Coronary sinus diverticulum: importance, function, and treatment
Iman Razeghian-Jahromi1*, PhD, Mohammad Hossein Nikoo,
MD1,2, Andrea Natale3,4,5,6,7,8
1 Cardiovascular research center, Shiraz University of
Medical Sciences, Shiraz, Iran
2 Non-Communicable Diseases Research Center, Shiraz
University of Medical Sciences, Shiraz, Iran
3Texas Cardiac Arrhythmia Institute, St. David’s
Medical Center, Austin, TX, USA;4Dell Medical School,
University of Texas, Austin, TX, USA; 5Department of
Biomedical Engineering, University of Texas, Austin, TX, USA;6MetroHealth Medical Center, Case
Western Reserve University School of Medicine, Cleveland, OH, USA;7Division of Cardiology, Stanford University,
Stanford, CA, USA; and 8Electrophysiology and
Arrhythmia Services, California Pacific Medical Center, San Francisco,
CA, USA
*Corresponding author: Iman Razeghian-Jahromi
Postal address: Cardiovascular Research Center, 3rdfloor, Mohammad Rasoolallah Research Tower, Namazi Hospital, Shiraz
University of Medical Sciences, Shiraz, Iran.
Postal code: 71936-35899
Tel: +98 713 628 1561
Fax: +98 713 612 2235
Email: razejahromi@yahoo.com
Acknowledgements: N/A
Competing interests: The authors declare that they have no competing
interests.
Funding: This research was supported by Vice Chancellor of Research of
Shiraz University of Medical Sciences.
Abstract
The importance of venous structure in the heart is usually overshadowed
by that of the arterial system. Coronary sinus is a part of cardiac
venous apparatus and connects left atria to the right atria. Other than
having role in physiological contractions of both atria, it contributes
substantially to cardiac electrical conduction system. Due to unique
placement and connections of the CS, it has become growing interest in
clinical cardiology. It is used in cardiac resynchronization therapy
with biventricular pacing, left-sided catheter ablation of arrhythmias
and administration of retrograde cardioplegia in cardiac surgery. In
some individuals, CS is presented with anatomical variants. CS
diverticulum is a congenital outpouching that provides muscular
connection between atria and ventricle. This connection provides a
suitable substrate for occurrence of arrhythmias, which even results in
life-threatening events such as sudden cardiac death. Early diagnosis
leads to treatment with ablation techniques which ultimately eliminates
origins of arrhythmias.
Keywords: coronary sinus diverticulum; arrhythmia; ablation
Introduction
Coronary sinus (CS) anomalies such as diverticulum, persistent left
superior vena cava or CS ostium dilatation are predominantly found in
patients with accessory pathway-related tachycardias
(1). Earlier studies have reported
diverticulum of proximal CS in 7-11% of patients with posteroseptal
accessory pathways (2). In this review, a
literature appraisal was performed regarding importance, function, and
ablation of CS diverticulum.
CS
Several cardiac procedures like targeted drug delivery, stem cell
therapy as well as mapping and ablation of arrhythmias make use of CS
(3). By a multipurpose catheter and
injection of contrast in LAO and RAO views, CS anatomy was delineated.
In the case of difficulty with catheter to cannulate, a deflectable
sheath is employed (4). The average length
ranges from 45 to 63mm. Different size of ostium ranges (4*5 to 9*16mm)
have also been reported (5).
CS drains 60% of cardiac venous blood into the right atrium. In
addition to the largest cardiac venous structure, it is an interatrial
connection (6). However, unlike the veins,
it has myocardial tissue which is the remnant of left atrial muscles
(7). Although CS has been regarded as a
venous structure for a long time but recently it was clarified its
crucial role in the pathophysiology of atrial tachyarrhythmia
(8-10).
The most common atrial arrhythmia in humans is atrial fibrillation (AF).
Although pulmonary veins are closely associated to AF pathogenesis, it
seems that ablation of these veins is not enough for disappearance of
persistent AF. Additional reentry mechanism, probably by the involvement
of CS was proposed (6). Muscular sleeve,
which is around the proximal 25-50mm of the CS length, connects the two
atria (11). Arrhythmia most likely
emerges from these connections (12).
Also, it was shown that CS has the capability for spontaneous
depolarization and slow conduction, an indicator of intrinsic
automaticity (13-15). Thereby,
spontaneous firing of the cells in the CS is in charge for triggering,
maintenance, and recurrence of AF (12,
16, 17).
Accordingly, ablation of CS together with pulmonary vein resulted in
long term improvement through decreasing the recurrences
(18).
CS diverticulum
Variation in CS anatomy in terms of position, length, and diameter was
seen among individuals (19). CS anomalies
are, but not limited to, enlargement, absence, atresia of right ostium,
and hypoplasia (6). These anomalies may
affect cardiac hemodynamics, which leads to clinical manifestations and
requiring prompt diagnosis and treatment. However, some others are
clinically occult without any obvious symptoms. They all have the
potential to increase morbidity and mortality after certain surgical
procedures. Moreover, electrophysiological characteristics of the CS are
influenced by the existence of these anomalies
(20, 21).
CS diverticulum is a one of such anomalies. It is a CS congenital
outpouching with a distinct neck that extends behind the left ventricle
(22, 23).
In most cases, diverticula were seen as a saccular dilatation and
sometimes it is a fusiform dilatation. In some patients, its sac was
bilobed. Contractility is its inherent characteristic
(4). Diverticula are commonly found at the
inferior aspect of the CS at its junction with the middle cardiac vein,
0 to 18mm away from the CS ostium. The neck of the CS diverticulum is 5
to 10-mm wide, opens into the CS and is proximal to the midcardiac vein
(24). The orifice of the diverticula
ranges between 2.6 to 15mm. The smallest and largest surface area was
0.73cm2 and 6.45cm2, respectively.
The mean diameter of the CS was 7.05mm ± 1.90. Thus, CS could be dilated
up to 11mm at measuring 3cm proximal to the CS ostium
(25, 26).
(Fig. 1)
Central parts of cardiac conduction system including atrioventricular
node and the His bundle are in the septal area. Approximately, one third
of accessory pathways (APs) are located at this complex anatomic region.
These pathways frequently have short refractory periods that predispose
to rapid ventricular response during atrial fibrillation, thus
increasing the risk of sudden death (24).
Therefore, precise localization of these pathways is critical during
ablation of APs. APs of this area are classified into anteroseptal,
midseptal, and posteroseptal (27).
Diverticula with posteroseptal APs were first reported in 1985
(28). This type of AP increases the
incidence of inducible AF (27).
Myocardial fibers of CS diverticulum establish a connection between CS
coat and the ventricle, which facilitates the incidence of AP
(29, 30).
Close proximity of the wall and the neck of the diverticula with
posteroseptal and left posterior APs endangers patients to arrhythmias
and even sudden cardiac death (22,
23).
Among 480 patients with posteroseptal or left posterior AP, CS
diverticula was found in only 36 (7.5%)
(30). It is a rare anomaly which often
diagnosed during venography and catheter ablation
(31). The existence of CS diverticula is
expected in the case of previous failed ablation, documented AF, when
the best location for ablation is at the proximal of CS, and in specific
ECG findings like polarity of the delta wave. A negative delta wave in
lead II is an indicator of CS diverticulum with highest specificity and
sensitivity (29,
30, 32,
33). (Fig 2.)
Treatment
Radiofrequency (RF) ablation is safe and treatment of choice for
resolving septal APs (28). Percutaneous
access for ablation of epicardial APs is feasible through CS
cannulation. This was performed even in patients with previously failed
endocardial ablation (34). Ablation of
the CS eliminated focal tachyarrhythmia with CS origin
(6). As CS has anatomic and
electropgysiological relationship with atria, origin of multifocal
tachyarrhythmia from either atria could be determined. If myocardial
part of the CS is the origin, high-frequency higher-amplitude component
indicates a near-field potential. Otherwise, (low-frequency
lower-amplitude) shows a far-field potential
(35, 36).
Epicardial and endocardial ablation of the CS increase AF cycle length
and eventually leads to AF termination
(8). One study reported posteroseptal AP
in a patient with a history of three previous failed attempts of
ablation. In such cases, open chest surgical ablation is deemed as the
only remaining choice. This difficult-to-ablate AP was managed by
epicardial mapping through pericardial catheter. Although, existence of
high impedance due to thick epicardial fat hampered the ablation by this
approach but a linear ablation within the CS targeting the earliest
activation area terminated the preexcitation
(37).
CS ablation is performed in patients with AF without previous pulmonary
vein ablation (38). The anomalies of the
CS sometimes becomes the crucial sites for successful ablation of
posteroseptal pathways (1). Findings
showed that CS diverticulum with APs were more prone to sudden death
during AF due to acceleration of atrioventricular conduction
(33). However, CS diverticulum is a
well-known cause of unsuccessful AP ablation in wolff-parkinson-white
syndrome. This fact underscores the necessity of identification and
reporting of CS anomalies especially that of diverticula
(32).
Epicardial approach and the diverticula neck are the helpful points
toward a successful ablation in patients with CS diverticulum and
posteroseptal APs (29,
30, 32).
The success rate of ablation in the neck of the diverticulum reaches
90% (2). After recording early retrograde
atrial signal at the neck by the ablation catheter which representing CS
activity, delivering controlled energy leads to elimination of APs
footprints (29). However, successful
ablation was also reported within the CS. In one patient with small
diverticulum, ablation was done in the adjacent CS. Overall, it seems
that neck of the diverticula is the site with highest rate of success
for ablation (2,
4).
Posteroseptal APs are sometimes difficult to ablate due to complex
anatomic arrangements (29,
39). Other than anatomic complexity, the
inherent nature of diverticula with a pouch and a neck increase the
intricacy of the task (39). Not only is
the matter the difficulty of ablation of posteroseptal APs but also are
the consequent life-threatening complications because of close proximity
to the coronary arteries (39). It was
reported that total occlusion of left circumflex artery during ablation
inside the CS augments the risk of arrhythmias
(40, 41).
Even ventricular fibrillation following by sudden cardiac death was
reported (40). In order to prevent
complications such as perforation, formation of coagulation, excess
heat, and right coronary artery stenosis during ablation procedure in
the CS, some recommendations have been made like temperature control
ablation, irrigated RF ablation, and cryoablation
(42, 43).
Low temperature RF ablation resulted in a safe and complication-free
ablation (44).
Conclusion
CS diverticulum is a variant of CS. Importantly, it has been substrate
of APs near epicardium. CS diverticulum with AP is a rare disorder.
During an electrophysiologic study seeking for the underlying reasons of
left posterior and posteroseptal APs, CS diverticulum is detected in
coronary vein angiography. Treatment of choice for such patients is RF
catheter ablation. The target site for ablation is typically the narrow
neck of the CS diverticulum.
List of abbreviations
CS: coronary sinus; AP: accessory pathway; EPS: electrophysiologic
study; RF: radiofrequency
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