Coronary Sinus Injury Research Articles

Echocardiographic imaging of a bifurcated double barrel coronary sinus

BackgroundThe coronary sinus (CS) is the terminal collecting vessel of the myocardial venous network, which returns deoxygenated blood used by the heart to the right atrium. The advent of high-fidelity imaging via CT and transesophageal echocardiography (TEE) has further defined the anatomy of the CS and its multiple tributaries. Understanding this anatomy is crucial for cardiac surgical cases that require the cannulation of the coronary sinus to deliver retrograde cardioplegia. However, anatomical variants of the CS may frustrate surgical retrograde catheter placement, in turn increasing the risk of CS injury or leading to inadequate cardioplegia delivery. Here, we present an especially unique CS presentation, a bifurcated, double-barrel CS, which was discovered via intraoperative TEE imaging that revealed a CS with two smaller lumens instead of the singular large os.Case presentationA 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.ConclusionsDiscovery of this patient’s double-barrel CS during the pre-bypass TEE was incidental, showing that such anatomical variants may be completely asymptomatic and benign in the non-operative setting. However, the delivery of cardioplegia proved challenging for this patient, highlighting some degree of risk with certain cardiac interventions. This case demonstrates the utility of intraoperative TEE to quickly ascertain unforeseen anatomical variants of the CS which could compromise the safety of cardiac surgery cases.

Coronary Sinus Injury in a Multisystem Thoracoabdominal Cut/Stab Wound

We report a case of successful treatment of a patient with multiple stab and cut wounds of chest and abdomen which resulted in the injuries of venous coronary sinus and abdominal organs. Surgical wound revision in the antishock unit, priorities of surgical accesses (thoracotomy and laparotomy) allowed timely cure the injury. A key feature of our case report is a coronary sinus trauma. Coronary sinus suturing in a closed heart surgery is technically difficult. It has the potential hazard due to the proximity of coronary arteries, stricture and thrombosis of the coronary sinus after suturing. Extracorporeal circulation and cardioplegia ensure reliable hemostasis and intact patency of the coronary sinus. Clinical case of suturing coronary sinus injury in a closed heart surgery proves the reasonable use of autopericardial strengthening strips and local hemostatic made of regenerated cellulose.

A Reproducible and Effective Technique for Coronary Sinus Injury Repair.

Objective: Coronary sinus injury related to the use of a retrograde cardioplegia catheter is a rare but potentially life-threatening complication with mortality reported as high as 20%. We present a series of iatrogenic coronary sinus injuries as well as an effective method of repair without any ensuing mortality. Methods: There were 3,004 cases that utilized retrograde cardioplegia at our institution from 2007 to 2018. Of these, 15 patients suffered a coronary sinus injury, an incidence of 0.49%. A pericardial roof repair was performed in 14 cases in which autologous pericardium was sutured circumferentially to normal epicardium around the injury with purified bovine serum albumin and glutaraldehyde injected into the newly created space as a sealant. Incidence of perioperative morbidity and mortality, operative time, and length of stay were collected. Results: In our series, there were no intraoperative or perioperative mortalities. Procedure types included coronary artery bypass grafting (CABG), valve replacement and repair, or combined CABG and valve procedures. Median (interquartile range) cross-clamp time was 100 (88 to 131) minutes, cardiopulmonary bypass duration was 133 (114 to 176) minutes, and length of stay was 6 (4 to 8) days. None of the patients returned to the operating room for hemorrhage, and there were no complications associated with the repair of a coronary sinus injury when using the pericardial roof technique. Conclusions: Coronary sinus injuries can result in difficult to manage perioperative bleeding and potentially lethal consequences from cardiac manipulation. Our series supports the pericardial roof technique as an effective solution to a challenging intraoperative complication.

Cardiac venous injuries: Procedural profiles and outcomes during left ventricular lead placement for cardiac resynchronization therapy

Injury to the cardiac venous structures can complicate left ventricular lead placement for cardiac resynchronization therapy (CRT). Little is known about the outcomes of coronary sinus (CS) dissection with or without perforation. The purpose of this study was to determine the outcomes in patients who had a CS injury during CRT implantation. All patients undergoing procedures for CRT implantation at the Cleveland Clinic (2001-2018) were enrolled in a prospectively maintained registry for procedural profiles and complications. All patients with cardiac venous injuries during the procedures were included. CS injury occurred in 35 of 5011 patients (0.7%; 6 perforations (17.1%), 29 dissections without perforation (82.9%)). In patients with dissection in the absence of perforation, attempts at CS lead placement after dissection were successful in 21 of 29 patients (72.4%). In those with perforation (n=6, 17.1%), CS lead placement was successful in one of them (16.7%). Cardiac tamponade occurred in 2 patients (5.7%), and the procedure was aborted in both of them. Overall, CS lead placement failed in 13 patients (37%) but 9 (25.7%) underwent subsequent CRT with CS lead placement (n=6, 17.1%; median 58 days later) or epicardial leads (n=3, 8.6%). Three of the remaining 4 patients (8.6%) refused to undergo further procedures, and the fourth (2.9%) died of a complicated course. CS injury is not common during CRT implantation procedures and did not preclude successful lead placement in 23 of 35 patients (65.7%) during the index procedure and 6 of 6 (100%) during the subsequent attempted procedures. A low rate of mortality was observed in such patients, but CS injury was associated with increased morbidity.

Vacuum-assisted vegetation removal with percutaneous lead extraction: a systematic review of the literature.

To perform a systematic review of reports in which the AngioVac™ percutaneous vacuum-assisted aspiration system was successfully used to debulk or remove vegetations prior to percutaneous lead extraction. We included all studies and case reports that used a percutaneous aspiration technique for vegetation removal or debulking with percutaneous lead extraction for patients with lead-associated endocarditis. Ten reports and retrospective data from our centers were used, which included a total of 88 patients and 205 leads. The percutaneous aspiration procedure was completely or partially successful in 86 patients (97.7%). The lead extraction procedure itself was successful in 87 patients (98.9%). The aspiration procedure and lead extraction were done concomitantly in 81 patients (92.0%). Four patients (4.5%) had major complications (two due to vascular injuries, one due to coronary sinus injury, and one due to tricuspid valve injury). There were no complications from the aspiration procedure, and no cases were associated with procedure-related mortality. While patients with large vegetations have historically been referred for surgical lead extraction, data are lacking in its techniques and outcomes. Existing data suggest that percutaneous vacuum-assisted aspiration for vegetation removal or debulking in endocarditis prior to or concurrent with percutaneous lead extraction has a high success rate with a low complication rate across a broad series of patients.

Avoidance of Coronary Sinus Injury During Retrograde Cardioplegia

Coronary sinus injury is a rare but critical complication of retrograde cardioplegia. Even after detection, successful repair with a pericardial patch is not always attained. Malalignment of the infusion cannula relative to the coronary sinus is likely to be partially responsible for the injury. Monitoring the location of the cannula tip can help prevent injury. Transesophageal echocardiography can indicate the vascular structure within which the cannula is located. This finding may be useful in preventing injury to the coronary sinus or middle cardiac vein.

A Case of Arterial and Venous Tear during Single Lead Extraction.

Transcutaneous lead extraction can be associated with significant morbidity and mortality. The risk of causing concomitant arterial and venous injury is rare. We report a case of marginal artery rupture with coronary sinus rupture after a CS lead extraction. A 71-year-old male was admitted for extraction of a 6-year-old implantable cardioverter-defibrillator lead due to fracture from insulation break. During the lead extraction, blood pressure fell precipitously and echocardiographic findings were consistent with pericardial effusion. After unsuccessful pericardiocentesis, open chest sternotomy and evacuation of hematoma was performed. Subsequent surgical repair of several injuries was completed including the distal coronary sinus, a large degloving injury of posterior portion of the heart, and first obtuse marginal branch bleed. This case demonstrates that when performing transcutaneous lead extraction (TLE) with laser sheath, a degloving injury can cause arterial rupture with concomitant coronary sinus injury. A multidisciplinary team-based approach can ensure patient safety. Learning Objective. Implantable cardioverter-defibrillator leads will falter over time. With the advancement of new technology for extraction more frequent and serious complications will occur. Active fixation CS leads present unique challenges. In the presence of hemodynamic changes during extraction the occurrence of both an arterial and venous injury must be considered.

A novel sutureless technique for the repair of coronary sinus injuries.

Coronary Sinus injury related to cardioplegia catheter insertion is a rare complication associated with significant morbidity and mortality risk. We describe a simple, safe and effective sutureless technique for the management of coronary sinus injury. This technique was developed in a porcine haemostatic workshop in Hamburg, Germany.

Initial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center.

BackgroundPlacement of a percutaneous coronary sinus catheter (CSC) by an anesthesiologist for retrograde cardioplegia in minimally invasive cardiac surgery is relatively safe in experienced hands. However, the popularity of its placement remains limited to a small number of centers due to its perceived complexity and potential complications.MethodsWe retrospectively reviewed all cardiac cases performed by one surgeon between December 2009 and April 2012. The reviewed cases were divided into two groups: cardiac cases with percutaneous CSC placement (CSC group) and cardiac cases without placement (control group). Anesthesia preparation time (APT) was then compared between the CSC group and control group. In the CSC group, cases were further divided into two groups. One group contained cases with an APT of less than 90 min (success group) and the other contained cases with an APT greater than or equal to 90 min or cases with CSC placement failure (delay/failure group). Patients’ characteristics, type of surgery, and transesophageal echocardiography (TEE) findings were compared between the two groups (success group vs. delay/failure group) to identify variables associated with prolongation of the APT or CSC placement failure.ResultsPercutaneous CSC placement was required in 83 cases (CSC group). The catheter was successfully placed in 74 of those cases. We experienced one complication, coronary sinus injury after multiple attempts at placing the catheter. The mean APT was 102 ± 31 min in the CSC group (n = 81) and 42 ± 15 min in the control group (n = 285). We could not identify any variables associated with prolongation of the APT or catheter placement failure.ConclusionsThe success rate of the placement was 89.1 % in our academic center. On average, placing the CSC added approximately one additional hour to the APT. This time is not an accurate representation of true catheter placement time, as it included time for preparation of the CSC, TEE, and fluoroscopy. We experienced one documented complication (coronary sinus injury), which was immediately diagnosed by TEE and fluoroscopy in the operating room. No variables associated with prolongation of APT or CSC placement failure were identified.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0203-4) contains supplementary material, which is available to authorized users.

Percutaneous Coronary Sinus Catheterization With the ProPlege Catheter Under Transesophageal Echocardiography and Pressure Guidance.

Percutaneous catheterization of the coronary sinus (CS) to enable the administration of retrograde cardioplegia may play an important role in minimally invasive cardiac surgery. A new specially designed device (ProPlege; Edwards Lifesciences, Irvine, CA) is described that can be placed under transesophageal echocardiography (TEE) and pressure guidance with a high rate of success and low rate of complications. Case series. A university-affiliated private hospital. Patients undergoing minimally invasive cardiac surgery. The ProPlege device was placed under TEE and pressure guidance only. Records of 70 patients managed with ProPlege were reviewed and analyzed. Successful placement was attained in 69 patients (98.6%) as confirmed by the ventricularization of the CS pressure curve and TEE images. Direct imaging of the ProPlege tip was possible in 34 patients (49.2%). The capacity to generate a CS pressure>30 mmHg during retrograde cardioplegia administration at a flow>150 mL/min was obtained in 64 patients; ProPlege displacement occurred in 5 cases (7.2%). Successful retrograde cardioplegia was delivered in 91.4% of cases. No CS perforation or other injuries to the right heart were noted at intraoperative TEE or direct surgical inspection. Percutaneous CS catheterization with ProPlege was performed with a high rate of success for positioning and low complication rate using TEE and pressure guidance only. Further studies are needed to more accurately determine complication rates and to establish the possible complementary role of fluoroscopy.

Identification of Coronary Sinus Injury by Transesophageal Echocardiography During Placement of a Retrograde Cardioplegia Catheter for Minimally Invasive Cardiac Surgery

Identification of Coronary Sinus Injury by Transesophageal Echocardiography During Placement of a Retrograde Cardioplegia Catheter for Minimally Invasive Cardiac Surgery

Myocardial oxidative stress protection with sevoflurane versus propofol

Editor, We read with great interest the scientific report by Ballester et al.1 We appreciate the conclusion they have drawn. However, we have several concerns. We would like to know whether coronary sinus injury occurred in their patients. The authors mention that the coronary sinus was catheterised and the catheter remained in situ while the distal coronary anastomoses were performed. Beating heart coronary artery bypass graft surgery involves manipulation of the heart, at times to extreme degrees. Leaving a coronary sinus catheter in situ could damage the coronary sinus. Coronary sinus injury can be difficult to repair and may result in death.2,3 It must have been difficult to manage the correct positioning of the coronary sinus catheter in a beating heart, as it would have repeatedly dislodged either into right atrium (RA) or further into the coronary sinus despite being anchored to the RA wall, thus hampering the venous drainage of the heart. Another concern that we wish to share is that a coronary shunt was not used for the conduct of the anastomosis. We appreciate that this must have been a surgical decision, but in a patient with coronary artery stenosis undergoing beating heart surgery, the degree of metabolic demand and supply mismatch is much higher than in a pleaged heart. A vascular shunt not only aids in conduct of the anastomosis but also ensures the available flow to the distal myocardial tissue in the affected territory.4,5 The authors did not mention if any other means of distal coronary perfusion was used in their patients. Complications observed in absence of distal coronary perfusion should also be described.

Reply to

Editor, We thank Tandon and Pandey1 for their interest in our study.2 We would like to make the following comments regarding their concerns about specific surgical points. First of all, we confirm we did not have any incidence of coronary sinus injury in any patient. Our group has a lot of experience, over many years, of retrograde myocardial protection with excellent results and no complications.3,4 In our study, we used a balloon retroplegia catheter for blood retrieval purposes only. We only inflated the balloon to obtain blood samples according to the study protocol at three different time points,2 reducing the possibility of complications that in most cases are due to overinflation. Moreover, we introduced the balloon catheter through a purse string in the lateral wall of the right atrium and, after each sample retrieval, we placed the tip of the cannula in the atrium cavity avoiding possible damage to the coronary sinus. When another sample was needed, we repositioned the catheter under finger control at the entry of the coronary sinus, as we usually do for myocardial protection purposes. Finally, the use of coronary shunts for the conduct of the anastomosis is a controversial issue. Our group has much experience in off-pump coronary artery bypass graft (CABG) surgery, performing around 200 cases per year. The mean number of grafts per patient is 3.1 and we do not use shunts. We agree with Mack5 that the placement of a shunt can be cumbersome and may damage the native vessel endothelium,6 especially in the distal part of the coronary vessel, causing early occlusion or late stenosis. Lucchetti et al.7 reported that intracoronary shunts are beneficial during off-pump CABG in patients with an isolated left anterior descending coronary artery lesion. They advised the use of intracoronary shunts only in patients with unstable angina and left ventricular dysfunction. Hangler et al.8 reported that the insertion of intracoronary shunts during beating heart surgery leads to severe endothelial denudation in human coronary arteries, and therefore they recommend using intracoronary shunts selectively in patients with critical ischaemia or in patients with technical difficulties as a result of anatomical conditions. In our study, we had no patients with these characteristics and we did not observe any complication due to the absence of distal coronary perfusion during performance of the anastomosis. Acknowledgements There are no conflicts of interest. None of the authors has received any financial support.

Sutureless patch-and-glue technique for the repair of coronary sinus injuries

Coronary sinus (CS) injury is a rare complication of CS catheter insertion. Its management can represent a technical challenge, leading to potential mortality. Several different surgical techniques have been proposed to repair CS injury, including pericardial or saphenous vein patches, 1-4 because the primary suture of the CS often leads to stricture. We report 7 cases in which CS injury was repaired with a sutureless patch-and-glue technique.

Efficacy and safety of right and left atrial ablations on the beating heart with irrigated bipolar radiofrequency energy: A long-term animal study

The Cox maze procedure is the most effective surgical treatment for atrial fibrillation; however, its complexity has limited its clinical utility. The purpose of this study was to simplify the procedure by using an irrigated bipolar radiofrequency ablation device on the beating heart without cardiopulmonary bypass. Six domestic pigs underwent median sternotomy. The pulmonary veins were circumferentially ablated. Electrical isolation was confirmed by pacing. Eight lesions were performed epicardially, and three lesions were performed through purse-string sutures with one of the jaws of the device introduced into the right atrium. After 30 days, magnetic resonance imaging was performed to assess atrial function, pulmonary vein anatomy, and coronary artery patency. Cholinergic stimulation and burst pacing were administered to induce atrial fibrillation. Histologic assessment of the heart was performed after the animal was killed. A modified Cox maze procedure was successfully performed with the irrigated bipolar radiofrequency device with no deaths. In every instance, the pulmonary veins were electrically isolated. Cholinergic stimulation with burst pacing failed to produce atrial fibrillation. Imaging studies revealed tricuspid regurgitation without evidence of pulmonary vein stenosis, coronary artery stenosis, or intra-atrial thrombus. Total atrial ejection fraction was 16.9% +/- 7.5%, a significant reduction. Histologically, 99% of the lesions were transmural, and there was no evidence of coronary sinus injury. Lesions on both the right and left atria can be created successfully on the beating heart with irrigated bipolar radiofrequency. The great majority of lesions with this device were transmural. This device should not be used on valvular tissue.

Management of Central Coronary Sinus Ruptures Using the Pericardial Patch Repair Technique

Intraoperative coronary sinus rupture is a rare event; however, it carries potential mortality and its' management is technically challenging. A repair technique should provide adequate bleeding control while avoiding narrowing or stricture of the coronary sinus. We retrospectively review our experience with a new pericardial patch repair technique. From January 1996 to May 2005 four cases of intraoperative coronary sinus injury were identified. Three female patients and one male patient with a mean age of 74 +/- 4 years underwent valve replacement and/or coronary artery bypass on cardiopulmonary bypass. A double pericardial patch technique sandwiched with human fibrin glue was used to cover the defect. In all patients treated with this method, the injury could be treated successfully. All patients were extubated on the first postoperative day and median intensive care unit stay was 3 days. Drains could be removed after 4 days median. Median hospital stay was 13 days. After a median follow-up of 33 months all patients are alive without any echocardiographic signs of impairments of the coronary sinus. We conclude that the pericardial patch technique is a safe and technically feasible technique for repair of central coronary sinus ruptures. Excellent bleeding control and, in our experience, no consecutive complications were observed.

Repair Of Coronary Sinus Rupture Secondary To Internal Cardiac Massage

Injuries secondary to external and internal cardiac massage have been reported. This is the first report of coronary sinus injury secondary to internal cardiac massage. The technique used to repair the coronary sinus injury is described. INTRODUCTION Coronary Sinus Injury is a rare complication of the retrograde delivery of cardioplegia [1, 2]. This report describes coronary sinus injury secondary to internal cardiac massage and the technique used for repair. CASE REPORT A 68-year-old lady underwent coronary artery bypass graft surgery for triple vessel disease. The procedure was uneventful and during insertion of sternal wires, there was an unexplained drop in blood pressure followed by asystolic cardiac arrest. The wires were removed and internal cardiac massage was commenced. This was not particularly helpful and the patient was placed on cardiopulmonary bypass. The internal cardiac massage had caused injuries to the anterior surface of the heart (a small epicardial tear on the surface of the right ventricle) and the coronary sinus. There was a large amount of bleeding from the back of the heart and a large hematoma was present in the region of the coronary sinus. There was considerable venous bleeding from the sinus. The hematoma had obscured the tissue planes and it was not possible to discern clearly the edges of the defect in the coronary sinus all round (Figure 1). Figure 1 Figure 1: Coronary Sinus injury resulted in a large hematoma with obliteration of tissue planes. The edges of the coronary sinus injury were not discernible all round. The cross clamp was applied and the heart arrested with antegrade cardioplegia. The edges of the coronary sinus injury were not clearly defined. A large patch of pericardium (Tissuemed, Leeds, UK) was laid over the defect and sutured to the epicardial fat with Teflon (Bard Inc, Tempe, AZ) reinforced 40 prolene (Ethicon, Somerville, NJ) sutures. Bio glue (Cryolife, Kennesaw, GA) was then liberally applied at the edges of the pericardial patch (Figure 2). Figure 2 Figure 2: Repair of the coronary sinus injury by a pericardial patch sutured to the epicardial fat and secured by glue. The anterior epicardial tear was repaired with 40 prolene sutures. The cross clamp was removed and the patient was weaned off bypass uneventfully. The repair was intact and there was no further bleeding. The cause of the initial aystolic arrest Repair Of Coronary Sinus Rupture Secondary To Internal Cardiac Massage 2 of 3 was unexplained and the patient made an uneventful recovery. DISCUSSION Injuries secondary to internal and external cardiac massage have been reported [3]. Coronary sinus injury can occur secondary to cannulation for delivering retrograde cardioplegia [1,2]. To our knowledge, coronary sinus injury secondary to internal cardiac massage has not been reported. A ruptured coronary sinus is very difficult to repair primarily as the edges are not clearly seen and the hematoma causes obliteration of normal tissue planes. A large pericardial patch can be laid over the defect and sewn to the epicardial fat. This causes re-establishment of venous drainage. The application of glue to the edges of the pericardial patch helped secure a watertight repair and there was no further bleeding from the low-pressure venous system. We believe this technique of repair using a large pericardial patch sewn to the epicardial fat and secured by glue, makes it easy to manage a very difficult complication. CORRESPONDENCE TO Mr V Zamvar Tel : +44-(29)-20747747 Fax: +44-(29)-20745439 Email: zamvarv@hotmail.com Address: University Hospital of Wales, Cardiff CF14 4XW, UK

Coronary Sinus Injuries following Retrograde Cardioplegia

A retrograde coronary sinus cardioplegia catheter was used for administration of retrograde cardioplegic solution in 620 of 942 coronary bypass procedures performed over a 3-year period. Coronary sinus injuries were encountered in 4 patients (0.65%).

Repair of coronary sinus rupture secondary to retrograde cardioplegia

Coronary sinus injuries related to retrograde cardioplegia administration are uncommon, but can be a lethal complication of this technique. This report describes a major coronary sinus disruption during retrograde cardioplegia administration and details a method of repair with suggestions for possible prevention of this complication.

Coronary sinus injuries during retrograde continuous normothermic blood cardioplegia

Injuries to the coronary sinus during cardioplegic arrest are rare but potentially lethal. We herein present case reports of injuries to the coronary sinus occurring during retrograde continuous normothermic blood cardioplegia, and emphasize preventive measures and treatment.