Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2022; 14(6): 372-381
Published online Jun 26, 2022. doi: 10.4330/wjc.v14.i6.372
Study of coronary sinus anatomy during levophase of coronary angiography
Akshyaya Pradhan, Vrishank Bajaj, Pravesh Vishwakarma, Monika Bhandari, Akhil Sharma, Gaurav Chaudhary, Sharad Chandra, Rishi Sethi, Varun Shankar Narain, Sudhanshu Dwivedi
Akshyaya Pradhan, Vrishank Bajaj, Pravesh Vishwakarma, Monika Bhandari, Akhil Sharma, Gaurav Chaudhary, Sharad Chandra, Rishi Sethi, Varun Shankar Narain, Sudhanshu Dwivedi, Department of Cardiology, King George Medical University, Lucknow 226003, Uttar Pradesh, India
Author contributions: All authors contributed equally regarding the conceptualization of project, data acquisition, data analysis, literature review and manuscript writing.
Institutional review board statement: The study was approved by institutional ethics committee.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: The data is available with corresponding author and can be made available on request.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Pravesh Vishwakarma, MD, DM, FESC, FSCAI, FAPSIC. Additional Professor, Department of Cardiology, King George’s Medical University, Shahmina Road, Chowk, Lucknow 226003, Uttar Pradesh, India. dr.pvishwakarma@gmail.com
Received: January 25, 2022
Peer-review started: January 25, 2022
First decision: March 16, 2022
Revised: April 13, 2022
Accepted: May 14, 2022
Article in press: May 14, 2022
Published online: June 26, 2022
Processing time: 146 Days and 18.4 Hours
Abstract
BACKGROUND

Coronary sinus (CS) imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular (LV) pacing during cardiac resynchronization therapy (CRT). Retrograde venogram is the current standard for imaging CS and its tributaries.

AIM

To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.

METHODS

In this prospective observational study, 164 patients undergoing routine coronary angiography for various indications (Chronic stable angina-44.5%, acute coronary syndrome- 39.5%, Dilated cardiomyopathy-11%, atypical chest pain-5%) were included. Venous phase (levophase) of left coronary injection was recorded in left anterior oblique - cranial and right anterior oblique -cranial views. Visibility of coronary veins, width and shape of CS ostium, angulations of proximal CS with body of CS were noted. Presence, size, take-off angle and tortuosity of posterolateral vein (PLV), anterior interventricular veins (AIV) and middle cardiac vein (MCV) were also noted.

RESULTS

During levophase, visibility grade (Muhlenbruch grade) for coronary veins was 3 in 74% and 2 in 26% of cases. Visibility of CS did not correlate with body mass index. The diameter of CS ostium was < 10 mm, 10-15 mm and > 15 mm in 48%, 42% and 10% of patients respectively. Proximal CS was tubular in 136 (83%) patients and funnel-shaped in 28 (17%) patients. Sharp take-off angulation between ostium and body of CS was seen in 16 (10%) patients. Two or more PLV were present in 8 patients while PLV was absent in 52 (32%) patients. Angle of take-off of PLV with body of CS was favourable (0°-45°) in 65 (40%) patients. The angle was 45°-90° in 36 patients and difficult take-off angle (> 90°) was seen in 8 patients. Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases. There was no tortuosity in 79 cases, a single bend in 29 cases and more than 2 bends in 4 cases. Thirty nine (24%) patients had other veins supplying posterior/Lateral wall of LV. There was a single vein supplying lateral/posterior wall in 31 (19%) patients. Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV.

CONCLUSION

Levophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.

Keywords: Posterolateral vein; Ostium; Angiography; Sharp take off; Favourable angulation

Core Tip: In this prospective, observational study, we assessed venous phase of coronary angiogram (n = 164) with the intent to evaluate coronary sinus anatomy for purpose of left ventricular (LV) lead placement during cardiac resynchronization therapy. Levophase analysis showed excellent visibility of coronary sinus and its tributaries irrespective of body mass index. Shape of ostium & angulations within body of coronary sinus could be delineated reliably. Number, size, take off angle and any tortuosity within postero-lateral vein could be well identified. We found levophase study of coronary angiography an acceptable alternative to retrograde venography for LV lead placement assessment.