Cardiac Vein Research Articles

Epicardial Space: Comprehensive Anatomy and Spectrum of Disease.

The epicardial space (ES) is the anatomic region located between the myocardium and the pericardium. This space includes the visceral pericardium and the epicardial fat that contains the epicardial coronary arteries, cardiac veins, lymphatic channels, and nerves. The epicardial fat represents the main component of the ES. This fat deposit has been a focus of research in recent years owing to its properties and relationship with coronary gossypiboma plaque and atrial fibrillation. Although this region is sometimes forgotten, a broad spectrum of lesions can be found in the ES and can be divided into neoplastic and nonneoplastic categories. Epicardial neoplastic lesions include lipoma, paraganglioma, metastases, angiosarcoma, and lymphoma. Epicardial nonneoplastic lesions encompass inflammatory infiltrative disorders, such as immunoglobulin G4-related disease and Erdheim-Chester disease, along with hydatidosis, abscesses, coronary abnormalities, pseudoaneurysms, hematoma, lipomatosis, and gossypiboma. Initial imaging of epicardial lesions may be performed with echocardiography, but CT and cardiac MRI are the best imaging modalities to help characterize epicardial lesions. Due to the nonspecific onset of signs and symptoms, the clinical history of a patient can play a crucial role in the diagnosis. A history of malignancy, multisystem diseases, prior trauma, myocardial infarction, or cardiac surgery can help narrow the differential diagnosis. The diagnostic approach to epicardial lesions should be made on the basis of the specific location, characteristic imaging features, and clinical background. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Anatomical Study of the Cardiac Veins and their Tributaries in Bovines (Bos indicus) in Comparison with Humans and Other Animal Species

Anatomical Study of the Cardiac Veins and their Tributaries in Bovines (Bos indicus) in Comparison with Humans and Other Animal Species

Anatomically Based Ablation of Left Ventricular Summit Premature Ventricular Complexes Guided by Intracardiac Echocardiography.

Catheter ablation of premature ventricular contractions (PVCs) arising from the left ventricular summit (LVS) presents technical challenges due to the regional anatomy and frequent intramural site of origin (SOO). Intracardiac echocardiography (ICE) and the CARTOSOUND® (Biosense Webster, Diamond Bar, CA, USA) module allow the operator to directly reconstruct and visualize the dimensions and orientation of the LVS live and present it in relation to neighboring structures. We retrospectively reviewed consecutive cases between January 2021 and December 2022 of patients undergoing PVC ablation for a presumed LVS origin. The LVS was reconstructed by creating a three-dimensional representation of the left ventricular septum, using two-dimensional ICE sections. The earliest site in each chamber was tagged on the reconstructed LVS, and the presumed SOO was localized using a geometrical center point from all sites. Ablation was first delivered to the earliest site, except when the presence of coronary branches precluded radiofrequency delivery within the great cardiac vein. Of 20 patients (8 women, 62.4 ± 7.1 years old) with a presumed LVS origin, 12 had PVC recurrence within the monitoring period after the initial ablation for 192.5 ± 37.2 s at the earliest site. Among them, earliest activation was seen at the sinus of Valsalva (SoV), coronary venous system (CVS), and left ventricular endocardium (LVE) in four, six, and two patients, respectively. Using the reconstructed LVS, the anatomically closest site to the SOO was identified in the SoV, CVS, and LVE in four, two, and six cases, respectively. Throughout the study period (14.5 months; range, 9.3-19.7 months), 17 patients (85%) had complete elimination of PVCs as evaluated by 24-h event monitors at the 12-month visit. In 50% of cases, among patients in whom ablation at the earliest signal was unsuccessful, the site of successful ablation did not correlate with the second earliest signal or had no identifiable signal during initial activation mapping. The reconstructed LVS not only guided activation mapping but also identified sites proximal to the center point that had either a late activation signal, a low-amplitude signal, or no signal at all.

Detection of Coronary Artery Fistula between the LAD and the Great Cardiac Vein on Coronary CT Angiography.

Coronary artery fistulas (CAFs) are abnormal communications of coronary arteries whereby venous circuits bypass the normal capillaries within the myocardium. Coronary artery-to-cardiac vein fistula is the third most common type of CAF, accounting for 7% of cases. Electrocardiographic-gated cardiac computed tomographic (CT) angiography has emerged as a noninvasive alternative method of choice for diagnosis due to its high spatial and temporal resolution and short acquisition time. Herein, we aimed to present a left anterior descending coronary artery opened into the greater cardiac vein at the distal level, consistent with a coronary artery-to-cardiac vein fistula in a 77-year-old woman. Teaching point: Coronary artery CT angiography provides a detailed evaluation of the complex anatomy of coronary artery fistula without the need for invasive methods.

Anomalous Great Cardiac Vein Mistaken for Left Main Coronary Artery Aneurysm in a Case of Anomalous Left Coronary Artery Arising from the Main Pulmonary Artery

Abstract Anomalous coronary venous drainage is rare and likely to be under-reported, with many cases found incidentally in cardiac imaging and autopsy studies. It may also occasionally have an important clinical implication. We report a rare case of anomalous great cardiac vein bypassing the coronary sinus to drain directly into the left brachiocephalic vein in a patient with anomalous left coronary artery arising from the main pulmonary artery. This anomalous course resulted in a misdiagnosis of coronary aneurysm on echocardiography.

Electrophysiological characteristics and ablation of ventricular arrhythmias originating from the intramural basal inferior septum.

The electrocardiographic and electrophysiological characteristics of ventricular arrhythmia (VA) arising from the intramural basal inferior septum (BIS) have not been specifically addressed to date. The aim of the current study was to characterize intramural BIS-VA and distinguish it from those with endocardial origins besides clarifying the anatomical configurations of the pyramidal space. Fifty-five consecutive patients undergoing catheter ablation of VAs from BIS were identified and divided into three groups: the left ventricular (LV)-BIS group (n = 28), right ventricular (RV)-BIS group (n = 8), and intramural group (Intra, n = 19). Compared with the LV-BIS and RV-BIS groups, patients in the Intra group presented with no adequate earliest activation time at the two-sided BIS and epicardial coronary system [right: 7.79 ± 2.38 vs. left: 7.16 ± 2.59 vs. the middle cardiac vein (MCV): 6.26 ± 1.73 ms, P = 0.173] and poor-matched pacing-produced QRS at each site. Under the intracardiac echocardiography view, the pyramidal base was the broadest part of the septum and served as the division of the two-sided BIS. Focal ablation yielded promising acute-term and long-term procedural success in the LV-BIS and RV-BIS groups. But for the Intra group, VAs disappeared only after stepwise ablation successively targeted early preferential exit. After follow-up, three patients in the Intra group had recurrent VA, and all of them were treated well by a redo procedure or drug therapy. Intramural VAs were relatively common in the BIS region in our series. Intra-procedural mapping was important to distinguish the intramural VAs from other VAs by comparing the local activation time and pacing mapping. Procedural success could be achieved by stepwise ablation on the counterpart sides of the BIS and within the MCV.

Radiofrequency ablation of right atrioventricular bypass associated with small cardiac vein in a child

Radiofrequency ablation of right atrioventricular bypass associated with small cardiac vein in a child

Experience of left ventricular outflow tract arrhythmia ablation in paediatric patients using limited fluoroscopy and three-dimensional mapping technique.

The left ventricular outflow tract is an important source of ventricular arrhythmias. Up to one-third of all idiopathic ventricular arrhythmias in patients with structurally normal hearts may arise from this region. We would like to share the results of our left ventricular outflow tract ablation using three-dimensional mapping and limited fluoroscopy. This is a single-centre retrospective cohort study. Forty-six consecutive patients who underwent left ventricular outflow tract ablation procedures between January 2015 and June 2023 were included in the study. The EnSite Precision System (Abbott, St. Paul, MN, USA) was used to facilitate mapping and to reduce or eliminate the need for fluoroscopy. The study group comprised 29 males and 17 females, with a mean age of 13.4 ± 4.5 years. The most common location for arrhythmias was the left coronary cusp (n : 21). Other locations, in sequence, included the junction of the right and left coronary commissure (n : 10), right coronary cusp (n : 10), left ventricular outflow tract endocardium (n:4), aorto-mitral junction (n : 1), and great cardiac vein (n : 1). Nine of these patients had previously undergone unsuccessful right ventricular outflow tract ablation at another centre. Cryoablation was performed in three patients, irrigated radiofrequency ablation in three patients, and conventional radiofrequency ablation in the remaining patients. The acute success rate was 100%, and no recurrences were observed. The mean follow-up period was 49.6 ± 24.4 months. All patients were asymptomatic and were being followed without antiarrhythmic medication. Although left ventricular outflow tract ablations pose a risk for coronary artery and heart valve complications, they can be performed successfully and safely with the guidance of three-dimensional mapping.

Development of a three-dimensional computer model of the equine heart using a polyurethane casting technique and in vivo contrast-enhanced computed tomography

Introduction/objectivesInsight into the three-dimensional (3D) anatomy of the equine heart is essential in veterinary education and to develop minimally invasive intracardiac procedures. The aim was to create a 3D computer model simulating the in vivo anatomy of the adult equine heart. AnimalsTen horses and five ponies. Materials and methodsTen horses, euthanized for non-cardiovascular reasons, were used for in situ cardiac casting with polyurethane foam and subsequent computed tomography (CT) of the excised heart. In five anaesthetized ponies, a contrast-enhanced electrocardiogram-gated CT protocol was optimized to image the entire heart. Dedicated image processing software was used to create 3D models of all CT scans derived from both methods. Resulting models were compared regarding relative proportions, detail and ease of segmentation. ResultsThe casting protocol produced high detail, but compliant structures such as the pulmonary trunk were disproportionally expanded by the foam. Optimization of the contrast-enhanced CT protocol, especially adding a delayed phase for visualization of the cardiac veins, resulted in sufficiently detailed CT images to create an anatomically correct 3D model of the pony heart. Rescaling was needed to obtain a horse-sized model. ConclusionsThree-dimensional computer models based on contrast-enhanced CT images appeared superior to those based on casted hearts to represent the in vivo situation and are preferred to obtain an anatomically correct heart model useful for education, client communication and research purposes. Scaling was, however, necessary to obtain an approximation of an adult horse heart as cardiac CT imaging is restricted by thoracic size.

Acute impact of the vein of marshall ethanol infusion on newly-formed lesion and mitral line block in persistent atrial fibrillation ablation

Abstract Catheter ablation in persistent atrial fibrillation (PeAF) has limited success. Strategies beyond pulmonary veins isolation failed to demonstrate improvement of long-term rhythm maintenance. The vein of Marshall (VoM) is a promising therapeutic target because it contains triggers and autonomic parasympathetic and sympathetic activity implicated in arrhythmogenesis of AF. Moreover, as the VoM colocalizes with the trajectory of the "mitral isthmus", alcohol infusion into the vein facilitates bidirectional block across the line eliminating protected epicardial connections (1,2). Purpose We evaluated acute impact on lesion formation post-VOM-ETHO and the mitral line block validation after an approach including VOM-ETHO, pulmonary vein isolation (PVI), roof-line, mitral line (ML) and cavo-tricuspid isthmus line in a population of PeAF patients (Figure 1). We aimed also to report procedural outcomes after a short follow-up period. Methods After a detailed electroanatomical map of the left atrium (LA) (filter at 0.05-0.5 mV if the patient was in sinus rhythm or 0.05-0.3 mV in the case of AF), we thus proceeded with the VoM-ETHO using the technique previously described (3,4). LA map was thus repeated to assess the extension of the newly-formed low voltage area (LVA). According to the newly-formed LVAs, mitral isthmus ablation was completed endocardially. PVI, roof-line and cavo-tricuspid isthmus line were performed to complete the ablation setting. Bidirectional block across line was then validated during pacing from left atrial appendage. In case of persistence of conduction through the mitral line due to epicardial gaps, additional ablations were applied in the "anchored wall" or in the "free-wall" of the great cardiac vein (GCV). Results Twenty-one PeAF patients (67±6 years; 67% male) underwent ablation. The medium value of basal LA-LVAs was 3.1±63.8 cmq and the newly-formed LVAs after the VoM-ETHO procedure was 12.35±67.28 cmq. All patients had bidirectional block validated across the roof-line. Bidirectional block of the ML was achieved in 19/21 patients: in 12/21 patients after endocardial line only and in 9/21 after epicardial gaps ablations into the coronary sinus. The ML procedural time was 11.3±65.9 minutes. No major complications occurred. One patient had mild pericardial effusion due to VoM perforation with a spontaneous resolution. After a short follow-up period (6±63 months), no relapse of AF was observed in 19/21 (90%) patients. 12/21 patients were free from antiarrhythmic drugs (AADs). Interestingly, recurrences happened in patients in whom bidirectional block of the mitral line was not achieved. Conclusions VoM ethanol ablation added to PVI and linear lesions in the context of a methodical and anatomical approach seems to have promising results in PeAF patients. This strategy seems to be safe and reproducible. A favourable outcome depended on the interventional setting completion and the procedural end-points validation is crucial.

A valuable electrophysiological insight to distinguish right from left outflow tract ventricular arrhythmia -local activation time in the anterior intraventricular vein and distal great cardiac vein-

Abstract Background Although several ECG criteria have been helpful to differentiate right from left outflow tract ventricular arrhythmias (OTVAs), discriminating OTVA origins especially with left bundle branch block (LBBB) is still considered challenging. Objective The aim of this study was to investigate the local activation time (LAT) in the anterior intraventricular vein (AIV) and distal great cardiac vein (d-GCV), and to identify an electrophysiological method of distinguishing right from left OTVAs. Methods We measured the LAT relative to the QRS onset of OTVAs in the AIV and d-GCV using a microelectrode with a lumen catheter in patients undergoing successful OT-VA ablation between January 2017 and July 2022 in our institution. The ECG parameters such as the V2 transition-ratio and V2S/V3R index to distinguish right-OT-VAs from left-OT-VAs with LBBB were also investigated. Results Local potentials at the AIV and/or d-GCV OTVA sites in 76 consecutive patients (mean age: 56.5±16.2 year-old, right-OTVAs:40, left-OTVAs:36) were analyzed. The LAT of the AIV/d-GCV was significantly shorter for right-OTVAs than left-OTVAs (d-GCV -26.7±26.8 vs. -2.7±21.4 msec, p<0.001, AIV -9.9±23.2 vs. 16.9±18.2 msec, p<0.001), and associated with the identification of right-OTVAs and left-OTVAs (AUC: d-GCV: 0.76 [95%CI 0.65-0.86], AIV: 0.81 [0.70-0.92]). Defining a LAT <0ms in the AIV (sensitivity: 0.74, specificity: 0.75), <-24ms in the d-GCV (sensitivity: 0.83, specificity: 0.60) as cutoff values respectively, the overall odds ratio (OR) increased more for right-OTVAs than left-OTVAs (OR; AIV: 6.7 [1.9-23.4], p=0.002, d-GCV: 7.5 [2.5-22.1], p<0.001). In the multivariate analysis, a LAT<-24ms in the d-GCV was revealed as an independent predictor certifying right-OTVA origins (OR 14.4 (2.1-95.1), p=0.006), which was superior to the V2 transition-ratio and V2S/V3R index. Conclusion The AIV/d-GCV activation time could outperform other previous ECG criteria to discriminate right-sided from left-OTVA ventricular arrhythmias with LBBB.

Biventricular or conduction system pacing for cardiac resynchronization therapy: a proposed treatment algorithm based on interventricular conduction delays

Abstract Background Cardiac resynchronization therapy (CRT) is usually performed with biventricular pacing (BiVP), but recently conduction system pacing (CSP) has been proposed as an alternative in case of unsuccessful coronary sinus lead implantation. However , further evidence is needed to determine when CSP should be used in lieu of BiVP to improve clinical benefit. Purpose To assess the clinical benefit of a treatment algorithm based on interventricular conduction delays (IVCD) to choose between BiVP or CSP in candidates to CRT. Methods Consecutive patients presenting at our Institution from January 2018 to December 2020 with an indication to CRT were prospectively enrolled in the study group (delays-guided resynchronization group, DRG). IVCD were measured after left ventricle (LV) lead positioning in a lateral or posterior-lateral cardiac vein, when feasible, using endocavitary electrogram. Treatment algorithm based on IVCD was used to decide whether to leave LV lead to perform BiVP or pull it out and perform CSP. An historical cohort of patients who underwent CRT from January 2016 to December 2017 independently from IVCD was used as a control group (standard resynchronization group, SRG). The primary endpoint was a composite of cardiovascular mortality, heart failure (HF) hospitalization, or urgent unplanned clinic visits at 1 year after the date of intervention. Results Study population consisted in 292 patients, of which 160 (54.8%) in the DRG and 132 (45.2%) in the SRG. Age, sex, HF etiology, NYHA class, left ventricular ejection fraction and QRS duration and morphology did not differ between the two groups. In the DRG 41 of 160 patients underwent CSP based on treatment algorithm (25.6%). The primary endpoint was significantly reduced in the DRG (35/160, 21.8%) compared to SRG (48/132, 36.4%)(hazard ratio (HR): 1.72; 95% confidence interval (CI):1.12-2.65; p=0.013). Conclusion A treatment algorithm based on IVCD shifted 1 patient every 4 from BiVP to CSP, with consequent reduction in cardiovascular deaths, HF hospitalizations or urgent unplanned clinic visits after implantation. Therefore, its application could be useful to determine whether to perform BiVP or CSP in CRT candidates.Treatment Algorithm

Abstract 17002: Platelet-Derived Purified Exosome Product to Treat In-Stent Restenosis Porcine Model

Introduction: Patients with coronary artery disease (CAD) not amenable to revascularization are reported to have a 3-year mortality >14%. Advances in treatment modalities including medical management, rotational atherectomy, balloon lithotripsy, and drug-eluting stents work for focal disease but poorly treat diffuse CAD. In a porcine model of in-stent restenosis, we here evaluated whether a pro-angiogenic platelet-derived exosome product (PEP) could be delivered into the perivascular space to foster collateral vessel formation. Methods/Results: Cobalt chromium stents were placed and were oversized by 1 mm in the left anterior descending (LAD) and posterior descending arteries (PDA) of sus scrofa domesticus pigs. In-stent restenosis was angiographically visualized at the 2-month timepoint, with hemodynamic significance documented with fractional flow reserve (FFR) of <0.8. To document feasibility of PEP delivery into the perivascular space, exosomes were labeled with a far-red fluorescent tag and delivered into the perivascular bed. Here, the Bullfrog® micro-infusion catheter was positioned either in the great cardiac vein or the middle cardiac vein and PEP was delivered with the microneedle pointed towards the LAD or the PDA. Biodistribution demonstrated exosome retention and uptake around cardiac veins. Using the Bullfrog® technique, PEP was delivered in the perivascular space adjacent to areas of significant coronary stenosis. Initial results 1-month post-treatment demonstrated improved FFR of treated stenotic vessels (from 0.68 to 0.85), while untreated vessels demonstrate no change from previous FFR measurement (from 0.79 to 0.78). Conclusions: Here, exosome-mediated angiogenesis in the perivascular space improved coronary blood flow, distal to areas of stenosis. In patients with diffuse CAD, delivery of biotherapy in cardiac veins running anatomically parallel to stenosed epicardial arteries provides a novel therapeutic opportunity to supplement the existing armamentarium of therapies available for in-stent restenosis.

Abstract 17689: Distal Ventricular Pacing for Drug-Refractory Mid-Cavity Obstructive Hypertrophic Cardiomyopathy: A Randomized, Placebo-Controlled Trial of Personalized Pacing

Introduction: Patients with refractory symptomatic left ventricular (LV) mid-cavity obstructive (LVMCO) hypertrophic cardiomyopathy (HCM) have extremely limited therapeutic options. Hypothesis: We hypothesized that site-specific-pacing would induce regionalized contractile dyssynchrony to reduce LVMCO gradients and improve symptoms. Methods: Symptomatic-drug-refractory LVMCO patients were recruited for a randomized blinded trial of personalized prescription of pacing (PPoP). Multiple LV and apical RV pacing sites were assessed during invasive hemodynamic study. Patient-specific optimal pacing site and atrioventricular (AV) delays were selected on basis of LVMCO gradient reduction and pacing parameters. Patients were randomized to 6 months active or back-up pacing in cross-over design. Primary outcome examined invasive gradient change with PPoP. Secondary outcomes assessed quality of life and exercise. Results: A total of 17 patients were recruited; 16 met primary endpoints. Baseline NYHA was 3±0.6 despite medical therapy. Hemodynamic effects were assessed during pacing at RV apex and a mean of 8 LV sites (range 4-16). Optimal PPoP was achieved via LV pacing in 14 (88%) patients and RV apex in 2. Mean baseline gradient 80±29 mmHg fell to 31±21 mmHg with PPoP (p<0.0001). Cardiac vein perforation occurred in one case, and 15 patients entered into cross-over; 2 withdrawals occurred during cross-over (myocardial infarction, persistent atrial fibrillation). Of the 13 completing cross-over, 9 (69%) chose active pacing as their preferred setting. PPoP was associated with better 6-minute walking test performance (329±100 vs 286±106 meters, p=0.018); other outcome measures also indicated benefit with PPoP. Conclusions: In a randomized placebo-controlled trial, PPoP reduces obstruction and improves exercise performance in severely symptomatic LVMCO patients. A personalized approach to pacing site selection is a key component of this novel therapy.

Circulating microRNAs and cardiomyocyte proliferation in heart failure patients related to 10years survival.

Mechanochemical signalling drives organogenesis and is highly conserved in mammal evolution. Regaining recovery in myocardial jeopardy by inducing principles linking cardiovascular therapy and clinical outcome has been the dream of scientists for decades. Concepts involving embryonic pathways to regenerate adult failing hearts became popular in the early millennium. Since then, abundant data on stem cell research have been published, never reaching widespread application in heart failure therapy. Another conceptual access, using mechanotransduction in cardiac veins to limit myocardial decay, is pressure-controlled intermittent coronary sinus occlusion (PICSO). Recently, we reported acute molecular signs and signals of PICSO activating regulatory miRNA and inducing cell proliferation mimicking cardiac development in adult failing hearts. According to a previously formulated hypothesis, 'embryonic recall', this study aimed to define molecular signals involved in endogenous heart repair during PICSO and study their relation to patient survival. We previously reported a study on the acute molecular effects of PICSO in an observational non-randomized study. Eight out of the thirty-two patients with advanced heart failure undergoing cardiac resynchronization therapy (CRT) were treated with PICSO. Survival was monitored over 10years, and coronary sinus blood samples were collected during intervention before and after 20min and tested for miRNA signalling and proliferation when co-cultured with cardiomyocytes. A numerically lower death rate post-CRT and PICSO as compared with control CRT only, and a non-significant reduction in all-cause mortality risk of 42% was observed (37.5% vs. 54.0%, relative risk=0.58, 95% confidence interval: 0.17-2.05; P=0.402). Four miRNAs involved in cell cycle, proliferation, morphogenesis, embryonic development, and apoptosis significantly increased concomitantly in survivors and PICSO compared with a decrease in non-survivors (hsa-miR Let7b, P<0.01; hsa-miR- 421, P<0.006; hsa-miR 363-3p, P<0.03 and hsa-miR 19b-3p P<0.01). In contrast, three miRNAs involved in proliferation and survival, determining cell fate, and recycling endosomes decreased in survivors and PICSO (hsa miR 101-3p, P<0.03; hsa-miR 25-3p, P<002; hsa-miR 30d-5p P<0.04). In vitro cellular proliferation increased in survivors and lowered in non-survivors showing a pattern distinction, discriminating longevity according to up to 10-year survival in heart failure patients. This study proposes that generating regenerative signals observed during PICSO intervention relate to patient outcomes. Morphogenetic pathways induced by periods of flow reversal in cardiac veins in a domino-like pattern transform embryonic into regenerative signals. Studies supporting the conversion of mechanochemical signals into regenerative molecules during PICSO are warranted to substantiate predictive power on patient longevity, opening new therapeutic avenues in otherwise untreatable heart failure.

Pre-arterialization of coronary veins prior to retroperfusion of ischemic myocardium: percutaneous closure device.

Chronic coronary retroperfusion to treat myocardial ischemia has previously failed due to edema and hemorrhage of coronary veins suddenly exposed to arterial pressures. The objective of this study was to selectively adapt the coronary veins to become arterialized prior to coronary venous retroperfusion to avoid vascular edema and hemorrhage. In 32 animals (Group I = 19 and Group II = 13), the left anterior descending (LAD) artery was occluded using an ameroid occlusion model. In Group I, the great cardiac vein was blocked with suture ligation (Group IA = 11) or with occlusion device (Group IB = 8) to arterialize the venous system within 2 weeks at intermediate pressure (between arterial and venous levels) before a coronary venous bypass graft (CVBG) was implemented through a left internal mammary artery (LIMA) anastomosis. Group II only received the LAD artery occlusion and served as control. Serial echocardiograms showed recovery of left ventricular (LV) function with this adaptation-arterialization approach, with an increase in ejection fraction (EF) in Group I from 38% ± 5% after coronary occlusion to 53% ± 7% eight weeks after CVBG, whereas in Group II the EF never recovered (41% ± 2%-33% ± 7%). The remodeling of the venous system not only allowed restoration of myocardial function when CVBG was implemented but possibly promoted a novel form of "collateralization" between the native arterioles and the newly arterialized venules, which revascularized the ischemic myocardium. These findings form a potential rationale for a venous arterialization-revascularization treatment for the refractory angina and the "no-option" patients using a hybrid percutaneous (closure device for arterialization)/surgical approach (CVBG) to revascularize the myocardium.

Venous anatomy of the left ventricular summit region: Insights from high-speed rotational retrograde angiography.

Mapping and ablation through the coronary venous system (CVS) have shown potential for ventricular arrhythmias originating from the left ventricular summit (LVS). Multielectrode catheters and balloons are frequently used for mapping and venous ethanol ablation (VEA). However, there is limited data on the venous size and drainage condition in the LVS region. This study aimed to investigate the morphology, angiographic size, and drainage condition of LV summit veins via high-speed rotational angiography (RA). We measured and analyzed the size of the great cardiac vein (GCV), the anterior interventricular vein (AIV), veins near to the LVS, and other main tributaries of CVS in 102 patients undergoing electrophysiology study. Rotational retrograde angiography of LVS was successfully performed in 81 patients. The diameter of GCV at the level of the Vieussens valve and the distal end of GCV (junction of GCV-AIV) was larger in males than females (6.8 ± 1.1 vs. 5.6 ± 1.2 mm, p < .001; 5.2 ± 0.9 vs. 4.6 ± 0.8, p = .002, respectively) while no significant gender differences were observed in other tributaries. The LV summit veins presented downward drainage direction in half of the patients, indicating potential anatomic adjacency with His bundle. Left anterior oblique (LAO) 45° projection might provide the practical and optimal view of the LV summit veins. The coronary veins of the LVS region present various anatomical morphologies and ostium sizes. We provide a systematic description and angiographic size spectrum of CVS. RA could facilitate assessing the feature of CVS comprehensively.

ANATOMICAL FEATURES OF THE CARDIAC VENOUS SYSTEM, SIGNIFICANT FOR THE LEFT VENTRICULAR LEAD PLACEMENT: LITERATURE REVIEW AND EXPERIENCE

HighlightsThe article is a comprehensive literature review on anatomical variations and anomalies of cardiac veins. A classification of coronary venous anatomy and anomalies detailing clinical, anatomical and radiological features is proposed. Developing such classification is important for the field of left ventricular lead placement, as it would cover a variety of clinically significant anomalies of cardiac veins. AbstractWith the advancements in the cardiac resynchronization therapy, the role of cardiac vein anatomy has become vital due to the complications associated with poor left ventricle lead placement. The cardiac vein anatomy varies much more than the anatomy of the coronary arteries, thus making cardiac veins much harder to study. In this article we have analyzed different approaches to description and naming of cardiac veins, and have summarized venous anomalies and features described in literature or encountered in real clinical practice. All anatomical features described in the article have a clinical significance in the left ventricle lead placement. Moreover, we have analyzed the wide variety of suggestions to overcoming anatomical obstacles. As a result of the analysis, we have proposed a clinical classification of the coronary venous anomalies and features that can be used during the implantation of cardiac resynchronization therapy devices.

Left-anterior descending chronic total occlusion percutaneous coronary intervention complicated by great cardiac vein fistula: An unusual route for intravascular ultrasound guided successful recanalization.

Left-anterior descending chronic total occlusion percutaneous coronary intervention complicated by great cardiac vein fistula: An unusual route for intravascular ultrasound guided successful recanalization.

Safety and efficacy of intra-coronary chilled saline infusion during epicardial ablation in the left ventricular summit

Abstract Funding Acknowledgements Type of funding sources: None. Background The left ventricular (LV) summit is the most common epicardial site of idiopathic premature ventricular complexes (PVC) and is frequently associated with PVC-induced cardiomyopathy. Catheter ablation in the LV summit can be challenging due to its proximity with the major coronaries. Hypothesis: Infusion of chilled saline (5-10 degree Celsius) into the left main coronary artery cools the endothelium during epicardial ablation in the LV summit and therefore, protects the coronaries from thermal damage. Purpose To determine the safety and efficacy of intra-coronary chilled saline infusion during epicardial ablation in the LV summit. Methods Patients with symptomatic idiopathic PVC from the LV summit formed the study population. Those with significant coronary artery disease (coronary stenosis &amp;gt;50%) or with a scar on cardiac MRI were excluded from the study. Irrigated ablation was performed in the epicardium either percutaneously or transvenously via the distal great cardiac vein (GCV). A coronary angiogram (CAG) was always performed before RF ablation (RFA) to delineate the distance of the ablation catheter from the proximal coronaries. Chilled saline (5-10 degree Celsius) was administered into the left main coronary artery (LMCA) via Judkins catheter at a constant rate of 50 ml/min throughout the entire duration of ablation. Post-RFA, CAG was repeated to exclude any damage to the coronary arteries. Results Between January 2020 and July 2022, 37 patients (mean age 47.2±11.6 years; 16 females) underwent epicardial ablation in the LV summit accompanied by intra-coronary chilled saline infusion. The mean LV ejection fraction was 46.6±7.9%, and 15 patients had LVEF &amp;lt;50% (PVC-induced cardiomyopathy). Epicardial ablation was performed percutaneously in six patients, whereas in 21 patients, it was done transvenously in the distal GCV. Chilled saline was infused into the LMCA during the entire duration of RFA without any untoward effect in any of the patients. Acute procedural success (complete elimination of the clinical PVC) was achieved in 34 out of the 37 patients. At a mean follow-up of 17±7.9 months, 35 patients (91.8%) were asymptomatic and free from the clinical arrhythmia. Conclusion Intra-coronary chilled saline administered during epicardial ablation in the LV summit is safe and effective in preventing RF-induced thermal injury to the proximal coronary arteries.