Coronary Sinus Ostium Research Articles

Coronary Sinus Diameter as a Potential Marker of Right Ventricle Impairment.

The aim of this study was to assess the influence of the parameters of the coronary sinus (CS) on the parameters that describe the function of the right ventricle (RV), which were calculated using cardiac computed tomography. Methods: A CT scan of the heart was performed on 150 patients due to suspicion of coronary artery disease using a Siemens Somatom Force (2 × 192 × 0.6) and a syngo.via workstation. The “CT coronary” and in some cases the generic presets were used to measure the CS ostium in millimeters (mm). The functional measurements of right heart ventricles were examined using the “CT cardiac function” automatic function on a 256 × 256 matrix. Results: The average diameter of the CS ostium was 16.29 ± 4.37 mm. In the group with RV impairment, it was 16.56 ± 4.76, whereas in the group with normal values of the RV, it was 15.98 ± 3.88 mm, p = 0.4199. The average angle of the entrance of the CS into the right atrium was 107.25° ± 9.68°. In the group with an RV impairment, it was 105.91° ± 9.22°, while in the patients with normal values of the RV, it was 108.82° ± 10.04°; p = 0.0682. A multiple regression showed that end systolic volume (p = 0.0017) and stroke volume (p = 0.0144) are important predictors of the CS ostium. Conclusions: Some relationships were found between the CS and the selected parameters that describe the function of the RV. This may suggest a role for the CS as a right ventricular buffer, which could potentially be treated as a marker of an RV impairment.

Optimized Computed Tomography Acquisition Protocol for Ethanol Infusion Into the Vein of Marshall.

This study sought to introduce a computed tomography (CT) protocol for optimal planning of vein of Marshall (VOM) catheterization. Ethanol infusion into the VOM (Et-VOM) is increasingly used in atrial fibrillation ablation. Preprocedural CT was performed with either a conventional (conv-CT; n=132) or an optimized CT protocol (VOM-CT; n=126) designed for obtaining on a single image both left atrial and coronary sinus (CS) enhancement. The detection rate and anatomical features of the CT-derived VOM were analyzed and the utility of VOM-CT protocol was assessed by comparing the procedural data. VOM was detected in 35% in conv-CT versus 63% in VOM-CT (P< 0.001). The VOM-CT protocol did not impair the assessment of left atrial anatomy and appendage patency. In VOM-CT, the detection of the VOM was related to body mass index and width of epicardial space on posterior wall. Mean distance between CS ostium and VOM was 36±7mm. Mean VOM diameter was 1.6 ± 0.3mm. On the CS circumference, the VOM emerged superiorly in 68% and postero-superiorly in 32%. Ethanol infusion into the VOM was attempted in 165 patients (77 conv-CT, 70 VOM-CT, and 18 without-CT). After registration in CARTO, the VOM segmented on CT matched its location on venography in all cases. As compared with conv-CT and without-CT, procedures guided by VOM-CT showed significantly shorter radiation time, shorter procedure time, lower amount of the contrast medium, and fewer contrast injections to obtain VOM catheterization. The proposed CT protocol allows for improved visualization of the VOM, translating into easier VOM catheterization.

Outcomes of Different Ablation Approaches for Para-Hisian Accessory Pathway and Ablation Safety at Each Site.

BackgroundThis study describes the electrophysiologic characteristics of the para-hisian accessory pathway (AP), the outcome of different ablation approaches, and ablation safety at different sites.MethodA total of 120 patients diagnosed as para-hisian AP were included in this study. The electrophysiologic characteristics and outcomes at different ablation sites were analyzed.ResultsIn total, 107 APs and 13 APs were diagnosed as right anteroseptal (RAS) and right midseptal (RMS), respectively. The significant ECG difference between RAS and RMS was lead III, which mainly manifested as positive and negative delta waves, respectively. Catheter trauma to AP was recorded in 21 of 120 (17.5%) patients. The recurrence rate of direct ablation at the “bumped” sites was higher than the conventional ablation method (37.5 vs. 14.1 %, p = 0.036). For RAS APs, there was no significant difference in the success rate between the inferior vena cava (IVC) and superior vena cava (SVC) approaches (76.6 vs. 73.3%, p = 0.63). The RAS was separated into three regions: (1) Site 1: superior part above the real “His” recorded site with far-field “His” potential; (2) Site 2 (true para-hisian): the site with near-field “His” potential; and (3) Site 3: inferior part below the biggest real “His” with far-field “His” potential. Mid-septal was defined as an area that is bounded anteriorly by His recording location and posteriorly by the roof of coronary sinus (CS) ostium. The incidence of atrioventricular (AV) conduction injury at different sites was as follows: 3 of 6 (50%) at Site 2, 4 of 13 (30.8%) at RMS, 7 of 34 (20.6%) at Site 3, and 3 of 46 (6.5%) at Site 1. Even if ablation was performed at the atrial side of the para-hisian region, the right bundle branch block (RBBB) was caused in 6 patients (5%).ConclusionAblation via IVC or SVC was comparative for para-hisian APs, but not for the noncoronary cusp (NCC) approach. The AV conduction injury risk ranks as follows: Site 2 > RMS > Site 3 > Site 1. RBBB could be caused while ablating at the atrial side, which could further demonstrate the His bundle longitudinal dissociation theory.

Association Between the Coronary Sinus Ostial Size and Atrioventricular Nodal Reentrant Tachycardia in Patients With Pulmonary Arterial Hypertension.

AimsThe incidence of atrioventricular nodal reentrant tachycardia (AVNRT) is higher in pulmonary arterial hypertension (PAH) patients than in the general population. AVNRT is reportedly associated with a larger coronary sinus (CS) ostium (CSo). However, the correlation between AVNRT and CSo size in PAH patients is poorly investigated. We aimed to investigate the impact of CSo size on AVNRT and identify its risk factors in PAH.Methods and ResultsOf 102 PAH patients with catheter ablation of supraventricular tachycardia (SVT), twelve with a confirmed AVNRT diagnosis who underwent computed tomographic angiography were retrospectively enrolled as the study group. The control group (PAH without SVT, n = 24) was matched for sex and BMI at a 2:1 ratio. All baseline and imaging data were collected. Mean pulmonary artery pressure was not significantly different between the two groups (65.3 ± 16.8 vs. 64.5 ± 17.6 mmHg, P = 0.328). PAH patients with AVNRT were older (45.9 ± 14.8 vs. 32.1 ± 7.6 years, P = 0.025), had a larger right atrial volume (224.4 ± 129.6 vs. 165.3 ± 71.7 cm3, P = 0.044), larger CSo in the left anterior oblique (LAO) plane (18.6 ± 3.3 vs. 14.8 ± 4.0 mm, P = 0.011), and larger CSo surface area (2.08 ± 1.35 vs. 1.45 ± 0.73 cm2, P = 0.039) and were more likely to have a windsock-shape CS (75% vs. 16.7%, P = 0.001) than those without AVNRT. A linear correlation was shown between CSo diameter in the LAO-plane and the atrial fractionation of the ablation target for AVNRT (R2 = 0.622, P = 0.012).ConclusionAnatomical dilation of the CSo is a risk factor for AVNRT development in patients with PAH.

Three-dimensional mapping systems for radiofrequency catheter ablation of slow pathway for the treatment of atrioventricular nodal reentrant tachycardia: About 2 cases

Radiofrequency ablation (RFA) of the atrioventricular nodal reentrant tachycardia (AVNRT) is associated with the risk of complete atrioventricular (AV) block. This risk is majored by some anatomic conditions and remains a serious complication in young patients. Herein, we would like to report 2 cases of 3D mapping system use to guide RF ablation of AVNRT. This is a case of a 57-year-old man with a long medical history of atrial fibrillation (AF). He presented with palpitation and dyspnea. Physical examination was normal. On ECG, supraventricular tachycardia (SVT) with a heart rate of 144 beats per minute was noted. RFA was indicated because of the recurrence of this symptomatic tachycardia. CARTO 3D system mapping was used as the patient has a medical history of multiple ablated AF. RF delivery below the Coronary sinus (CS) ostium showed an accelerated junctional rhythm. No SVT was reproducible at the end of the procedure. A 50-year-old patient reported chest pain and dyspnea related to SVT. Physical examination and tranthoracic echocardiography were unremarkable. On ECG, a supraventricular tachycardia with long RP’ with ST depression was noted. Blood tests showed troponin elevation. Coronary angiography was normal. This patient had a long medical history of tachycardia that often starts and ends suddenly, not improved by beta-blockers treatment. RFA was indicated. RHYTHMIA Mapping system was used. The EP study reproduced the clinical tachycardia, which was a slow-slow AVNRT. RF delivery for 90 minutes below the CS ostium and 12 mm under the His bundle eliminated completely the slow pathway. The 3D mapping systems is an interesting tool for AVRNT RF ablation. It is correlated with lower radiation exposure and shorter procedure time. It may offer more security in young patient and those with a short distance between His bundle and CS ostium.

P-Wave Morphology in Focal Atrial Tachycardia: An Updated Algorithm to Predict Site of Origin.

This study sought to report P-wave morphology (PWM) from a series of paraseptal (PS) atrial tachycardia (AT), revise then prospectively evaluate a simplified PWM algorithm against a contemporary consecutive cohort with focal AT. The 2006 PWM algorithm was useful in predicting the origin of focal AT. An updated algorithm was developed given advances in multipolar 3-dimensional mapping, potential limitations of PWM in separating PS sites, and a renewed interest in the P-wave in mapping non-pulmonary vein triggers. The PWM from a consecutive series of 67 patients with PS AT were analyzed. PS sites included were coronary sinus ostium, perinodal, left and right septum, septal tricuspid annulus, superior mitral annulus, and noncoronary cusp. Next the P-wave algorithm was revised and prospectively evaluated by 3 blinded assessors. The P-wave for PS sites was neg/pos (n= 50), iso/pos (n= 10), or isoelectric (n= 4) in lead V1 (96%). The P-wave algorithm was modified and prospectively applied to 30 consecutive patients with focal AT who underwent successful ablation. Foci (n=30) originated from the right atrium (33.3%), left atrium (30%), and PS (36.7%). Using the PW algorithm, the correct anatomic location was identified in 93%. Incorrect interpretation of the terminal positive P-wave component (n=3) and initial negative P-wave deflection (n=1) in lead V1 misidentified 4 paraseptal cases. The revised PWM algorithm offers a simplified and accurate method of localizing the responsible site for focal AT. The P-wave remains an important first step in mapping atrial arrhythmias.

Change in VA interval by a single atrial premature depolarization - What is the mechanism?

A long VA tachycardia during a typical atrioventricular nodal reentrant tachycardia (AVNRT) can be a concomitant atypical AVNRT, atrial tachycardia or rarely atrio-ventricular reentrant tachycardia (AVRT). There are reported associations of AVNRT with other tachycardia substrates. Maneuvers are useful for differentiating the mechanism of the second tachycardia. Atrial tachycardia (AT) is one common association. When the AT originates from the lower triangle of Koch/near coronary sinus ostium, it can mimic slow-slow/fast-slow AVNRT. We encountered an interesting case where a longer VA tachycardia got reproducibly induced when a critically timed atrial premature depolarisation was delivered on typical AVNRT. It was proved to be an AT. A slow pathway modification in the lower TOK was successful to eliminate both the tachycardia substrate.

Permanent pacemaker implantation in Ebstein anomaly with metallic tricuspid valve

Right ventricular endocardial pacing is partially contraindicated in the presence of mechanical tricuspid valve. Occurrences of atrioventricular block are commonly associated in postoperative period in Ebstein anomaly repaired with mechanical tricuspid valve. Coronary sinus (CS) pacing is the preferred site in this scenario. However, the anatomical variations in Ebstein anomaly leads to difficulties in hooking the CS. With the help of real time left coronary injection enabled in understanding the anatomical orientation of CS ostium take off, leading to successful CS lead implantation.

Anatomical dilation for the coronary sinus ostium in patients with pulmonary arterial hypertension and its impact to trigger the atrioventricular reentrant tachycardia: a case control study

Abstract Background The incidence of atrioventricular reentrant tachycardia (AVNRT) in pulmonary arterial hypertension (PAH) patients is higher than the general population [1–3]. AVNRT had been reported with larger coronary sinus (CS) ostium in general population, while the mechanism and correlation between AVNRT and the CS ostium in PAH patients are poorly understood. Purpose We aim to investigate the impact of the CS ostium on AVNRT and find out its risk factors in PAH patients. Methods Of 102 pulmonary arterial hypertension (PAH) patients with catheter ablation of SVT, 10 patients confirmed AVNRT who underwent computed tomographic angiography (CTA) were enrolled as study group. The control group (PAH patients without SVT, n=20) were matched in a ratio of 2:1 based on gender and BMI. We measured maxium diameter of CS ostium in axial and LAO plane by CTA. All baseline characteristics and imaging materials were collected. Results PAH patients with AVNRT were older (45.9±14.8 vs. 32.1±7.6 years, P=0.025) and more likely to have larger CS ostium in LAO plane (18.6±3.3 vs. 14.8±4.0 mm, P=0.011) than those without AVNRT. The maximal diameter of CS ostium in LAO plane was an independent predictor for AVNRT in PAH patients (Odds ratio, 1.389; 95% confidence interval, 1.003–1.923; P=0.048). The cut-off value of CS ostium in LAO plane was 14.1mm (Area under curve = 0.79, P=0.012), and the sensitivity and specificity were 90% and 55%, respectively. Conclusions The larger CS ostium in LAO plane correlated with the higher prevalence of AVNRT in PAH patients with age. Patients with CS ostium larger than 14.1mm in LAO plane are more likely to develop AVNRT. Funding Acknowledgement Type of funding sources: None. Measurements and diagnosis value

B-PO05-048 INSERTION OF CORONARY SINUS LEAD UTILIZING INTRACARDIAC ECHOCARDIOGRAM, 3D ELECTRO-ANATOMICAL MAPPING, 3D PRINTED HEART MODEL AND FLUOROSCOPY IN A PATIENT WITH MARFAN SYNDROME AND PECTUS EXCAVATUM

A 30-year-old woman with a history of pectus excavatum and Marfan syndrome s/p Bentall procedure 7 years prior developed complete heart block after aortic mechanical prosthesis and underwent PPM implant with one RA and two RV leads (RV apex and RVOT) in lieu of failed traditional CRT. She developed a reduced ejection fraction to 30% and was referred to our institution for CRT-D upgrade. Describe a case of CS lead insertion in a patient with complex anatomy. N/A CRT-P system and two RV leads were extracted using laser lead extraction. A CS lead could not be placed despite an extensive traditional approach. A cardiac CT was performed in order to better define CS anatomy, a 3D heart model was printed for procedural planning and CT images were merged with Carto 3D electro-anatomical system. Reviewing the model and images above, a significant cranial displacement of the CS ostium was noted with an acute angulation of the proximal CS. We proceeded with 3D anatomical mapping, ICE, and fluoroscopic guided insertion of a decapolar® catheter in CS via right femoral vein which was then exchanged for a glide wire in order to mechanically straighten the angulation in proximal CS. Then, using a long sheath from the left subclavian approach, the ostium of CS was engaged. The sheath was cautiously advanced under fluoroscopy and Carto mapping using a Bard quadripolar catheter. CS lead was inserted in a posterolateral branch with a recorded RV-LV separation of 150 msec. Multi-modality imaging and mapping can help insert CS leads in patients with prior unsuccessful attempts at cardiac synchronization therapy.

B-AB16-02 P WAVE MORPHOLOGY IN FOCAL ATRIAL TACHYCARDIA: AN UPDATED 2021 ALGORITHM TO PREDICT SITE OF ORIGIN

The 2006 P wave morphology (PWM) algorithm was useful in predicting the origin of focal atrial tachycardia (AT). An updated algorithm was developed given advances in three dimensional(3D) mapping, potential limitations of PWM in separating paraseptal (PS) sites, and a renewed interest in the P wave in mapping non- pulmonary vein triggers in atrial fibrillation ablation. To report PWM from a series of PS AT, revise then prospectively evaluate a simplified PWM algorithm against a contemporary cohort with focal AT. The P wave morphology from a consecutive series of 67 patients with PS AT were analysed. PS sites included: CS ostium, perinodal, left and right septum, septal tricuspid annulus, superior mitral annulus and non-coronary cusp. Next the P wave algorithm was revised and prospectively evaluated by 3 blinded assessors. The PWM was not useful in separating PS sites. Generally the PS P wave was negative/positive, isoelectric/positive or isoelectric in lead V1 in 93% of cases. The P wave algorithm was prospectively applied to 30 consecutive patients with focal AT who underwent successful ablation. Foci (30) originated from right atrium (33.3%), left atrium (30%) and PS (36.7%). Using the P wave algorithm, the correct anatomic location was identified in 93%. Incorrect interpretation of the terminal positive P wave component(3) and initial negative P wave deflection(1) in lead V1 misidentified 4 paraseptal cases. The revised 2021 P wave morphology algorithm offers a simplified and accurate method of localising the responsible site for focal atrial tachycardia. The P wave remains an important first step in mapping atrial arrhythmias.

Usefulness of the angiographic anatomy of the vein of marshall for ablation procedures for persistant atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Ethanol Infusion in the Vein of Marshall (EIVOM) was recently proposed as an efficient adjunctive technique for obtaining mitral isthmus block during catheter ablation for persistent atrial fibrillation. Purpose Given these considerations the objective of this research was to delineate the angiographic anatomy of the Vein of Marshall (VOM). Methods Fluoroscopy images were obtained retrospectively in 124 patients with persistent atrial fibrillation who underwent coronary sinus angiography for EIVOM (96 patients) or cardiac resynchronization implant (18 patients). The measurements were performed using Osirix DICOM reader using the known diameter of the angiographic catheter for calibration. The distance between the ostium of the coronary sinus (CS) and the ostium of the VOM was measured in the anteroposterior view. Additionally, the angle at which the ostium of VOM opens in the CS was obtained. Results The diameter of the VOM ostium was 1.8 ± 0.6mm. The length of the VOM was 18.6 ± 9.1mm. The distancebetween the CS ostium and VOM ostium was as follows: less than 10mm for 1 patient (1%), between 11-20mm for 10 patients (10.41%), between 21-30mm for 38 patients (39.58%), 31-40mm for 31 patients (32.29%), between 41-50mm for 15 patients (15.62%) and &amp;gt;50mm for 1 patients (1%) (53mm). The average takeoff angleof the VOM from the CS between the main branch of the VOM and the CS was measured at 140 degrees (range 90-175 degrees). No correlation could be made between the takeoff angle and the distance between CS ostium and VOM ostium. In the group of patients undergoing cardiac resynchronization the takeoff angle from the CS was 153°±17° and it correlated significantly with the left ventricular systolic diameter and the left ventricular ejection fraction determined by echocardiography(r = 0.52; p = 0.008 and respectively r = 0.50; p = 0.009). Conclusions Understanding the anatomy of the Vein of Marshall (VOM) is crucial in helping operators efficiently exploit the therapeutic potential of ethanol injection after accurate localization of such an important branch of the left atrial venous system. Abstract Figure. 1 Fig 1 Angle CS-VOM

Voltage bridge mapping in atrioventricular nodal reentry tachycardia ablation in adult population: results from a multicenter registry

Abstract Funding Acknowledgements Type of funding sources: None. Background The presence of Low Voltage Bridge (LVB) in Atrioventricular Nodal Reentry Tachycardia (AVNRT) ablation has been described in children populations. Slow pathway ablations visualizing and targeting the LVB has been described to be safe and effective. However, the incidence of LVB in AVNRT ablation has not been widely explored in adult population. Purpose We aim to investigate the presence of LVB in adult patients (pts) undergoing AVNRT ablation, and the relationship between the LVB and the successful ablation site. We have also investigated the correlations between the Koch’s triangle (KT) anatomy and biophysical pts data. Methods The observational registry prospectively collected data of 165 pts. undergoing AVNRT ablation guided by 3D electroanatomical mapping system (EnSite - Abott, St Paul, MN) in 6 EP centers. Gender: 90F – 75M (55% - 45%) - Age: 57 ± 17 ys (min 15 – max 87) - Weight: 73 ± 15 kgs (min 42 - max 150) Prior of ablation a voltage map of KT was created using diagnostic and ablation catheters. We define as Type I LVB a clear, long area of low voltage within the KT between the CS ostium and the AV node with the base on the edge of the tricuspid annulus and Type II LVB a narrow low voltage channel between normal-voltage regions with the base on the edge of the tricuspid annulus. The relationship between LVB and successful site was evaluated at the end of the procedure. KT anatomical data were correlated to gender, age and weight. Results The LVB was identified in 134 pts (81%) with a prevalence of type I (91 - 68%) over type II (33 - 25%). In 10 pts (7%) the LVB did not match type I nor type II. When an LVB was identified, the correspondence between the LVB and the successful ablation site was verified in 117 pts (87%). In addition, a shorter RF time was applied when an LVB was found (396s vs 298s; p = 0.03). Strong correlations between KT anatomy and biophysical pts data were not identified. The distance between His electrograms and the successful ablation site weakly correlated (ρ = -0.24, p &amp;lt; 0.01) with pts age suggesting a shortening in the distance with age progression. Conclusion The visualization of the Low Voltage Bridge may be a helpful tool to guide AVNRT ablation in a large cohort of pts; furthermore it is associated with reduced RF applications time. The KT characteristics are difficult to be predicted a priori according to patient gender, age or weight.

Electrophysiologic evidence of epicardial connections between low right atrium and remote right atrial region or coronary sinus musculature: Relevance for catheter ablation of typical atrial flutter

The coronary sinus (CS) is surrounded by a myocardial coat with extensive connections to the left and right atria that contributes to the interatrial electrical connection. Whereas epicardial connections between CS musculature and the left atrium have largely been demonstrated, clinically relevant epicardial connections from the CS musculature toward the low right atrium (LRA) and epicardial connections between two regions of the right atrium remain questionable ( Fig. 1 ). Five patients underwent electrophysiology (EP) study for typical atrial flutter (AFl) using either conventional multipolar catheters (four patients) or three-dimensional high-density mapping system (one patient). All five patients had a similar sequence of events during the EP studies. After several cavotricuspid isthmus (CTI) radiofrequency (RF) applications, double potentials were recorded along the ablation line while tachycardia persisted. The right atrial activation pattern strongly suggested the presence of a complete endocardial CTI line of the block. Based on the detailed conventional atrial mapping, RF applications at the middle cardiac vein/CS ostium allowed sinus rhythm restoration in four patients. High-density mapping showed an early breakthrough site at the septal side of the ablation line, close to the CS ostium during counterclockwise AFl, in the fifth patient. RF applications at this site resulted in tachycardia termination. Our observations suggested the existence of epicardial fibers connecting the LRA with either the CS musculature or a remote right atrial region. When AFl ablation fails whereas evidence for the local endocardial block is observed, the operators should integrate this finding in the diagnosis and ablation strategy.

Peculiarities in coronary sinus anatomy: implications for successful cannulation from an autoptic study.

AimsThe number of cardiovascular procedures using the coronary sinus (CS) as a gateway is constantly increasing. The present study aimed to define specific structures within CS, which could potentially complicate CS cannulation and to develop a new Thebesian valve (TV) classification system.Methods and resultsThe study was performed on 560 consecutive unfixed cadaveric hearts during routine autopsy examination (1–3 days post-mortem). Basic CS dimensions were measured and the presence and dimensions of the TV and the Vieussens valve (VV) were assessed. Thebesian valves were classified according to their morphology into six main types: remnant fold, semilunar, fenestrated, chord, fused strands, and mixed shaped. The median age of hearts was 48 years (range 16–95 years), and 38.9% were female. Thebesian valve was present in 79.5%. The most common TV type was semilunar (54%) followed by fenestrated (8.2%), remnant fold (5.5%), fused strands (4.8%), chord (4.0%), and mixed shaped (3.0%). In 1.1% of hearts, TV totally covered the coronary sinus ostium (CSO). The VV was detected in 67.9%. Potentially occlusive VV was found in 1.1% hearts and in all of which it coexisted with obstructive TV. The median CSO area was 87.9 mm2 [interquartile range (IQR): 56.5–127.1 mm2] and median CS length was 38 mm (IQR: 29.5–45 mm). The CSO area and CS length correlated with each other and with the right atrium’s dimensions.ConclusionWe identified six types of TVs, among which only 1.1% TVs caused total occlusion of CSO. The obstructive TV co-existed with potentially occlusive VV what might hinder CS cannulation.

High-power, short-duration ablation in the coronary sinus: clinical cases and preliminary observations on swine hearts

PurposeCoronary sinus-related arrhythmias are common; however, it is difficult to perform radiofrequency (RF) ablation at these sites efficiently and safely. High-power, short-duration ablation (HPSD) is a proven alternative strategy for pulmonary vein isolation (PVI); whether it can be applied to ablation of the coronary sinus is unknown. The purpose of this preliminary study was to evaluate the feasibility and safety of HPSD ablation in the coronary sinus.MethodsFirstly, we demonstrated 4 clinical cases of 3 types of arrhythmias who had unsuccessful ablation with standard power initially, but received successful ablations with HPSD. Secondly, RF ablation was performed in the coronary sinus ostium (CSO) and middle cardiac vein (MCV) of 4 in vitro swine hearts. Two protocols were compared: HPSD (45 W/5 S×5 rounds) and a conventional strategy that used low-power, long-duration ablation (LPLD: 25 W/10 S ×5 rounds). The total duration of HPSD protocol was 25 s, and which of LPLD was 50 s.ResultsA total of 28 lesions were created. HPSD can produce longer, wider, deeper, and larger lesions than LPLD. This difference was more pronounced when the ablation was in the MCV. One instance of steam pop occurred during LPLD in the MCV.ConclusionsHPSD is an effective alternative strategy for ablation in coronary sinus according to clinical applications and preliminary animal study. However, the safety needs to be further evaluated based on more animal and clinical studies.

Age-Related Changes in the Anatomy of the Triangle of Koch: Implications for Catheter Ablation of Atrioventricular Nodal Re-entry Tachycardia

BackgroundAtrioventricular nodal re-entrant tachycardia is the most common type of paroxysmal supraventricular tachycardia. We sought to assess whether important anatomic factors, such as the location of the slow pathway, proximity to the bundle of His, and coronary sinus ostium dimensions, varied with patient age, and whether these factors had an impact on procedural duration, acute success, and complications. MethodsBaseline demographic and procedural data were collected, and the maps were analyzed. Linear regression models were performed to evaluate the associations between age and these anatomic variations. Associations were also assessed, with age categorized as being ≥ 60 years or < 60 years. ResultsThe slow pathway was more commonly located in a superior location relative to the coronary sinus ostium in older patients. The location of the slow pathway moved in a superior direction by 1 mm for every increase in 2 years from the mean estimate of age. Additionally the slow pathway tended to be closer to the coronary sinus ostium in older patients, and the diameter of the ostium was larger in older patients. This resulted in longer procedure time, longer ablation times, and a greater need for long sheaths for stability. ConclusionsThe location of the slow pathway becomes more superior and closer to the coronary sinus ostium with increasing age. Additionally, the coronary sinus diameter increases with age. These factors result in longer ablation and procedural times in older patients.

Innovative Cardiac Resynchronization: Deployable Lead as an Anchor to Facilitate Guidewire Advancement

An acutely angulated coronary sinus ostium coupled with a dilated right atrium presents technical challenges for cardiac resynchronization therapy (CRT) implantation. Innovative use of a deployable left ventricle lead as an anchor to support guidewire navigation within the cardiac venous system permits optimal CRT deployment. (Level of Difficulty: Advanced.)

Temporal changes of the diameter of the coronary sinus during the cardiac cycle.

Currently, there are no studies that analyse the changes in the cardiac venous system that are dependent on the phase (RR interval) of reconstruction. The aim of the study was to assess the size of the coronary sinus at two measurement sites depending on the phase of the heart cycle. Fifty patients were included. Cardiac computed tomography was performed in all of the patients due to a suspicion of coronary artery disease (typical indications) using a dual-source Siemens Somatom Force scanner. The "MM reading" presets were used to measure the coronary sinus ostium (measurement 1) and the coronary sinus trunk, which is close to the great cardiac vein (measurement 2) in millimetres. All of the calculations were performed on axial scans using 0%-100% and a 256×256 matrix. The largest CS was found at the 30%, 40% and 50% RR interval-this phenomenon occurred in 37 of the 50 cases (74%). The CS was largest in the 30% phase (9/50 cases; 18%), in the 40% phase (17/50 cases; 34%) and in the 50% phase, and it was the largest in 11 of the 50 cases (22%). There were also no gender-related differences. The size of the coronary sinus varies with the phase of the heart cycle. At the 40% phase, it is largest in most cases.

Vein of Marshall visualization in cardiac computed tomography

Abstract The oblique vein of the left atrium (vein of Marshall) is a small vessel that descends obliquely on the back of the left atrium and ends in the coronary sinus near the area where great cardiac vein continues into the coronary sinus. Its cannulation can be useful, e.g. before selected electrophysiology procedures such as paroxysmal focal atrial fibrillation ablation. Because the vein of Marshall should also be avoided at the site of the implantation of the left ventricle lead, knowledge about its existence, position or diameters could be useful. There is a lack of complex data about the possibilities of visualizing the vein of Marshall in cardiac computed tomography. Methods 354 patients were included into the research. Cardiac computed tomography (Aquilion 64, Toshiba: 64 slices, 0.5 mm; retrospective gating; contrast enhanced) was performed for all of the patients. A precise retrospective analysis of the CT data in all phases (every 10%) of the cardiac cycle during post processing was performed including searching for the target vein by using Vitrea workstations (Vital Images). Both multi planar reformatted reconstructions (MPR) and 3D volume renderings were used. The analyses were performed by two experienced researchers (more than 200 coronary venous system analyses previously performed). Results The vein of Marshall was found in 66 of the 354 patients (16.6%). An example of the visualization is presented in the figure below (MPR and 3D volume rendering). Its ostium to coronary sinus was found an average of 42.6±10.8 mm from the coronary sinus ostium to the right atrium. This value was statistically higher (p=0.0082) in the men (45.3±11.2) compared to the women (38.5±9.7). The vein of Marshall is a small vessel; its average diameter was 1.8±0.8 mm and length of the visible vessel that was measured was 8.7±7.5 mm. It was visualized statistically more frequently (p=0.0009) in the end-systolic phases (30–40–50% RR; 68.85% cases) compared to the end-diastolic phases (70–80% RR; 21.31% cases). Occasionally, it was optimally visualized in the other phases (9.83%). Conclusion It is possible to visualize the vein of Marshall using cardiac computed tomography. Because it exists in about 20% of population, during visualization, special attention needs to paid to obtaining quality images in CT especially in the end-systolic phases. Vein of Marshall imaging (VR, MPR) Funding Acknowledgement Type of funding source: None