Unroofed coronary sinus and persistent left superior vena cava: A case report

The unroofed coronary sinus is a spectrum of cardiac anomalies in which part or all of the common wall between the coronary sinus and the left atrium is absent. Most cases are associated with anomalous systemic venous return, such as persistent left superior vena cava.The diagnosis of this lesion is important to the prognosis of the patient, but it is often difficult because of nonspecific clinical features.Here we report a case of a complete unroofed coronary sinus and persistent left superior vena cava discovered during a computed tomographic investigation for pulmonary hypertension.     

Characterization of human coronary sinus valves by direct visualization during biventricular pacemaker implantation

BACKGROUND: The precise reasons for failure to cannulate the coronary sinus during biventricular device implantation are unknown. Visualization of the coronary sinus ostium during electrophysiology procedures may enhance understanding of how unusual anatomy can affect successful cannulation of the coronary sinus. OBJECTIVES: The aim of this study was to describe the morphology of valves at the coronary sinus ostium (CSO) visualized directly with an illuminated fiberoptic endoscope during implantation of biventricular devices. METHODS: The coronary sinus anatomy of one hundred consecutive patients undergoing implantation of biventricular devices was investigated using a fiberoptic endocardial visualization catheter (EVC). RESULTS: The CSO was clearly visualized in 98 patients using the EVC. A Thebesian valve was seen in 54% of these. Almost all Thebesian valves were positioned at the inferior (61%) or posterior (33%) aspect of the CSO. Only six patients had Thebesian valves that covered more than 70% of the CSO, but all were successfully implanted with a transvenous left ventricular pacing lead after cannulating the coronary sinus under direct visualization. CONCLUSIONS: Over half of patients undergoing biventricular device implantation have identifiable Thebesian valves. Even valves covering the majority of the ostial area may be traversed using direct visualization and modern catheterization techniques.     

Interventional approach to CRT in a patient with drainage of the superior vena cava into the coronary sinus

A persistent left superior vena cava markedly increases the size of the coronary sinus (CS), which can increase the difficulty of left ventricular (LV) lead placement in patients receiving cardiac resynchronization therapy (CRT). We present a case where the entire superior vena cava drains into the coronary sinus, creating a massive CS. We also describe an interventional approach to LV lead implantation utilizing a combination of delivery systems from different vendors.     

超声诊断左位下腔静脉引流入左上腔静脉1例

患者男,19岁,因"腰腿疼痛伴盗汗、乏力2月余"入院,临床诊断为L2、3腰椎结核.超声:心脏位置正常,心房正位,心室右袢,房室连接正常,右心房轻度增大,房间隔中部连续性中断(约6.4 mm);主动脉走行、位置正常,腹主动脉右侧未见下腔静脉;左右髂总静脉在左右髂总动脉分叉处左下方汇合后于腹主动脉左后方上行(图1A),穿过膈肌回流至左上腔静脉;下腔静脉肝后段缺如,肝左、肝右及肝中静脉直接汇入右心房(图1B);左颈内静脉、左锁骨下静脉汇入左上腔静脉,右无名静脉部分血流汇入右侧上腔静脉,另一部分于主动脉弓水平汇入左上腔静脉(图1C);左上腔静脉经冠状静脉窦回流至右心房;冠状静脉窦增宽,窦壁完整.     

Cardiac resynchronization after left ventricular lead extraction: usefulness of angioplasty in coronary sinus stenosis

A 68-year-old man, 54 months after having been implanted with a biventricular device, underwent successful extraction of the malfunctioning left ventricular (LV) lead using mechanical dilation. During LV lead reimplantation, venography documented stenosis of the coronary sinus (CS). To overcome the obstacle, balloon angioplasty was performed and a LV lead was then inserted into a lateral tributary of the CS. The procedure was complicated by local infection and, after 2 months, removal of the entire unit became necessary. During controlateral device implantation, a second angioplasty was carried before insertion of the new LV lead because, in the meantime, restenosis had developed in the CS.     

Implantation of active fixation leads in coronary veins for left ventricular stimulation: report of five cases

BACKGROUND: Securing transvenous left ventricular (LV) pacing leads without an active fixation mechanism in proximal coronary vein (CV) segments is usually challenging and frequently impossible. We investigated how active fixation leads can be safely implanted in this location, how to avoid perforating the free wall of the CV, and how to recognize and respond to perforations. MATERIALS AND METHODS: In five patients with no alternative to LV pacing from proximal CV segments, 4 Fr SelectSecure (Medtronic, Minneapolis, MN, USA) leads, which have a fixed helix, were implanted through a modified 6 Fr guide catheter with a pre-shaped tip (Launcher, Medtronic). RESULTS: Active fixation leads were successfully implanted in proximal CVs in five patients. There were no complications. Acute and chronic pacing thresholds were comparable to those of conventional CV leads. The pre-shaped guide catheter tip remains in close proximity to the myocardial aspect of the CV, directing the lead helix toward a safe implantation site. CONCLUSIONS: If only proximal CV pacing sites are available, 4 Fr SelectSecure leads can be safely implanted through a modified Launcher guide catheter, avoiding more invasive implantation techniques. Other than venous stenting or implantation of leads with retractable tines, SelectSecure leads are expected to remain extractable.     

Left ventricular pacing lead positioning in the target vein of the coronary sinus: description of a challenging case

The optimal left ventricular pacing location for cardiac resynchronization therapy should be individualized according to the site of maximal mechanical delay. However, the presence of vein stenosis or kinking in coronary sinus (CS) anatomy could hamper lead implantation in the target vessel. We describe the case of a patient with dilated cardiomyopathy and a dual-chamber pacemaker referred for upgrading to a biventricular device owing to New York Heart Association III heart failure symptoms. Tissue Doppler analysis before implantation showed that the area of maximum activation delay was located in the posterolateral region of the left ventricle. Insertion of the lead into a posterolateral vein of the CS by means of the standard over-the-wire approach was unsuccessful due to the presence of a stenosis at the ostium of the vein. Lead placement in an anterior vein of the CS was unsatisfactory owing to a poor local delay from QRS onset. After balloon vein angioplasty, the pacing lead passed through the stenotic tract at the ostium of the target vein and was successfully positioned in the posterolateral region. Three months after pacemaker implantation, echocardiography showed an important reduction in the indexes of both inter- and intraventricular asynchrony and a significant left ventricular reverse remodeling     

Deep vein thrombosis in patient with left-sided inferior vena cava draining into the hemiazygos vein: A case report

BACKGROUNDAbnormalities of the inferior vena cava (IVC) are uncommon, and in many cases they are asymptomatic. Even so, it is vital that clinicians be aware of such anomalies prior to surgery in affected individuals. In the present report, we describe a rare anatomical variation of the IVC.CASE SUMMARYA 66-year-old male was admitted to the hospital due to deep vein thrombosis of the right lower extremity. Upon contrast-enhanced computed tomography imaging, we found that this patient presented with a case of left-sided IVC draining into the hemiazygos vein, while his hepatic vein was directly draining into the atrium.CONCLUSIONCases of left-sided IVC can increase patient susceptibility to thromboembolism owing to the resultant changes in blood flow and/or associated vascular compression.     

Ruptured sinus valsalva aneurysm originating from the left coronary sinus: report of a rare case with computed tomography findings

Sinus valsalva aneurysm is a rare condition. Most aneurysms usually originate from the right or non-coronary sinus. A few series were reported about the sinus valsalva aneurysm describing its origin, diagnostic tools and prognosis. We describe a case of a sinus valsalva aneurysm originating from the left coronary sinus that ruptured into the right atrium, diagnosed with echocardiography and cardiac computed tomography, confirmed by angiography and operational findings.     

心脏再同步化治疗引起冠状窦夹层2例

病例1:男,60岁,因"劳力性呼吸困难6年,加重4个月"入院.既往无高血压和冠心病史.查体:血压130/70 mmHg,双肺底少许湿啰音,心界向左下扩大,心率92次/分,律不齐,心音低钝,双下肢轻度水肿.ECG:心房纤颤,完全性左束支传导阻滞.     

右冠状动脉-上腔静脉瘘并巨大上腔静脉瘤超声表现1例

患者因“胸痛”于外院行超声心动图诊断：“右冠状动脉-左房瘘”,经我院行系列影像学检查明确诊断：右冠状动脉-上腔静脉瘘,上腔静脉呈瘤样扩张。经冠状动脉造影证实,行瘘口封堵术,术后经胸超声心动图显示无残余分流。院外检查者误把上腔静脉瘤视作左房、未扫查到上腔静脉瘤样扩张。对于冠状动脉瘘,需耐心追踪异常血流路径,仔细辨认典型解剖结构,多切面扫查,减少漏诊、误诊。     

Undiagnosed inferior vena cava type of sinus venosus atrial septal defect in a middle-aged woman: A rare case report

Sinus venosus atrial septal defect (ASD) accounts for 5% to 10% of ASDs. In contrast with the more common superior vena cava (SVC) type, the inferior vena cava (IVC) type of sinus venosus ASD with overriding IVC is extremely rare. The sinus venosus defect occur posterior to the fossa ovalis and is not regarded as true ASD. Transesophageal echocardiography (TEE) is a diagnostic procedure of choice due to close proximity of atrial septum to TEE transducer. However; it may not constantly yield detailed anatomical and functional characterization, and other imaging modalities such as cardiac magnetic resonance imaging (MRI) may be needed. We report the case of a 45-year-old woman with an undiagnosed hemodynamically significant IVC-type ASD without any anomalous drainage of pulmonary veins, who presented with progressive dyspnea.     

A giant aneurysm of the circumflex coronary artery with fistulous connection to the coronary sinus: a case report

Non-atherosclerotic coronary artery aneurysms are rare and most of them remain asymptomatic. We report a case who has a giant circumflex coronary artery aneurysm with fistulisation into the coronary sinus. The patient presents with dyspnea and palpitation due to atrial fibrillation with rapid ventricular response. The diagnostic contributions of echocardiography, coronary angiography are discussed. The hemodynamic effects of this anomaly are reviewed.     

An incidental finding of unroofed coronary sinus during angiography confirmed by 3D echocardiography; A case report

Unroofed coronary sinus (UCS) is an uncommon congenital heart anomaly and the most unusual type of atrial septal defect. This report presents a 71‐year‐old female with palpitation and dyspnea following an emotional stress, who was referred for ablation of typical atrial flutter. Finally diagnosed with a partially unroofed CS causing a bidirectional shunt.     

Congenital absence of the right coronary artery: A case report

BACKGROUNDAs a rare anomaly, congenital absence of the right coronary artery (RCA) occurs during the development of coronary artery. Patients with congenital absence of the RCA often show no clinical symptoms, and this disease is considered benign. The left coronary artery gives blood supply to the whole myocardium. The prevalence of congenital absence of the RCA is approximately 0.024%-0.066%. There are few cases reported as for this disease. In this work, a patient, with congenital absence of the RCA diagnosed by coronary angiography (CAG), was described. CASE SUMMARYA 41-year-old man arrived at our hospital for treatment, due to the repeated palpitations for a duration of one year. Considering the possibility of coronary heart disease, the patient underwent CAG that indicated the congenital absence of the RCA. Unfortunately, the patient refused to accept computed tomography coronary angiography (CTCA), to further confirm the congenital absence of the RCA.CONCLUSIONSingle coronary artery is a rare type of coronary artery abnormality, which usually has no obvious clinical manifestations and is considered as a benign disease. CAG is the main means by which congenital absence of the RCA can be diagnosed, and the disease can also be further confirmed by CTCA.     

Coronary fistula of right coronary artery to vena cava superior and ectasia of pulmonary artery

Summary  We report on a patient with coronary heart disease, a coronary fistula of right coronary artery to vena cava superior and pulmonary hypertension. Combined with coronary artery revascularization, the coronary fistula was closed successfully.