Retrograde coronary sinus perfusion to maintain viability during cardiac
      surgery means that a connection via the capillary system to the coronary
      arteries, and potentially bypass grafts, may be possible. Coronary sinus
      (CS) venography prior to resynchronisation therapy in this patient with
      previous bypass grafting was associated with visualisation of these
      grafts

Jordaens, L.J.L.M. (Luc)

Scholten, M.F. (Marcoen)

Thornton, A.S. (Andrew)

Thornton, AS (Andrew)

Scholten, MF (Marcoen)

Jordaens, Luc

EUR Research Repository

CARDIOVASCULAR JOURNAL OF SOUTH AFRICA Vol 17, No. 2, March/April 2006 73Imaging of a coronary artery bypass graft  during coronary sinus venographyANDREW S THORNTON, MARCOEN F SCHOLTEN, LUC J JORDAENSSummaryRetrograde coronary sinus perfusion to maintain viabil-ity during cardiac surgery means that a connection via the capillary system to the coronary arteries, and poten-tially bypass grafts, may be possible. Coronary sinus (CS) venography prior to resynchronisation therapy in this patient with previous bypass grafting was associated with visualisation of these grafts.Cardiovasc J South Afr 2006; 17: 73–74  www.cvjsa.co.zaThe use of the coronary sinus to enable maintenance of myocardial viability during cardiac surgery has been known for some time.1 This means that retrograde blood flow from the coronary sinus to the myocardial micro-vascular bed and the coronary capillary system must be possible. Retrograde flow to the coronary arterial system may also be possible since this is clearly in continuity with the coronary capillary system. Continuity of blood vessels also means that coro-nary sinus (CS) venography in patients with severe coronary artery disease and previous coronary artery bypass grafting (CABG) may be associated with visualisation of parts of the arterial system of the heart, as well as their associated bypass grafts.Case reportA 65-year-old man was referred to the Department of Electrophysiology for assessment for a biventricular ICD system. In 1995 he had suffered a large anterior myocardial infarction, complicated by ventricular fibrillation. In 2002 he underwent a CABG for triple-vessel disease with poor left ventricular (LV) function. He received a left internal mam-mary artery (LIMA) graft to the left anterior descending artery (LAD), and vein grafts to the diagonal branch of the LAD, obtuse marginal branch of the circumflex artery and the posterolateral and posterior descending branches of the right coronary artery. Following surgery he had numerous admissions for heart failure and had been assessed for transplantation, but was not placed on the waiting list. In view of the recurrent heart failure despite maximal medical therapy, evidence of an extremely broad QRS complex with an LBBB-type morphology, as well as clear intra-ventricular dyssynchrony on echocardiography, a biventricular pacing system with back-up ICD was thought necessary and a bridge to eventual transplantation. During an otherwise unremarkable and successful implan-tation, a coronary sinus venogram was performed to delineate the venous anatomy before LV lead placement. An occluding balloon catheter (Attain Venogram Balloon Catheter, 6215, Medtronic Inc) was inserted through a guiding sheath, and after inflation of the balloon in the mid CS, a hand injection of contrast was given. At review of the angiogram after the procedure, it was noted that there was retrograde filling of arterial structures as well as of a vascular structure above the level of the aortic cusps, which was presumed to be a venous bypass graft, possibly that anastamosed to the obtuse marginal branch (Figs 1 and 2).DiscussionPerfusion of a vascular bed, whether anterograde or retro-grade, depends on determinants of flow, such as pressure gradients and resistance. The usefulness of retrograde coro-nary cardioplegia during cardiac surgery has been recog-nised for many years, particularly in cases where anterograde flow may be significantly impaired.1,2 It has been shown to restore blood flow to ischaemic tissue, reduce infarct size and improve left ventricular pump function in animal studies.3-5 This is especially true when coronary sinus ostial occlusion is also performed.6 Studies on hearts explanted at the time of transplant surgery have shown that retrograde blood cardioplegia administered into the coronary sinus is Department of Clinical Electrophysiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, The NetherlandsANDREW S THORNTON, MB BChMARCOEN F SCHOLTEN, MDLUC J JORDAENS, PhD   Case Report74 CARDIOVASCULAR JOURNAL OF SOUTH AFRICA Vol 17, No. 2, March/April 2006able to produce sufficient capillary blood flow to exceed the metabolic requirements of the left ventricle, septum, apex and posterior RV wall, although the blood supply to the rest of the RV is tenuous.7,8In this case, during occlusion CS angiography, the bypassed area of myocardium filled retrogradely from the coronary sinus, with associated retrograde filling of a venous graft. This suggests some impediment to anterograde flow in the graft as well as the native coronary arterial system. As far as we were able to ascertain, this is the first description of visualisation of part of the coronary arterial anatomy and an associated venous bypass graft during CS venography. Given what we know from the surgeons who have used this route for years to perfuse hearts during surgery, and that electrophysiologists frequently visualise the coronary sinus during electrophysiological studies and left ventricular lead implantations,9,10 there are undoubtedly others who have seen this phenomenon. Visualisation of the graft during venous injection could conceivably be seen after anastamosis of a graft to a venous structure, but this would be an arterio- venous connection and would be associated with signifi-cantly different angiographic features.While late-phase coronary angiography has always been used to identify the course and position of the coronary sinus, the inverse has never previously been described.References1.  Davies AL, Hammond GL, Austen WG. Direct left coronary artery surgery employing retrograde perfusion of the coronary sinus. J Thorac Cardiovasc Surg 1967; 54(6): 848−855.2.  Lust RM, Beggerly CE, Morrison RF, Austin EH, Chitwood WR, Jr. Improved protection of chronically inflow-limited myocardium with retrograde coronary sinus cardioplegia. Circulation 1988; 78(5 Pt 2): III217−223.3.  Anyanwu E, Konermann C, Klinke F, Dittrich H. The influence of non-coronary collateral blood supply on the electively arrested heart during ischemia and reperfusion. Res Exp Med (Berl) 1983; 182(2): 111−126.4.  Kar S, Nordlander R. Coronary veins: an alternate route to ischemic myocardium. Heart Lung 1992; 21(2): 148−157.5.  Katircioglu SF, Yucel D, Saritas Z, Yamak B, Elsheikh AE, Kose K. Simplified retroperfusion system preserves the myocardial function during acute coronary artery occlusion. Thorac Cardiovasc Surg 1998; 46(1): 1−6.6.  Rudis E, Gates RN, Laks H, Drinkwater DC, Ardehali A, Aharon A, et al. Coronary sinus ostial occlusion during retrograde delivery of car-dioplegic solution significantly improves cardioplegic distribution and efficacy. J Thorac Cardiovasc Surg 1995; 109(5): 941−946; discussion 946−947.7.  Ardehali A, Gates RN, Laks H, Drinkwater DC, Jr., Rudis E, Sorensen TJ, et al. The regional capillary distribution of retrograde blood car-dioplegia in explanted human hearts. J Thorac Cardiovasc Surg 1995; 109(5): 935−939; discussion 939−940.8.  Gates RN, Laks H, Drinkwater DC, Pearl JM, Zaragoza AM, Lewis W, et al. Gross and microvascular distribution of retrograde cardioplegia in explanted human hearts. Ann Thorac Surg 1993; 56(3): 410−416; discussion 417.9.  Weiss C, Cappato R, Willems S, Meinertz T, Kuck KH. Prospective evaluation of the coronary sinus anatomy in patients undergoing elec-trophysiologic study. Clin Cardiol 1999; 22(8): 537−543.10. Gilard M, Mansourati J, Etienne Y, Larlet JM, Truong B, Boschat J, et al. Angiographic anatomy of the coronary sinus and its tributaries. Pacing Clin Electrophysiol 1998; 21(11 Pt 2): 2280−2284.Fig. 1. Coronary sinus angiogram in anteroposte-rior view showing contrast delivered through the balloon catheter (1) filling the coronary sinus (2). There is subsequent late-phase filling of the coro-nary arterial system and then a venous bypass graft (3)Fig. 2. Coronary sinus angiogram in left anterior oblique (35 degrees) view showing contrast deliv-ered through the balloon catheter (1) filling the coronary sinus (2). There is subsequent late-phase filling of the coronary arterial system and then a venous bypass graft (3)

English

Imaging of a coronary artery bypass graft during coronary sinus venography

Erasmus University Digital Repository

http://repub.eur.nl/pub/10408/16733600.pdf

Imaging of a coronary artery bypass graft during coronary sinus venography

Abstract

Similar works

Full text

Available Versions

EUR Research Repository

EUR Research Repository

Erasmus University Digital Repository