Anatomy of the coronary sinus and epicardial coronary venous system in 620 hearts: an electrophysiology perspective.
BACKGROUND
Cannulation of the coronary sinus (CS) is a prerequisite for left ventricular (LV) pacing and certain ablation procedures. The detailed regional anatomy for the coronary veins and potential anatomic causes for difficulty with these procedures has not been established.


RESULTS
Therefore, we performed macroscopic measurements in 620 autopsied hearts (mean age 60 ± 23 years, 44% female). The CS was preserved for analysis in 96%. Sixty-three percent had a Thebesian valve that covered the posterior aspect of the CS ostium with extension to the superior (50%) and inferior aspects (18%) and was obstructive with fenestrations in 3 specimens. Partial or near occlusive valves were present occasionally at the ostium of the great cardiac vein (Vieussens; 8%) and middle cardiac vein (5%). Ninety-three percent had left atrial branches, and 41% had at least one branch with lumen > 3 French. For CRT lead placement, the mid-lateral LV was accessible from the middle cardiac vein (20%), the left posterior vein (92%) or the anterior interventricular vein (86%). Among specimens where the left phrenic nerve was preserved it crossed the LV mid-lateral wall in 45%.


CONCLUSIONS
Epicardial coronary vein anatomy is variable, and the mid-lateral LV wall can potentially be accessed through various tributaries of the epicardial veins. The orientation of the Thebesian valve favors cannulation of the CS from an anterior (ventricular) and inferior approach. Anterobasal, mid-lateral, and inferior apical LV coronary veins lie in proximity to the course of the phrenic nerve.
Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Amit
A
Noheria
Christopher V
CV
DeSimone
Nirusha
N
Lachman
William D
WD
Edwards
Apoor S
AS
Gami
Joseph J
JJ
Maleszewski
Paul A
PA
Friedman
Thomas M
TM
Munger
Stephen C
SC
Hammill
David L
DL
Hayes
Douglas L
DL
Packer
Samuel J
SJ
Asirvatham
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D054326:Coronary Sinus / Q000033:anatomy & histology*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D008953:Models, Anatomic; D008955:Models, Cardiovascular; D010496:Pericardium / Q000033:anatomy & histology*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D055815:Young Adult