Angiographic patterns of coronary sinus anatomy and its relation to successful ablation sites in accessory pathway patients

Abstract

The epicardial coronary venous system assumes importance in accessory pathway (AP) ablation especially in case of lengthy or failed attempts of ablation. Epicardial accessory pathways may be related to CS myocardial coat along one of its tributaries or to a CS diverticulum. The purpose of the present study was to use CS angiography to evaluate the relation of different patterns of CS anatomy to successful ablation sites of APs. 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). CS diverticuli represented (41%) of the encountered CS anomalies. Seventy-one percent of the CS diverticuli were seen in posteroseptal and left posterior locations of APs. Successful ablation site was related to CS-anomalies in seven (15.2%) patients (five patients with CS diverticulum, one patient with CS aneurysm, and one patient with CS angulation). Successful ablation was achieved from within the CS (coronary sinus – accessory pathway) (CS AP) in 10 patients (21.7%) (in relation to CS tributary in six (13%) and in relation to the neck of a CS diverticulum in four patients). CS AP represented 50% of the encountered posteroseptal and left posterior APs. CS angiography can guide us in reaching successful ablation sites of AP inside or outside the CS. CS diverticulum is the most common CS anomaly in posteroseptal and left posterior APs.