Coronary Sinus Diverticulum Research Articles

Comparison between conventional approach and three-dimensional mapping system in the catheter ablation of accessory pathway associated with coronary sinus diverticulum: A single-center experience.

Posteroseptal accessory pathways (APs) associated with coronary sinus (CS) diverticulum present a rare and challenge for ablation. This study aimed to compare the safety and efficacy of conventional approach and three-dimensional (3D) mapping system in the catheter ablation. This was a retrospective study of all patients (from January 2013 to July 2022) who underwent catheter ablation of posteroseptal AP associated with CS diverticula in our center. Patients who underwent catheter ablation using the traditional fluoroscopy method were included in the conventional method group (n = 13). Patients who underwent catheter ablation using the 3D mapping method were included in the 3D mapping group (n = 11). Clinical characteristics, ablation procedure, and outcomes were recorded and analyzed between the two groups. Out of 669 patients with posteroseptal APs, 24 of them (3.6%) were associated with CS diverticula. All patients in both groups successfully completed the electrophysiological study. In the conventional method group, two patients experienced complications (one patient with pericardial effusion and the other patient with femoral arterial hematoma), and two patients had recurrence. However, no patients suffered from complications or recurrence during follow-up. The procedure time and fluoroscopy time in the conventional method group were significantly longer than those in the 3D mapping method group. The utilization of 3D mapping led to reduced fluoroscopy time, shorter procedure duration, enhanced acute success rates, and decreased incidence of complications.

Coronary sinus ablations in pediatric patients with supraventricular arrhythmias.

Intracoronary sinus ablations have been performed for various arrhythmical substrates. The aim of this study is to report our experience on pediatric patients of the safety and efficacy of ablations in the coronary sinus. This is a retrospective study of all patients who underwent ablations in the coronary sinus from October 2013 to October 2021 at a single center. Clinical presentation, type of arrhythmia causing tachycardia, ablation procedure, and outcome were recorded. A total of 27 patients were included in the study. Nineteen (69%) of those followed up received a diagnosis of Wolff-Parkinson-White syndrome (WPW), 4 (15%) were cases of supraventricular tachycardia with concealed accessory pathway (AP), 2 (8%) were cases of focal atrial tachycardia, and 2 (8%) were cases of permanent junctional reciprocating tachycardia. Negative delta wave was noteworthy especially in lead II in 11/19 (58%) cases and coronary sinus diverticulum was detected in the WPW cases. Of those with manifest AP (19 cases), 15 (79%) had a high-risk AP and the AP in all WPW cases was adenosine unresponsive. Radiofrequency (RF) catheter ablation was performed in 25/27 (93%) cases during the procedure, and 16/25 (64%) of these were irrigated RF catheters. No complications were observed in the follow-up, including coronary artery injury. Catheter ablation of supraventricular tachyarrhythmias can be accomplished effectively and potentially safely within the coronary sinus. Coronary sinus diverticula should be suspected in patients with manifest posteroseptal APs who have a previous failed ablation and typical electrocardiographic signs.

Successful catheter ablation of the accessory pathway in an unusual location in a 13-year-old girl with a coronary sinus diverticulum and Wolff-Parkinson-White syndrome.

Wolff-Parkinson-White syndrome is a congenital cardiac pre-excitation syndrome that is effectively treated by ablating the accessory pathway. However, accessory pathways located in the posteroseptal region can sometimes be challenging. In this paper, we present the successful ablation of the epicardial posteroseptal accessory pathway through the middle cardiac vein in a 13-year-old girl with a coronary sinus diverticulum and Wolff-Parkinson-White syndrome, after unsuccessful ablation attempts at different locations. If the ablation procedure fails, the possibility of the posteroseptal pathway should be kept in mind, and coronary sinus angiography should be performed. In cases with a coronary sinus diverticulum where ablation is not successful, other coronary sinus structures, for example, the middle cardiac vein should be considered as potential accessory pathways.

PO-03-142 ABLATION OF EPICARDIAL POSTEROSEPTAL ACCESSORY PATHWAYS IN CHILDREN

Epicardial posteroseptal accessory pathways (Epi-PSAPs) within the coronary sinus (CS) are a rarely reported ablation target in children. They are often associated with abnormal CS anatomy as well as risk of coronary artery (CA) injury. To assess characteristics associated with successful outcome of Epi-PSAP ablation in children. Retrospective cohort study at a tertiary care institution including all patients aged ≤18 years who underwent ablation of Epi-PSAP from 2000-2022. Clinical/electrophysiological characteristics and outcomes were analyzed. Epi-PSAP was targeted in 19 patients. Mean age at procedure was 13.4 (12.1-14.7) years, mean weight was 62.5 (47-78) kg. Prior ablations had been attempted in 7/19 patients. Ventricular preexcitation was present in 12/19 (63%) patients, with steep negative delta wave in lead II in all cases, and 8/12 (67%) demonstrating high risk antegrade conduction. CS angiogram to define the anatomy was performed in all patients. In 5/5 (100%) of cases where CS diverticulum was identified by CS angiogram, it proved to be the ablation target. CA angiogram to define arterial proximity (5mm cutoff) was obtained in 17/19 (90%). CA system was right dominant in 10/17 (59%), and closest arteries were ≥5mm away from the target in 11/17 (65%). Primary energy was RF in 12/19 (63%, artery ≥5mm) and cryo in 7/19 (37%, artery <5mm). Ablation was acutely successful in 18/19 (95%) patients, chronically successful in 15/18 (83%) of patients, over 98.2 (57.8-138.7) months of follow up.There was no apparent difference in outcome between ablation sites in 1) coronary vein; 2) CS diverticulum; or 3) floor of CS (FIG1.A.). The presence of a sharp unipolar accessory pathway potential (FIG1.B.) at the target site was significantly associated with acute (p=0.003) and chronic (p=0.005) success. Choice of energy was not significantly associated with outcome. Performance of CS angiogram (FIG1.C) was significantly associated with acute (p=0.04) and chronic (p=0.03) success when all ablation attempts were analyzed. There was no incidence of major adverse events. Majority of Epi-PSAP in children are manifest with high risk antegrade conduction properties. They can be ablated with RF energy when the coronary arteries are ≥5mm from ablation target, or alternatively with cryoablation. Localizing a sharp unipolar AP potential, identification of CS anatomy by CS angiogram, and delineation of arterial proximity by CA angiogram are associated with successful ablation.

Intramyocardial dissecting hematoma associated with a coronary sinus diverticulum: a rare cause of chest pain.

Intramyocardial dissecting hematoma associated with a coronary sinus diverticulum: a rare cause of chest pain.

Precordial reverse pattern break: A predictor of posteroseptal accessory pathways ablatable from the proximal coronary sinus.

Posteroseptal accessory pathways (PSAPs) occasionally may lie within the coronary sinus (CS) or its tributaries, in a CS diverticulum, or along the epicardial surface. Catheter ablation is challenging in this subset of patients.1 Certain electrocardiographic (ECG) characteristics have been described in patients with proximal coronary sinus (PCS)-related PSAPs.1,2 We encountered precordial

PO-687-04 TRANSJUGULAR ABLATION OF CORONARY SINUS DIVERTICULUM-RELATED ACCESSORY PATHWAYS

Up to 7.5% of posteroseptal or left posterior accessory pathways may demonstrate a coronary sinus diverticulum (CSD), and their presence can make ablation challenging due to oblique course of fibers and may result in failed ablations. It is unclear if a jugular approach to mapping and ablation of coronary sinus (CS) accessory pathways (CSAPs) within CSDs is better than a femoral approach.

CE-542-01 PRECORDIAL ‘REVERSE PATTERN BREAK’: A NOVEL PREDICTOR FOR EPICARDIAL POSTEROSEPTAL ACCESSORY PATHWAYS

Posteroseptal (PS,also known as inferior paraseptal) accessory pathways(AP) may occasionally lie within the coronary sinus (CS), its tributaries, in a CS diverticulum (CSD) or along the epicardial surface. We encountered precordial reverse pattern break (RPB) of QRS morphology in some patients with epicardial APs and analysed all ECGs of posteroseptal accessory pathway(PSAP) cases. Inclusion criteria:Consecutive patients aged> 18 years, who underwent successful RF ablation in the PS region. Exclusion criteria- Failed ablation,Ablation at the left sided endocardium,Ablation deep inside the main CS, beyond 3 cm of the CS ostium (left free wall epicardial pathways). The cases were divided into two groups: Group En: Endocardial ablation; Group Ep: Ablation within the CS/CSD/epicardial surface. Definition:RPB is defined as monophasic tall R in V2 larger than V1 and V3 along with either (i) R/S < 1 in V3, or (ii) S wave in V3 > 4 mV. Among 66 cases [Age: 32±12 year, 40 males], 53 were ablated endocardially and 13 cases epicardially (12 inside a CS diverticulum, one in epicardium after gaining pericardial access).The baseline characteristics were comparable.RPB was present in 10/13 of Group Ep, but only in 6/53 cases of Group En.The sensitivity and specificity of RPB for epicardial location were 63% and 94% respectively, while the positive predictive value(PPV) was 77 %. The negative predictive value (NPV) was 89% and the accuracy was 87%. Among the patients who underwent ablation for PS accessory pathways,RPB was more often observed on the preexcited ECGs in patients having epicardial APs. This pattern may indicate the need for mapping within the CS/CSD or or epicardium.

Use of 3D mapping system for ablating an accessory pathway associated with coronary sinus diverticulum

BackgroundThis is a rare and challenging case of Wolff–Parkinson–White syndrome due to a posteroseptal accessory pathway located in the coronary sinus diverticulum. It is often difficult to precisely locate this type of accessory pathway, and the ablation procedure could be associated with collateral damage to the neighbouring coronary arteries.Case PresentationThe patient was a 49-year-old female with Wolff–Parkinson–White syndrome who was referred for catheter ablation. She had had a previous unsuccessful attempt at ablation and had remained symptomatic despite drug therapy. The pre-procedural cardiac computed tomography scan revealed the presence of a diverticulum in the proximal coronary sinus. Using an advanced three-dimensional cardiac mapping system, the electroanatomic map of the diverticulum was created. The accessory pathway potential was identified within the diverticulum preceding the ventricular insertion. The accessory pathway was then successfully ablated using radiofrequency energy.ConclusionWe have demonstrated that the advanced three-dimensional cardiac mapping system plays a very important role in guiding clinicians in order to precisely locate and safely ablate this type of challenging accessory pathway.

Coronary sinus diverticulum: Importance, function, and treatment.

The importance of venous structure in the heart is usually overshadowed by that of the arterial system. Coronary sinus (CS) 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.

Outcomes of ablation in Wolff-Parkinson-White-syndrome: Data from the German Ablation Registry

AimsCatheter ablation is recommended for symptomatic WPW-syndrome. Commonly perceived low recurrence rates were challenged recently. We sought to identify patient strata at increased risk. MethodOf 12,566 patients enrolled at 52 German Ablation Registry sites from 2007 to 2010, 789 were treated for WPW-syndrome. Patients were included for symptomatic palpitations and tachycardia documentation. Follow-up duration was one year. Overall complications were defined as serious, access-related, and ablation-related. We adjudicated WPW-recurrence for re-ablation during follow-up. Risk strata included: admission for repeat ablation at registry entry; accessory pathway localization; antiarrhythmic medical treatment before the ablation. ResultsWPW-syndrome patients were 42.8 ± 16.2 years on average; 39.9% were women. A majority of 95.9% was symptomatic; in 84.4%, a tachycardia was documented. Seventy-six (9.6%) patients presented for repeat procedures. Accessory pathways were located in the left atrium (71.4%), right atrium (21.1%), septum (4.4%), or coronary sinus diverticula (2.1%). Prior antiarrhythmic medication was used in 43.7% of patients. No serious events occurred. The overall complication rate was 2.5% (ablation related 1.2%, access-related 1.3%). Major determinants for complications were presentation for re-ablation as registry index procedure (6.9% vs 2.2%; p = 0.016) and septal pathway location (left 2.0% vs septal 9.1%, p = 0.014). The overall re-ablation rate was 9.7%. Usage of prior antiarrhythmic medication was associated with higher recurrence rates (12.2% vs. 7.6%; p = 0.035). ConclusionsPatients at higher complication risk may be identified by repeat procedure and septal pathway location. Prior antiarrhythmic medication was associated with higher recurrence rates. Our findings may help improving peri-procedural patient management and information.

Posteroseptal Accessory Pathways Ablation: do not forget the Coronary Sinus Diverticulum

Posteroseptal Accessory Pathways Ablation: do not forget the Coronary Sinus Diverticulum

Remaining challenges in catheter ablation of accessory pathways: rare entity of coronary sinus diverticulum-associated pathways.

A limited number of case reports of coronary sinus (CS) diverticula complicating catheter ablation have been published. We retrospectively analysed 2245 patients who underwent ablation of an accessory pathway (AP) at our institution between 1/11/1993 and 31/10/2016. Eight patients (0.36%) were found to have a CS diverticulum in venography. APs showed a mean antegrade conduction time of 276 ± 23ms (range 220-310ms) and a mean retrograde conduction of 301 ± 45ms (230-350ms). Four patients had 1 (n = 2), 2 (n = 1), or 3 (n = 1) previously failed ablation attempts. Pathways could not be ablated with a conventional 4mm tip catheter in 7 of 8 cases. In seven patients, ablation was successful, in two using an 8-mm ablation catheter, in two using cryoablation, and in the remaining three with an irrigated tip ablation catheter. After failed femoral approach, one 9-year-old female was successfully ablated via the right jugular vein. In one 75-year-old female, ablation was not successful. During a mean follow-up of 8.9 ± 6.4 years, all patients remained free of recurrences. In inferoseptal pathways, especially with previous failed ablation attempts, venographies of the CS should be performed. After successful ablation long-term prognosis is excellent.

Percutaneous Catheter Ablation of Epicardial Accessory Pathways

Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff-Parkinson-White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.

Percutaneous Catheter Ablation of Epicardial Accessory Pathways

Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff–Parkinson–White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.

Trans-subclavian Approach for Radiofrequency Ablation of Atrioventricular Accessory Pathway Associated with Coronary Sinus Diverticulum

A 20-year-old Chinese male presented with narrow-complex tachycardia related to type B pre-excitation pattern (Figure 1A and 1B). During the electrophysiological study, the earliest ventricular and atrial activation was adjacent to the coronary sinus (CS) electrode 9,0 during sinus rhythm and 7,8 during ventricular pacing (Figure 1D, 1E and 1G), respectively. An orthodromic atrioventricular reentry tachycardia could be induced reproducibly. Subsequently, a conventional 4 mm tip ablation catheter (Triguy, APT Medical, PRC) was introduced into the right ventricle via a long sheath (SR0, St. Jude Medical, USA). Repeated radiofrequency (RF) energy (50 W at 55 8C) delivery at the target site failed to eliminate the antegrade accessory pathway (AP) conduction due to rising impedance and poor power delivery. Considering the possibility of the AP located at the epicardium, coronary sinus angiography was implemented by Amplatz left 1 catheter. Two CS diverticula were identified near the ostium (Figure 1G, Online Video 1 and 2). A salineirrigated ablation catheter (Triguy, APT Medical, PRC) was reintroduced into the CS via the right femoral vein

Catheter ablation for Wolff–Parkinson–White syndrome with coronary sinus diverticulum in a 15-year-old boy

The left posterior and posteroseptal accessory pathways often have an epicardial accessory and are associated with coronary vein anomalies, such as diverticulum, fusiform, or bulbous enlargement. We report the case of a 15-year-old boy who suffered from palpitation due to Wolff–Parkinson–White syndrome with coronary sinus diverticulum. An electrophysiology study revealed a left posterior accessory pathway and orthodromic atrioventricular reciprocating tachycardia. After the transseptal puncture, we performed mapping around the mitral annulus during sinus rhythm. We could not detect typical atrioventricular fusion accompanied with accessory pathway potential and failed to ablate around the mitral annulus. We revealed typical accessory pathway potential in a coronary vein and successfully ablated. After ablation, a right atrium angiography showed a successful ablation site was just at the neck of coronary sinus diverticulum. It is important for a successful and safe ablation to evaluate coronary vein anomalies in patients with left posterior and posteroseptal accessory pathways.<Learning objective: In pediatric patients, Wolff–Parkinson–White syndrome with the posteroseptal accessory pathway with coronary sinus diverticulum is rare. It is important to predict the left posterior and posteroseptal accessory pathways from the polarity of the delta wave; ablation for pediatric patients seems to be more effective and safe in confirming coronary sinus diverticulum by echocardiogram before electrophysiology study and performing coronary vein angiography before mapping of the accessory pathway.>

Radiofrequency ablation of posteroseptal accessory pathways associated with coronary sinus diverticula.

Posteroseptal accessory pathways may be associated with a coronary sinus (CS) diverticulum. Our purpose was to describe the clinical characteristics, mapping and ablation of these pathways. This was a retrospective study of all patients who underwent ablation of posteroseptal accessory pathways in a single centre. Patients with a diverticulum of the CS or one of its tributaries were included in group I, while the other patients formed group II. Clinical presentation, ablation procedure and outcome were compared between the two groups. A total of 51 patients were included, 16 in group I and 35 in group II. There were no significant differences in age or sex distribution. Atrial fibrillation (AF) and previous unsuccessful ablation were more common in group I. A negative delta wave in lead II was the ECG finding with best sensitivity and specificity for the presence of a diverticulum. A pathway potential was common at the successful site in group I, and the interval between local ventricular electrogram and delta wave onset was shorter (19.5 ± 8 vs 33.1 ± 7.6ms, p < 0.001). There was a trend toward lower procedural success rate and higher recurrence rate in group I, although this was not significant. CS diverticula should be suspected in patients with manifest posteroseptal accessory pathways who have a previous failed ablation, documented AF or typical electrocardiographic signs. A discrete potential is frequently seen at the successful site, but the local ventricular electrogram is not as early as in other accessory pathways.

Accessory atrioventricular pathways refractory to catheter ablation: role of percutaneous epicardial approach.

Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed. We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access. Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial-epicardial approach.

Computed tomography and magnetic resonance imaging of the coronary sinus: anatomic variants and congenital anomalies.

The coronary sinus (CS) is an important vascular structure that allows for access into the coronary veins in multiple interventional cardiology procedures, including catheter ablation of arrhythmias, pacemaker implantation and retrograde cardioplegia. The success of these procedures is facilitated by the knowledge of the CS anatomy, in particular the recognition of its variants and anomalies. This pictorial essay reviews the spectrum of CS anomalies, with particular attention to the distinction between clinically benign variants and life-threatening defects. Emphasis will be placed on the important role of cardiac CT and cardiovascular magnetic resonance in providing detailed anatomic and functional information of the CS and its relationship to surrounding cardiac structures. Teaching Points • Cardiac CT and cardiovascular magnetic resonance offer 3D high-resolution mapping of the coronary sinus in pre-surgical planning.• Congenital coronary sinus enlargement occurs in the presence or absence of a left-to-right shunt.• Lack of recognition of coronary sinus anomalies can lead to adverse outcomes in cardiac procedures.• In coronary sinus ostial atresia, coronary venous drainage to the atria occurs via Thebesian or septal veins.• Coronary sinus diverticulum is a congenital outpouching of the coronary sinus and may predispose to cardiac arrhythmias.