Double‐Barrel Coronary Sinus

Abstract

A 78-year-old woman with severe nonischemic cardiomyopathy (EF 25%), congestive heart failure (persistent NYHA class III symptoms), left bundle branch block, and intermittent Mobitz Type II second-degree heart block with a previously implanted dual-chamber pacemaker was referred for upgrade to a biventricular defibrillator system. After the coronary sinus was selectively engaged, a balloon-occluding catheter was placed in the mid-portion of the vessel and an angiogram was performed in orthogonal views. Initial images showed retrograde opacification of the main coronary sinus, great cardiac, and anterior interventricular veins, but there appeared to be a complete absence of posterolateral branches from the left ventricular free wall. After manipulation of the catheter, contrast injection closer to the ostium identified a faint shadow of a second coronary sinus lumen. An ostial injection confirmed an anomalous “double-barrel” coronary sinus, with the second vessel running parallel to the main coronary sinus and terminating into two posterolateral branches (see Fig. 1), one of which was successfully used for left ventricular lead placement. Right anterior oblique view taken after catheter manipulation and contrast reinjection from the coronary sinus ostium. An anomalous “double-barrel” coronary sinus was revealed, with the second vessel running parallel to the main coronary sinus. Off this second lumen, two posterolateral branches were clearly visualized, one of which is seen with a guide wire in place. A left ventricular lead was then successfully placed. Comprehensive understanding of coronary venous anatomy and its anomalies is becoming increasingly important as more biventricular devices are being placed. Catheter manipulation and reinjection of contrast may be needed multiple times to ensure accurate visualization of the coronary venous system. Our case demonstrates that posterolateral venous branches may arise selectively from one “barrel” of a “double-barrel” coronary sinus. This anomaly of the coronary sinus should be considered when there is apparent angiographic lack of posterolateral branches.