿拖带 ,左房和卵圆窝呈现显性拖带 ,平均放电 9± 6次 ,均达到右房峡部双向阻滞。CSO起搏时体表心电图Ⅱ、Ⅲ、aVF导联P波形态发生改变。结论 :隐匿、显性拖带对判断峡部依赖性逆钟向房扑有较高价值 ,CSO起搏时心内电图激动顺序和体表心电图P波改变可做为判断峡部消融达到双向阻滞的标志