Coronary Venous Angiography Research Articles

The veins of the left ventricular summit in patients undergoing cardiac resynchronization therapy

Abstract Introduction While the coronary sinus and its left ventricular branches have been extensively described, the veins of the left ventricle summit (LVS) have been much less studied. The emergence of new ablation techniques for ventricular tachycardias, which make use of the LVS veins, has generated a renewed interest in the anatomy of these venous conduits. Purpose The aim of the study was to describe in detail the anatomy of the LVS veins using rotational venous angiography. Material and methods All patients (N=106, age 68±12 years, 72 men) underwent coronary venous angiography during the cardiac resynchronization implant procedures. Results The LVS veins identified were the great cardiac vein (GCV), the anterior interventricular vein (AIV) and the mitro-aortic LVS vein (MALVSV). The MALSV emerged from the GCV between 12 and 2 o'clock on the mitral ring, coursed inside the left atrioventricular groove, towards the aorto-mitral continuity (AMC), where it turned towards the ventricular septum and coursed parallel to the AIV, tapered down and ended at midventricular level. Most of the course of this vein was in the region of the LVS. The diameter of the venous conduit at the GCV-AIV junction was 4.9±1.0 mm. The MALVSV was present in 76 patients (72%; Figure 1). The MALVSV diameter was 2.4±0.6mm at the ostium (Figure 2) and 1.8±2.0 mm at the AMC. The takeoff angle was 134±27°. The total length of the vein was 34±16 mm, of which 23±14mm were inside the AV groove and 11±9mm, were along the ventricular septum. The length of the MALSV segment embedded in the left AV groove as well as the total length of MALSV correlated significantly with the left atrial diameter (r=0.44; P=0.040 and r=0.45; p=0.016 respectively) as well as with the right ventricular systolic pressure (r=0.50; p=0.028 and r=0.57; P=0.030 respectively). Conclusions This study brings new insights into the angiographic anatomy of the LVS veins. Detailed knowledge of these venous tributaries could help with the development of new strategies for ablation of LVS tachycardias. Funding Acknowledgement Type of funding sources: None.

Impact of Myocardial Viability and Left Ventricular Lead Location on Clinical Outcome in Cardiac Resynchronization Therapy Recipients with Ischemic Cardiomyopathy

Cardiac resynchronization therapy (CRT) recipients with ischemic cardiomyopathy (ICM) have scar segments that may limit ventricular resynchronization and clinical response. The impact of myocardial viability at the left ventricular (LV) pacing site on CRT response is poorly elucidated. A retrospective cohort of 160 ICM patients with single photon emission computed tomography-myocardial perfusion imaging before device implantation were included. Coronary venous angiography and chest radiographs helped classify segmental location of LV lead (LVL). The primary outcome was a composite of heart failure (HF) hospitalization and mortality at 3 years, and secondary outcome was change in systolic function at 6 months. The patients were divided into groups based on the myocardial substrate at the site of LVL: LVL on or adjacent to (1) normal myocardium (LVL-N, n = 64), (2) segmental scar (LVL-S, n = 62), and (3) scar and ischemia (LVL-SI, n = 34). Upon follow-up, 75 (47%) patients reached primary endpoint with a higher incidence noted in LVL-S (60%), and LVL-SI (53%), compared to 31% in LVL-N (P = 0.004). Kaplan Meier method demonstrated poor event free survival for primary outcome in LVL-S (P = 0.002), and LVL-SI (P = 0.03). In Cox proportional hazard model, LVL-S (HR: 2.26, P = 0.004), and LVL-SI (1.9, P = 0.047) were independent predictors of primary outcome. In CRT recipients with ICM, scar and reversible ischemia in or adjacent to LV pacing site were independent predictors of HF hospitalization and death.

Usefulness of multidetector computed tomography coronary venous angiography examination before cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is a treatment option for selected heart failure patients. In this study, the aim was to evaluate the usefulness of noninvasive cardiac vein imaging using multidetector computed tomography (MDCT) angiography before CRT. The MDCT scans of 34 patients (20 men; age range 47-65 years) with a history of cardiac failure were studied for CRT in two centers prospectively. The anatomy of the cardiac venous system, particularly the target veins [left marginal vein (LMV) and posterior vein of the left ventricle (PVLV)], was evaluated with noninvasive MDCT. The coronary sinus, anterior interventricular vein, and posterior interventricular vein were observed in all patients. The PVLV was present in 30 (88.2%) patients. The PVLV was chosen in 30 (88.2%) patients for CRT. If the PVLV had two or more branches, the widest branch was chosen for lead implantation. In four (11.7%) patients, the PVLV was absent and the LMV was chosen instead for lead implantation. In one patient (2.9%), partial thrombosis was detected in the coronary sinus with MDCT angiography. MDCT can be used to guide interventionalists for CRT by providing anatomical details of the cardiac venous system rapidly and noninvasively.

Assessment of coronary veins in patients with isolated coronary artery ectasia by antegrade coronary venous angiography

Coronary artery ectasia (CAE) is characterized by an abnormal dilatation of the coronary arteries. The most common cause of CAE is atherosclerosis but other possible etiologies include congenital abnormalities and inflammatory and connective tissue disease. Earlier studies have documented the association of CAE with the presence of aneurysms in other vascular beds. However, cardiac venous system in patients with isolated CAE has not been studied earlier. In this study, we aimed to assess coronary venous vessels by antegrade coronary venous angiography in patients with isolated CAE. Twenty-four patients with isolated CAE without significant stenosis and 21 age-matched and sex-matched controls without CAE were included in this study. The anatomy of the coronary venous system was imaged in a left anterior oblique view at an angle of 45° by antegrade coronary angiography. Patients with isolated CAE had significantly larger coronary veins compared with control individuals with angiographically normal coronary arteries (coronary sinus ostium: 10.1 ± 1.0 vs. 8.5 ± 2.2 mm, respectively, P=0.003; coronary sinus mid level: 7.9 ± 1.4 vs. 6.5 ± 1.6, respectively, P=0.003; great cardiac vein: 5.6 ± 1.0 vs. 4.3 ± 0.8, respectively, P=0.001; middle cardiac vein: 3.9 ± 1.3 vs. 3.7 ± 1.4, respectively, P=0.52; posterior or lateral vein: 3.2 ± 1.1 vs. 2.4 ± 0.7, respectively, P=0.016). We have shown for the first time a significant dilatation in the coronary veins in patients with isolated CAE, suggesting the presence of a more extensive vascular destruction in the coronary circulation.

Assessment of the post-implant final left ventricular lead position: a comparative study between radiographic and angiographic modalities

Post-implant lateral and postero-anterior chest X-rays (CXR) are often utilized to determine the final LV lead tip position after cardiac resynchronization therapy (CRT). This study sought to compare post-implant standard CXRs with intra-procedural rotational coronary venous angiography (RCVA) to localize the final LV lead position. Sixty-four patients undergoing CRT (69.2 ± 11.4years; males 68.7%; ischemic cardiomyopathy 59.4%; NYHA class 2.9 ± 0.5 and LV ejection fraction 24% ± 9%) were included in the study. RCVA was done by recording a rapid 4-second isocentric cine-loop from RAO 55° to LAO 55° (120 frames). Conventional CXR method (CC) and a composite CXR strategy (CM) based on two-view CXR were separately compared with RCVA. The most common pacing site was lateral (64.1%), followed by postero-lateral (23.4%) and antero-lateral (10.9%). In 73.4% (47) cases, the LV lead position was misclassified by CC as compared to RCVA. Among the 47 (73.4%) cases misclassified by CC approach, 35 had lateral LV lead position misclassified by CC as postero-lateral (77%), posterior (20%) and antero-lateral (3%). On the other hand, CM strategy classified the LV lead position correctly in 46 (71.9%) of the patients (p < 0.0001). The composite CXR strategy is a useful method for post-procedure LV lead localization. Due to its simplicity, it can be widely applied in post-implant evaluation of LV lead position in CRT patients.

Impact of Tricuspid Regurgitation and Prior Coronary Bypass Surgery on the Geometry of the Coronary Sinus: A Rotational Coronary Angiography Study

The coronary sinus (CS) is often distorted in patients with advanced cardiomyopathy, making CS cannulation difficult. The objective of this study was to examine the impact of the underlying cardiac pathology on the variability of the CS anatomy, using rotational coronary venous angiography (RCVA). Seventy-nine patients undergoing RCVA for cardiac resynchronization therapy (CRT) were evaluated: age 63 +/- 15 years, 43% with prior coronary artery bypass grafting (CABG). Aspects of the CS anatomy which could impact cannulation were examined: the CS ostial angle, the posterior displacement of the CS away from the atrioventricular groove, a measure of CS curvature, and the presence of stenoses and aneurysmal dilatations. The CS ostial angle was variable (65-151 degrees, mean 119 +/- 19 degrees, <90 degrees in 8 patients) and decreased significantly (P = 0.0022) with increasing severity of tricuspid regurgitation (TR), reaching 94 +/- 18 degrees in patients with severe TR. The posterior displacement of the CS was significantly more accentuated in patients with prior CABG when compared with the patients without CABG (7.1 +/- 3.7 vs 4.5 +/- 2.8 mm; P = 0.0246). The decrease in luminal diameter at the CS-great cardiac vein (GCV) junction was 2.0 +/- 1.0 mm, being more pronounced in patients with prior CABG versus nonCABG (26 vs 20%; P = 0.042). Stenoses and aneurysmal dilatations of the CS-GCV were encountered in 4 (5%) and 6 (8%) of patients, respectively, all of them with prior CABG, representing 12% and 18% of the CABG group. The CS anatomy in patients undergoing CRT is variable, and is impacted by the severity of the underlying TR and history of a prior CABG.

Coronary Sinus Diverticulum and Accessory Pathway

A rare case of coronary sinus diverticulum is herein presented in a patient with classical Wolff-Parkinson-White syndrome undergoing catheter ablation of a posteroseptal accessory pathway. Only after a coronary venous angiogram was performed was the location of the accessory pathway identified and successfully ablated. I N T R O D U C T I O N Although ECG criteria can localize an accessory pathway, the presence of congenital anomalies like a coronary sinus diverticulum may complicate the matter. The epicardial location of such pathways can only be uncovered via coronary venous angiography. We present herein such a case in a patient presenting with symptomatic Wolff-Parkinson-White syndrome.

Usefulness of High-Speed Rotational Coronary Venous Angiography During Cardiac Resynchronization Therapy

Standard coronary venous angiography (SCVA) provides a static, fixed projection of the coronary venous (CV) tree. High-speed rotational coronary venous angiography (RCVA) is a novel method of mapping CV anatomy using dynamic, multiangle visualization. The purpose of this study was to assess the value of RCVA during cardiac resynchronization therapy. Digitally acquired rotational CV angiograms from 49 patients (mean age 69 +/- 11 years) who underwent left ventricular lead implantation were analyzed. RCVA, which uses rapid isocentric rotation over a 110 degrees arc, acquiring 120 frames/angiogram, was compared with SCVA, defined as 2 static orthogonal views: right anterior oblique 45 degrees and left anterior oblique 45 degrees . RCVA demonstrated that the posterior vein-to-coronary sinus (CS) angle and the left marginal vein-to-CS angle were misclassified in 5 and 11 patients, respectively, using SCVA. RCVA identified a greater number of second-order tributaries with diameters >1.5 mm than SCVA. The CV branch selected for lead placement was initially identified in 100% of patients using RCVA but in only 74% of patients using SCVA. RCVA showed that the best angiographic view for visualizing the CS and its tributaries differed significantly among different areas of the CV tree and among patients. The area of the CV tree that showed less variability was the CS ostium, which had a fairly constant relation with the spine in shallow right anterior oblique and left anterior oblique projections. In conclusion, RCVA provided a more precise map of CV anatomy and the spatial relation of venous branches. It allowed the identification of fluoroscopic views that could facilitate cannulation of the CS. The final x-ray view displaying the appropriate CV branch for left ventricular lead implantation was often different from the conventional left anterior oblique and right anterior oblique views. RCVA identified the target branch for lead implantation more often than SCVA.

Abstract 3240: High Speed Rotational Coronary Venous Angiography Improves Delineation of Coronary Venous Anatomy during Cardiac Resynchronization Therapy

Background: The implantation of the left ventricular lead for biventricular devices can be challenging due to anatomic variation in the branching pattern of the coronary sinus (CS). Standard coronary venous (CV) angiography (SCVA) provides a static, fixed projection of the CV tree. Typically multiple contrast injections are obtained to gain a better understanding of vessels overlap and foreshortening. But, even in this situation, the site of side branch takeoff, its angulation and course cannot be reliably predicted - particularly in the presence of complex branching patterns. High-speed rotational CV angiography (RCVA) permits a dynamic, multi angle visualization of the CV anatomy. Objective: To compare RCVA with SCVA during cardiac resynchronization therapy. Methods: Digitally acquired RCVA from 10 patients were analyzed. RCVA uses a rapid isocentric rotation over a 180° arc, RAO 54° to LAO 54° in 4 sec, acquiring 121 frames /angiogram with a single injection of 20 ml of contrast (Infinix, Toshiba). The CV anatomy assessed by RCVA was compared with 2 static perpendicular views: RAO 45° and LAO 45°. Results: Three-dimensional models of the venous tree were reconstructed (Figure ), and the rotational images were analyzed using a full range of gantry angles, providing the operator with considerably more information about the CV anatomy than SCVA images. Conclusion: RCVA provides a better understanding of the CV anatomy and the special relationship of its branches. The SCVA view which optimally displayed the appropriate CS branch for left ventricular lead implantation was often different from the conventional RAO and LAO views.

Integrating Functional and Anatomical Information to Facilitate Cardiac Resynchronization Therapy

Multiple imaging modalities are required in patients receiving cardiac resynchronization therapy. We have developed a strategy to integrate echocardiographic and angiographic information to facilitate left ventricle (LV) lead position. Full three-dimensional LV-volumes (3DLVV) and dyssynchrony maps were acquired before and after resynchronization. At the time of device implantation, 3D-rotational coronary venous angiography was performed. 3D-models of the veins were then integrated with the pre- and post-3DLVV. In the case displayed, prior to implantation, the lateral wall was delayed compared to the septum. The LV lead was positioned into the vein over the most delayed region, resulting in improved LV synchrony.

AB10-3: High speed rotational coronary venous angiography improves delineation of coronary venous anatomy during cardiac resynchronization therapy

Standard 2-view coronary venous angiography (SCVA) provides a static, fixed projection of the coronary venous (CV) tree, often leading to a suboptimal delineation of the takeoff, angulations, or course of the venous tributaries. High-speed rotational CV angiography (RCVA) permits a dynamic, multi angle visualization of the CV anatomy.

Integration of three-dimensional coronary venous angiography with three-dimensional echocardiography for biventricular device implantation

A 58-year-old man with ischemic cardiomyopathy and congestive heart failure refractory to medical treatment was referred for biventricular implantable cardioverter-defibrillator (ICD) placement. During the procedure, a rotational angiogram of the coronary sinus (CS) was performed, followed by three-dimensional (3D) reconstruction of the CS tree as described previously.1 Three frames from the 55° right anterior oblique (Figure 1a), anteroposterior (Figure 1b), and 55° left anterior oblique (Figure 1c), obtained by rotational angiogram of the coronary venous tree are shown.

Angiography of the coronary venous system. Use in clinical electrophysiology

To study the angiographic anatomy of human coronary veins and the possibility of epicardial venous mapping through microelectrode catheters. We evaluated 30 patients with sustained ventricular tachycardia using a catheter which provided occlusion of the coronary sinus ostium during venous angiography. They were 25 males, 5 females, ages ranging from 24 to 76 years (mean = 52.7). The veins were studied according to their number, caliber and distribution in the anterior and posterior wall of the left ventricle. Coronary sinus was catheterized in all patients. No discomfort or complication were observed. The number of veins from posterior wall of the left ventricle was 3.1 and anterior wall, 1.9, p < 0.05. The caliber of the coronary veins were: anterior interventricular vein (distal segment = 1.19 +/- 0.22 mm, middle segment = 1.65 +/- 0.35 mm), posterior interventricular vein (distal segment = 1.83 +/- 0.47 mm, middle segment = 2.00 +/- 0.52 mm), left posterior vein (distal segment = 1.45 +/- 0.25 mm, middle segment = 2.49 +/- 0.92 mm); p < 0.05. The balloon occlusion technique for coronary venous angiography is feasible and safe. The number and the caliber (distal and middle) of the veins from the posterior wall of the left ventricle were significantly greater than those from the anterior wall. Anatomic conditions for venous epicardial mapping are more adequate in the posterior wall of the left ventricle.