Variability of coronary venous anatomy in patients undergoing cardiac resynchronization therapy: A high-speed rotational venography study

Blendea, Dan; Shah, Ravi V.; Auricchio, Angelo; Nandigam, Veena; Orencole, Mary; Heist, E. Kevin; Reddy, Vivek Y.; McPherson, Craig A.; Ruskin, Jeremy N.; Singh, Jagmeet P.

doi:10.1016/j.hrthm.2007.05.023

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Volume 4, Issue 9 , Pages 1155-1162, September 2007

Variability of coronary venous anatomy in patients undergoing cardiac resynchronization therapy: A high-speed rotational venography study

Dan Blendea, MD, PhD
- Cardiology Division, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, Connecticut
Ravi V. Shah, MD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Angelo Auricchio, MD, PhD
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.
Veena Nandigam, MD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Mary Orencole, NP
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
E. Kevin Heist, MD, PhD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Dr. E. Kevin Heist has served on the speaker bureau and has received research support from Guidant and St. Jude; Dr. Vivek Reddy has served on the speaker bureau and has served as a consultant for St. Jude; Dr. J. Ruskin has served as a consultant for Medtronic; Dr. J. P. Singh has served as a consultant and received research grants from Guidant, St. Jude, Medtronic, and Biotronik.
Vivek Y. Reddy, MD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Dr. E. Kevin Heist has served on the speaker bureau and has received research support from Guidant and St. Jude; Dr. Vivek Reddy has served on the speaker bureau and has served as a consultant for St. Jude; Dr. J. Ruskin has served as a consultant for Medtronic; Dr. J. P. Singh has served as a consultant and received research grants from Guidant, St. Jude, Medtronic, and Biotronik.
Craig A. McPherson, MD
- Cardiology Division, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, Connecticut
Jeremy N. Ruskin, MD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Dr. E. Kevin Heist has served on the speaker bureau and has received research support from Guidant and St. Jude; Dr. Vivek Reddy has served on the speaker bureau and has served as a consultant for St. Jude; Dr. J. Ruskin has served as a consultant for Medtronic; Dr. J. P. Singh has served as a consultant and received research grants from Guidant, St. Jude, Medtronic, and Biotronik.
Jagmeet P. Singh, MD, PhD
- Cardiac Arrhythmia Service, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Address reprint requests and correspondence: Jagmeet P. Singh, M.D., Ph.D., GRB 109, Director, Cardiac Resynchronization Therapy Program, Cardiac Arrhythmia Service, Heart Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114.
- Dr. E. Kevin Heist has served on the speaker bureau and has received research support from Guidant and St. Jude; Dr. Vivek Reddy has served on the speaker bureau and has served as a consultant for St. Jude; Dr. J. Ruskin has served as a consultant for Medtronic; Dr. J. P. Singh has served as a consultant and received research grants from Guidant, St. Jude, Medtronic, and Biotronik.

Received 26 April 2007; accepted 21 May 2007. published online 11 June 2007.

Background

Imaging the coronary venous (CV) tree to delineate the coronary sinus and its tributaries can facilitate electrophysiological procedures, such as cardiac resynchronization therapy (CRT) and catheter ablation. Venography also allows visualization of the left atrial (LA) veins, which may be a potential conduit for ablative or pacing strategies given their proximity to foci that can trigger atrial fibrillation.

Objective

The aim of this study was to provide a detailed description of CV anatomy using rotational venography in patients undergoing CRT.

Methods

Coronary sinus (CS) size and the presence, size, and angulation of its tributaries were determined from the analysis of rotational CV angiograms from 51 patients (age 68 ± 11 years; n = 12 women) undergoing CRT.

Results

The CS, posterior veins, and lateral veins were identified in 100%, 76%, and 91% of patients. Lateral veins were less prevalent in patients with a history of lateral myocardial infarction than in patients without such a history (33% vs. 96%; P = .014). The diameters of the CS and its tributaries were fairly variable (7.3–18.9 mm for CS, 1.3–10.5 mm for CS tributaries). The CS was larger in men than in women and in cases of ischemic than in cases of nonischemic cardiomyopathy (all P <.05). The vein of Marshall, the most constant LA vein, was identified in 37 patients; its diameter is 1.7 ± 0.5 mm, and its takeoff angle is 154° ± 15°, making the vein potentially accessible for cannulation.

Conclusions

Differences in CV anatomy that are related to either gender or coronary artery disease could have important practical implications during the left ventricular lead implantation. The anatomical features of the vein of Marshall make it a feasible potential conduit for epicardial LA pacing.

Keywords: Coronary venous anatomy, Left atrial veins, Cardiac resynchronization therapy, Heart failure, Coronary venous angiography