Thebesian Veins Research Articles

Clarification of misused terminology in the context of thebesian veins.

Clarification of misused terminology in the context of thebesian veins.

Response to commentary on 'Dynamic Thebesian veins anomaly in a patient with recurrent tako-tsubo-like syndrome'.

Response to commentary on 'Dynamic Thebesian veins anomaly in a patient with recurrent tako-tsubo-like syndrome'.

Dynamic Thebesian veins anomaly in a patient with recurrent tako-tsubo-like syndrome.

Dynamic Thebesian veins anomaly in a patient with recurrent tako-tsubo-like syndrome.

Case of Myocardial Infarction with Nonobstructive Coronary Arteries Caused by Thebesian Veins Thrombosis

Introduction: The causes of myocardial infarction with nonobstructive coronary arteries are heterogeneous and include different reasons. Clinical cases of myocardial infarction without obstruction represent a difficult diagnostic task where cardiac magnetic resonance is increasingly used. Objective: This research aimed to demonstrate the evaluation protocol of myocardial infarction with nonobstructive arteries. Method: The object of this study was a 49-year-old male patient who presented at the emergency department with atypical chest pain, notably elevated troponin levels. To establish the diagnosis was performed electrocardiogram, echocardiography, stress-echocardiography, coronary angiography, and cardiac magnetic resonance.

Multiple coronary artery microfistulae are common and progress in adult patients late after Fontan operation

Abstract Background Coronary angiograms of adult Fontan patients sometimes show the abnormal multiple coronary artery microfistulae (mCAFs) that drain directly into the ventricular chamber. They look like coronary artery fistulae or Thebesian vein. Angiographically detectable mCAFs are a rare finding sometimes associated with myocardial ischemia due to coronary steal and volume overload of ventricles in non-CHD adults. However, there are limited data concerning these mCAFs in the setting of CHD patients. Purpose The aim of this study is to demonstrate presence, character, and changes with growth of mCAFs in adult patients late after Fontan operation. Methods This study is single-center retrospective review of adults (16 years old or older) with Fontan circulation patients who had undergone cardiac catheterization for routine Fontan surveillance between 2009-2022. We assessed the presence of angiographically detectable mCAFs from ascending aortography. After identification of the characteristic cases, we examined the ventricular morphology, the portion of drainage, and compared with previous findings of angiograms. SaO2, EF of main ventricle, CVP, EDP of main ventricle, BNP, and use of pulmonary vasodilators were compared between mCAFs(+) group and mCAFs(-) group. We also reviewed clinical manifestation and findings of exercise stress ECG of the patients. Pulmonary atresia with intact ventricular septum was excluded because abnormal coronary arterial communications have been well documented in this condition. Results Among 90 Fontan patients who had undergone catheterization, significant mCAFs were observed in a total of 18 cases (20%). There were 10 right-dominant single ventricle, 4 left-dominant single ventricle, and 4 unbalanced two ventricles. In all cases, including left-dominant single ventricle, all fistulae drained into right ventricle cavity, never into left ventricle. The patients who underwent serial catheterizations demonstrated that the dilation and tortuosity of fistulae progressed over time. The comparison of two groups showed SaO2 was low, BNP and CVP was high significantly in mCAFs(+) group. There were no significant differences in other factors including age at catheterization and the use of pulmonary vasodilators. Among 10 patients who had underwent exercise stress ECG, only 1 patient showed ST segment depression. None had clinical history of chest pain, and arrhythmia, and ischemic event. Conclusions MCAFs are common and progress in adult patients late after Fontan operation. Although the clinical significance and etiology of these findings remains uncertain, particular attention should be given to subclinical Fontan failure caused by hhigh CVP, volume overload, and myocardial ischemia for the future of adult Fontan patients who have prominent mCAFs.

Myocardial Edema Provides a Link Between Pulmonary Arterial Hypertension and Pericardial Effusion.

Myocardial Edema Provides a Link Between Pulmonary Arterial Hypertension and Pericardial Effusion.

Evidence that the myocardium is a continuous helical muscle with one insertion

Introduction and objectivesAnatomically, the heart cannot be suspended in the thorax without structural continuity of the heart muscle to pump blood at a speed of 200cm/s with an efficacy that allows ejecting 70% of the left ventricular volume with only 12% shortening of its contractile unit, the sarcomere. The aim of this study was to investigate a) whether the myocardium is a single, continuous, helical muscle; b) the origin and end of the myocardial muscle; and c) the sliding movement between the myocardial segments during ventricular torsion–detorsion. This forces us to think of an antifriction mechanism. MethodsA total of 18 hearts (10 bovine and 8 human) were used for anatomical and histological studies. Histological an histochemical analysis of the samples were performed, using the Alcian Blue technique to confirm hyaluronic acid and its antifriction mechanism. ResultsThe myocardium could be defined as a single, continuous, and helical muscle that is inserted at its origin and end, according to the specimens analyzed, to an osseus-chondroid-tendinous nucleus called cardiac fulcrum, thus limiting the 2 ventricular chambers. Hyaluronic acid was found in the excision planes between the myocardial bundles. ConclusionsThe myocardium in its longitudinal continuity adopts a spiraling spatial configuration, inserted at its end to a nucleus called cardiac fulcrum. The Thebesian veins and hyaluronic acid could have an essential role in the antifriction mechanism, due to the resistance between the sliding myocardial muscle surfaces in their torsion (systole) and detorsion (suction) motions.

Another Mention of Thebesian Veins in the Heart: Should It Be the Last?

Another Mention of Thebesian Veins in the Heart: Should It Be the Last?

Abstract 12874: Thebesian Veins Are Common and Progress in Adult Patients Late After Fontan Operation

Introduction: Thebesian veins (ThVs) are coronary veins that drain directly into the atrial or ventricular chamber. Angiographically detectable ThVs are a rare finding sometimes associated with myocardial ischemia due to coronary steal and volume overload of ventricles in adults. However, there are limited data concerning ThVs in the setting of congenital heart disease. The purpose of this study is to demonstrate presence, character, and changes with growth of ThVs in adult patients late after Fontan operation. Methods: This study is single-center retrospective review of adults with Fontan circulation patients who had undergone cardiac catheterization for routine Fontan surveillance between 2009-2019. We assessed the presence of angiographically detectable ThVs from ascending aortography. After identification of the characteristic cases, we examined the ventricular morphology, the portion of ThVs drainage, and compared with previous findings of angiograms. We also reviewed clinical manifestation and findings of exercise stress ECG of the patients. Pulmonary atresia with intact ventricular septum was excluded because abnormal coronary arterial communications have been well documented in this condition. Results: Among 75 Fontan patients who had undergone catheterization, significant ThVs were observed in a total of 12 cases (16%). There were 6 right-dominant single ventricle, 4 left-dominant single ventricle, and 2 unbalanced two ventricles. In all cases, including left-dominant single ventricle, all ThVs drained into right ventricle cavity, never into left ventricle. The patients who underwent serial catheterizations demonstrated that ThVs dilation and tortuosity progressed over time. Among 6 patients who had underwent exercise stress ECG, only 1 patient showed ST segment depression, however, none had clinical history of chest pain. Conclusions: ThVs are common and progress in adult patients late after Fontan operation. Although the clinical significance of these findings remains uncertain, particular attention should be given to myocardial ischemia and volume overload for the future of adult Fontan patients who have prominent ThVs.

Supraventricular tachycardia in patients with coronary sinus stenosis/atresia: Prevalence, anatomical features, and ablation outcomes.

Supraventricular tachycardia (SVT) with coronary sinus (CS) ostial atresia (CSA) or coronary sinus stenosis (CSS) causes difficulty in electrophysiological procedures, but its characteristics are poorly understood. Study the anatomical and clinical features of SVT patients with CSA/CSS. Of 6128 patients with SVT undergoing electrophysiological procedures, consecutive patients with CSA/CSS were enrolled, and the baseline characteristics, imaging materials, intraoperative data, and follow-up outcomes were analyzed. Thirteen patients, seven with CSA and sixwith CSS, underwent the electrophysiological procedure. Decapolar catheters were placed into the proximal CS in three cases, while the rest were placed at the free wall of the right atrium. Fourteen arrhythmias were confirmed: four atrioventricular nodal reentrant tachycardias, five left-sided accessory pathways, three paroxysmal atrial fibrillations, and two atrial flutters (AFLs). In addition to three patients who underwent only an electrophysiological study, the acute ablation success rate was 100% in 10 cases, with no procedure-related complications. After a median follow-up period of 59.6 months, only one case of atypical AFL recurred. For those cases (seven CSA and two CSS) with a total of 10 anomalous types of CS drainage, three types were classified: from the CS to the persistent left superior vena cava (n = 3), from an unroofed CS (n = 3), and from the CS to the small cardiac vein (n = 3) or Thebesian vein (n = 1). Patients with CSA/CSS may develop different kinds of SVT. Electrophysiological procedures for such patients are feasible and effective. An individualized mapping strategy based on the three types of CS drainage will be helpful.

Visualization of the Thebesian veins during coronary angiography in a 57-year-old woman.

A 57-year-old woman was hospitalized due to a type 2 respiratory failure. Electrocardiogram at admission showed inverted T waves in leads V2–V4. Coronary angiogram was performed showing no relevant stenosis. However, this exam allowed visualization of the Thebesian veins outlining the left ventricle.

All’s Not Well(ens) that Ends Well: Case Study of Significant Thebesian Veins Mimicking Wellens Syndrome

Thebeisan veins are microfistulous connections between a coronary arterial branch directly to a ventricular or atrial chamber. Extensive thebesian veins that empty into the left ventricle can cause typical chest pain symptoms, troponin elevation, and ischemic EKG changes from coronary steal leading to acute coronary syndrome in extreme cases. Literature review exposed a consistent pattern of EKG findings among patients with extensive thebesian veins involving all three major coronary arteries. We present a case study as an example of this rare anatomic finding of extensive thebesian veins draining into the left ventricle causing acute coronary syndrome in a symptomatic patient with elevated troponin and ischemic changes on EKG. This same EKG pattern that is present in our patient was discovered to be consistent among available case studies reviewed that had included an EKG tracing in their report. A newly proposed association between the ischemic changes on EKG due to extensive thebeisan veins and those of a severe proximal left anterior descending coronary artery stenotic lesion was discovered. The newly discovered consistency in the EKG pattern with acute coronary syndrome caused by extensive thebesian veins is the same pattern as that seen in Wellens Syndrome.

P240 Thebesian veins draining to the left ventricle mimicking left ventricular non-compaction

Abstract Description We report about a 59-year old asymptomatic woman initially presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC). An additional cardiac magnetic resonance imaging (cMRI) showed positive diagnostic criteria for LVNC. Six years later a diagnostic coronary angiogram revealed by a coincidence extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids). Finally color Doppler flow confirmed that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly. Initial work up A 59-year old asymptomatic woman presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC) with deep recesses and a systolic non-compacted to compacted ratio in short axis of >2. To confirm the diagnosis cardiac magnetic resonance imaging (cMRI) was performed. Quality was not optimal due to premature contractions and insufficient breath-hold, but positive diagnostic criteria for LVNC (as described by Petersen, Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. JACC, 2005 July 5;46(1):101-5) were reported (Figure 1A). Diagnosis and Management Six years later, the patient was referred to our institution for catheter ablation of a suspected paroxysmal supraventricular tachycardia causing palpitations. Since the patient also complained about recurrent chest pain, a coronary angiogram was performed in the same session and revealed a chronic total occlusion of the right coronary artery. However, also extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids) was observed (Figure 1B, arrows). Follow-up In light of this new finding, echocardiography was repeated and color Doppler flow revealed diastolic filling of the recesses not from the LV cavity but from the coronary system, confirming that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly (Figure 1C, apical short axis view, upper panel color Doppler in diastole, lower panel color M-mode). To exclude concurrent LVNC a cardiac CT was performed, confirming that the recesses, which initially led to the diagnosis of LVNC, exhibited diastolic flow from the coronary system (Figure 1D). Conclusion This case exemplifies that for the diagnosis of LVNC all echocardiographic criteria as defined by Oechslin and Jenni (Left ventricular non-compaction revisited: a distinct phenotype with genetic heterogeneity. EHJ, 2011 June;Volume 32, Issue 12, Pages 1446–1456) need to be fulfilled – including color Doppler assessment of flow in the recesses. Consequently, it illustrates that cMRI alone is not sufficient for the diagnosis of LVNC but both echocardiographic and cMRI criteria need to be applied. Abstract P240 Figure.

Adam Christian Thebesius' Channels into the Human Heart: the Thebesian Veins and the Thebesian Valve.

In 1708, Adam Christian Thebesius, a 22-year-old student at Leiden University, presented his graduate thesis, Disputatio medica inauguralis de circulo sanguinis in corde. More than a doctoral dissertation, this groundbreaking work opened new channels into the study of the human coronary venous system. Thebesius' theory about the vascular communication between the coronary arteries and the chambers of the heart helped to advance understanding of hemodynamic principles and to clarify the physiologic pathways of the coronary circulation. The following article-the third in a trilogy about Lower Silesian scientists-provides an overview of the life story and achievements of this Silesian physician and innovator, whose name was immortalized in 2 cardiac eponyms: the Thebesian veins and the Thebesian valve.

PP-458 - Coronary Arterio-Venous Angiogram With Massive Myocardial Staining

Myocardial staining is a complication of coronary angiography or intervention procedures and consists of extravasations of contrast material into the myocardium. The powerful injection of contrast (myocardial staining) is caused by the improper positioning of the angiography or guiding catheter may results in dye extravasating into peri-coronary space. Indeed, the half of circumference of the coronary artery is represented by the myocardium and the remaining is related directly to the pericardial aspect. A 37-year-old female undergone angiography for investigation of chest pain via the right femoral approach. The left coronary angiogram revealed normal coronary arteries. However, repeated attempts at cannulating the selective right coronary artery were unsuccessful and failed to visualize the ostium due to preferentially cannulation of separate origin of a conus branch. We considered to perform a “hit and run” technique; but unfortunately, massive myocardial staining of interventricular septum (white arrow in Figure 1) developed with visualization of the thebesian vein (black arrow in Figure 1) and coronary venous sinus (gray arrow in Figure 1). Fortunately, no arrhythmia developed. The thebesian veins are valveless conduits arising from all four cardiac chambers and communicating with the coronary sinus. Various forms and courses of the intramural venous tunnel, sinus or channel of the right atrium have been also found. This images illustrates the value of careful manipulation and positioning of the coronary catheter during coronary angiogram. It is imperative to check the position of the catheter tip with a small amount of contrast injection prior to coronary angiography to avoid these types of complication.

Long‐Term Survival of Adult Cardiac Myocytes in Large Transmural Post‐Myocardial Infarction Scars Is Supported by a Functional, Local Microvascular Network

The presence of surviving cardiac myocytes in post‐myocardial infarction (MI) scars has been repeatedly documented in humans as well as in various laboratory animals, particularly in rats. In the majority of cases, the long‐term survival of cardiac myocytes in post‐MI scars has been attributed either to continuing arterial blood supply from the bordering noninfarcted myocardium or to a rapid reestablishment of blood perfusion through the original coronary artery after a transient period of ischemia. On the other hand, in a rat model of chronic MI produced by permanent ligation of the left coronary artery, the persistent survival of adult cardiac myocytes in remote areas of the large transmural scar remains yet poorly understood. Considering the fact that in such model the left coronary artery remained permanently occluded for the duration of an entire experimental period, the presence of viable cardiac myocytes in mature scars has been often explained by simple diffusion of oxygen and nutrients from either the left ventricular (LV) cavity or large subepicardial veins. In order to test this hypothesis, in our current study, a special emphasis has been made on investigation of the regional microenvironment, particularly the source of nourishing blood supply, which could facilitate long‐term survival of adult cardiac myocytes in scars. A large transmural MI was induced in 12‐month‐old male Sprague‐Dawley rats by permanent ligation of the left coronary artery. The patency of residual blood vessels was assessed in vivo in 4‐, 8‐ and 12‐week‐old scars by infusion of 15‐micron microspheres into the LV cavity shortly before euthanasia. The hearts were collected 3 days, 1, 2, 4, 8 and 12 weeks after MI and evaluated with histology, immunohistochemistry and quantitative morphometry. We found that, at all time points, the large, transmurally infarcted/ scarred area had a sparse population of viable cardiac myocytes primarily localized in subendocardial and subepicardial regions. We also confirmed the finding that in the subepicardial region, the groups of surviving cardiac myocytes were often seen around large residual veins. However, further examination has revealed that all clusters of surviving cardiac myocytes were always associated with a network of patent microvessels, including capillaries, venules and arteriolar‐like vessels. Most importantly, the presence of microspheres in the venules of such microvascular networks has substantiated the concept that blood perfused through these microvessels was originated from the LV cavity. This hypothesis was further strengthen by the fact that the endocardial surface of some transmural scars revealed the presence of patent orifices from the Thebesian veins, suggesting that the remnants of the venous vascular system within the scars, including subendocardial and subepicardial venous plexuses as well as intramural venous sinusoids, could to some extent undergo retrograde perfusion with arterial blood. Taken together, our current findings suggest that long‐term survival of adult cardiac myocytes in large, transmural post‐MI scars is sustained by the local microcirculatory networks which are structurally and functionally coupled with the residual venous system that maintains direct connections with the cavity of the left ventricle.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Preservation of Functional Microvascular Bed Is Vital for Long-Term Survival of Cardiac Myocytes Within Large Transmural Post-Myocardial Infarction Scar.

This study was aimed to understand the mechanism of persistent cardiac myocyte (CM) survival in myocardial infarction (MI) scars. A transmural MI was induced in 12-month-old Sprague-Dawley rats by permanent coronary artery ligation. The hearts were collected 3 days, 1, 2, 4, 8, and 12 weeks after MI and evaluated with histology, immunohistochemistry, and quantitative morphometry. Vasculature patency was assessed in 4-, 8-, and 12-week-old scars by infusion of 15-micron microspheres into the left ventricle before euthanasia. The infarcted/scarred area has a small continually retained population of surviving CMs in subendocardial and subepicardial regions. Surprisingly, whereas the transverse area of subepicardial CMs remained relatively preserved or even enlarged over 12 post-MI weeks, subendocardial CMs underwent progressive atrophy. Nevertheless, the fractional volume of viable CMs remained comparable in mature scars 4, 8, and 12 weeks after MI (3.6 ± 0.4%, 3.4 ± 0.5%, and 2.5 ± 0.3%, respectively). Despite the opposite dynamics of changes in size, CMs of both regions displayed sarcomeres and gap junctions. Most importantly, surviving CMs were always accompanied by patent microvessels linked to a venous network composed of Thebesian veins, intramural sinusoids, and subepicardial veins. Our findings reveal that long-term survival of CMs in transmural post-MI scars is sustained by a local microcirculatory bed.

Intertraffic of Endothelin 1 and Thrombospondin 1 between lungs and myocard via pulmonary circulation can alter cardiac loads, tissue integrity and atrial blood coagulability

Similar expression patterns of mRNA profiles for Endothelin 1 (ET-1) and Thrombospondin 1 (TSP1) from GeneAtlas U133A, gcrma, suggest that these two mediators are dominantly synthesized in the myocard and lungs. This paper proposes that intertraffic of these two mediators between myocard and lungs via pulmonary and coronary vessels optimizes cardiopulmonary functions and maintains their tissue integrity. A controlled delivery of endocrine mediators to the left and to the right heart is done by the coronary sinus (CS) that drains venous blood to the right atrium, and Thebesian veins (TVs) that open in all four heart cavities. Myocard and pulmonary capillaries are connected as a bidirectional portal system. Mediators from lungs can directly influence myocardial cells after entering the coronary circulation, while mediators in the myocardial venous blood that drain into the right heart will initially affect lungs. Strain induced myocardial ET-1 secretion into the right heart and pulmonary circulation increases the right heart afterload by constricting pulmonary vasculature. The same action reduces the left heart preload. Pulmonary ET-1 secretion can protect lungs from overperfusion by increasing the left heart afterload through constriction of peripheral arterioles. Chronic tissue overexposure to ET-1 leads to pulmonary and myocardial fibrosis. TSP1 availability is important in tissues under mechanical stress, since TSP1 is an adhesive glycoprotein involved in cell-to-cell and cell-to-matrix interactions. Pulmonary and myocardial TSP1 secretion that enter the fibrillating left atrium can mimic actions of the platelet-derived TSP1 in promoting the thrombus formation.

Angiographically detectable Thebesian veins are a dynamic and reversible finding in the setting of congenital heart disease.

Angiographically detectable Thebesian veins (ThVs) are a rare finding sometimes associated with coronary steal and myocardial ischemia in adults, but there are limited data regarding prominent ThVs in the setting of complex congenital heart disease (CHD). This study represents the largest series to date describing the presence and temporal changes of angiographically detectable ThVs in children with CHD. This is a single center case series describing the clinical characteristics and coronary anatomy in children with CHD and angiographicall detectable ThVs. After identification of the index case, additional patients were identified in a prospective manner during the course of routine clinical care. We developed a qualitative scale to grade ThV burden, with changes tracked over time in the subset of patients who underwent serial cardiac catheterizations. A total of 10 patients are included in this report. There was a predominance of female gender (8 of 10 patients), right-dominant single ventricle physiology (7 of 10 patients), and heterotaxy syndrome (6 of 10 patients). The degree and location of epicardial coronary artery tortuosity was qualitatively related to ThV burden. The subset of patients who underwent serial cardiac catheterizations demonstrate that ThV dilation can progress or regress over time. Angiographically detectable Thebesian veins are a rare finding in patients with congenital heart disease and may represent global changes in the coronary circulation. This is the first report, adult or pediatric, to demonstrate that ThV dilation is a dynamic process capable of both progression and regression. The physiologic impact of these findings remains to be elucidated.

Cardiac Structural Changes and Long-Term Survival in Patients With Prominent Thebesian Veins

Although rare, numerous case reports suggest that Thebesian veins confer increased morbidity and mortality. No study has evaluated their effects on cardiac structure or long-term patient outcomes. Patients undergoing coronary angiogram at the study institution from October 2002 and January 2015 were assessed for a diagnosis of prominent Thebesian veins. A matched control group was created and comparisons between clinical, echocardiographic, and survival measures were made. Of 50,116 total patients, 31 (0.06%) were found to have prominent Thebesian veins on angiography and were compared with a matched control group of 596 patients. Patients were matched for age, gender, angiogram date, location and extent of coronary disease, and dominance. Demographic and clinical data were similar between cohorts, with a median follow-up period of 26months. Patients with Thebesian veins had lower Doppler E wave (0.7 vs 0.8; p= 0.007) and A wave (0.6 vs 0.8; p= 0.001) mitral inflow velocities suggesting some decrease in normal mitral inflow, potentially due to direct shunting into the ventricle from the Thebesian vein network. However, there was no observed difference in left ventricular size or ejection fraction between groups. There was also no significantly increased mortality associated with the presence of Thebesian veins (hazard ratio 1.11, 95% CI 0.58 to 2.13). In conclusion, although previous reports have suggested adverse outcomes from Thebesian veins, our case-control study demonstrated no significant associated adverse cardiac structural changes or increase in mortality, although patients with Thebesian veins were noted to have a decrease in mitral inflow velocities.