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

Maounis, Themos

Poulos, George

Hospital Chronicles (E-Journal)

Coronary Sinus Diverticulum  and Accessory PathwayGeorge Poulos, MD & Themos Maounis, MDA B S T R A C TA rare case of coronary sinus diverticulum is herein presented in a patient with classi-cal 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 NAlthough ECG criteria can localize an accessory pathway, the presence of con-genital anomalies like a coronary sinus diverticulum may complicate the matter.1-3 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.C A S e  R e p O R TA 30-year-old man with a long history of palpitations and multiple visits to the emergency room for supraventricular arrhythmias treated with intravenous adenosine, was referred for radiofrequency ablation. The 12-lead ECG (Fig. 1) showed manifest preexcitation consistent with a left posteroseptal accessory pathway. A 24-hour Holter monitor and event recorders showed episodes of narrow complex tachycardia. An echocardiography study was unrevealing. The patient had been receiving atenolol 50 mg po qd.During the electrophysiology study a narrow-complex tachycardia was easily inducible (Fig. 2), and the intracardiac recordings were consistent with orthodromic atrioventricular reentrant tachycardia (AVRT) with retrograde conduction via a postero-septal accessory pathway (earliest atrial activation at the proximal coronary sinus-CS). Intracardiac recordings were also consistent with a posteroseptal accessory pathway with earliest ventricular activation also at the proximal CS catheter (Fig. 3). However, the precise location became apparent only after a coronary sinus venogram was performed (Fig. 4).CASe RepORTOnassis Cardiac Surgery Center, Athens, GreeceHOSPITAL CHRONICLES 2008, 3(1): 45–48Correspondence to:Themos Maounis, MDOnassis Cardiac Surgery CenterAthens, GreeceE-mail: maounis@yahoo.comKey WORDS: accessory pathway; preexcitation syndrome; coronary sinus diverticulum; supraventricular tachycardiaAbbreviAtionsAV = atrioventricularAVRT = atrioventricular reentrant tachycardiaCS = coronary sinusWPW = Wolff-Parkinson-White (syndrome)Presented in part at “Cardiology Update 2004”, International Cardiology Symposium of Evagelismos General Hospital of Athens, Athens, Greece, October 14-16, 200446HOSPITAL CHRONICLES 3(1), 2008FIgURe 1. Patient’s 12-lead ECG showing classical signs of pre-excitation (Wolff-Parkinson-White syndrome) indicating a left posteroseptal accessory pathway.FIgURe 2. 12-lead ECG of the induced orthodromic AVRT.CS DIVERTICuLuM AND WPW SyNDROME47FIgURe 3. Intracardiac recording during sinus rhythm indicating shortest AV interval at the proximal CS catheter.FIgURe 4. Coronary sinus (CS) venography revealing a large CS diverticulum.D I S C U S S I O NPostero-septal accessory pathways account for ~25% of all accessory pathways. In 65% of cases they are accessible within the right atrial chamber and in 20-25% of cases from the left ventricle. In 10-12% of patients the accessory pathways are lo-cated within the coronary sinus. Approximately in 2% of cases, pathways can be found in coronary sinus diverticuli at the edge of their origin.1-6 Earliest retrograde atrial activation could be found in multiple sites. Delivery of low energy lesions~30W is recommended to avoid complications with rupture of venous structures and hemopericardium. Success rates of radiofre-quency catheter ablation are high around 95%.In the present case the surface ECG was consistent with a left-sided posteroseptal accessory pathway. However, attempts to ablate this pathway via either a right or left endocardial approach would be bound to fail, since this type of accessory pathway has its location at the muscle connections at the neck of the CS diverticulum. unless one performs a coronary venous angiogram to uncover the diverticulum, a classical ap-proach to ablate the pathway will certainly fail.48HOSPITAL CHRONICLES 3(1), 2008FIgURe 5. The successful ablation site was located at the neck of the CS diverticulum.R e F e R e N C e S 1.  Gerlis LM, Davies MJ, Boyle R. Preexcitation due to accessory sinoventricular connections associated with coronary sinus an-eurysms. A report of two cases. Br Heart J 1985; 53: 314-22. 2. Guiraudon GM, Guiraudon CM, Klein GJ, Sharma AD, yee R. The coronary sinus diverticulum: a pathologic entity associated with the Wolff-Parkinson-White syndrome. Am J Cardiol 1988; 62(10 Pt 1):733-735. 3.  Stamato N, Goodwin M, Foy B. Diagnosis of coronary sinus di-verticulum in Wolff-Parkinson-White syndrome using coronary angiography. Pacing Clin Electrophysiol 1989;12:1589-1591. 4.  Lesh MD, Hare van G, Kao AK, Scheinmann MM. Radiofre-quency catheter ablation for Wolff-Parkinson-White syndrome associated with a coronary sinus diverticulum. PACE 1991; 14:1479-1484. 5.  Beukema WP, Van Dessel PF, Van Hemel NM, Kingma JH. Radiofrequency catheter ablation of accessory pathways as-sociated with a coronary sinus diverticulum. Eur Heart J 1994; 15:1415-1418. 6.  Bennett D, Hall M. Coronary sinus diverticulum containing posteroseptal accessory pathway. Heart 2001; 86: 539.

Coronary Sinus Diverticulum and Accessory Pathway

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Coronary Sinus Diverticulum and Accessory Pathway

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