Bereza, Tomasz

Konarska, Monika

Kucharska, Aleksandra

Kuniewicz, Marcin

Mazur, Małgorzata

Walocha, Klaudia

Wandzel-Loch, Brygida

English

Jagiellonian Univeristy Repository

Morphometric parameters of human coronary sinus — based on study of 80 human heartsBrygida Wandzel-Loch1, Małgorzata Mazur2, Klaudia Walocha2, Marcin Kuniewicz2, Monika Konarska2, Tomasz Bereza2, Aleksandra Kucharska21Klinika Kardiologii, 5 Wojskowy Szpital Kliniczny z Polikliniką w Krakowie  ul. Wrocławska 1–3, 30-901 Kraków, Poland2Department of Anatomy, Jagiellonian University Medical College  ul. Kopernika 12, 31-034 Kraków, PolandCorresponding author: Małgorzata Mazur MD, PhD, Department of Anatomy, Jagiellonian University Medical College ul. Kopernika 12, 31-034 Kraków, Poland; Phone/fax +48 12 422 95 11; E-mail: mazurmalg@poczta.onet.plAbstract: The study was carried out on 80 human hearts (64 male and 16 female). The whole material has been divided into 4 groups: I — aged 19–40; II — aged 41–50; III — aged 51–60 and IV — aged 61–70. The venous vascular bed of 80 hearts was injected through the coronary sinus with Duracryl plus (Spofa Dental, Czech Republic) and next corroded. Thus obtained specimens were measured using electronic caliper (MAU-a E 0-150, Horex, Poland). The length of the coronary sinus varied from 15–50 mm (with the mean value of 30 mm in male hearts and 25 mm in female hearts). The caliber of the vessels varied from 7–13 mm. The length of the coronary sinus is not age-dependent, however it is longer in male than female hearts. Generally the caliber of male coronary sinus is bigger than in the female, although it isn’t statistically significant.Key words: coronary sinus, anatomy, corrosion casting, morphology.IntroductionCoronary sinus acts recently as one of the main paths through which electrocardiologists may perform complicated cardiac procedures. It empties into right atrium of the heart di-rectly. Proper positioning of the orifice of this vessel is especially important, since it may decrease the number of unhappy events during cardiac catheterization [1–4]. Multiple variations considering both structure, location and course of the vessel and its tributaries may be advantages for specialists on intervention cardiology. The study describes the main FOLIA MEDICA CRACOVIENSIA Vol. LV, 3, 2015: 5–13  PL ISSN 0015-56166morphological parameters of the coronary sinus, based on measurements carried out on obtained corrosion casts.Material and methods80 human hearts were obtained from 16 female and 64 male cadavers aged 19–70 years. The whole material has been divided into 4 age groups > Group I included hearts of in-dividuals aged 19–40 years; group II — 41–50 years; group III — 51–60 years and group IV — 61–70 years. The distribution is presented in Table 1:Table 1. Distribution of age groups.Age Number Percentage17–40 16 20.0041–50 24 30.0051–60 28 35.0061–70 12 15.00Total 80 100.00The hearts were washed in running tap water to remove clots and next injected with saline (0,9% solution of NaCl — Baxter Terpol, Poland) at room temperature. Also the car-diac veins were simultaneously washed. To measure the coronary sinus (the length and the width), the connective and fat tis-sues were removed to expose the vessel. The length was evaluated using electronic caliper. The beginning of the vessel was considered to be at the junction of the oblique vein of the left atrium into coronary sinus, while the end was at the orifice of the coronary sinus in the right atrium. Also using electronic caliper we measured the width of the coronary sinus in the middle of its course.To obtain 3-D cast of cardiac venous tree, the specimens were injected with acrylic mass (Duracryl plus (Spofa Dental, Czech Republic), dyed with blue ink, through the orifice of the coronary sinus, filling this vessel and its tributaries. Thus obtained specimens were washed in running tap water and corroded in 10% solution of potassium hydroxide. Corrosion process last about 3 weeks. Next the specimens were washed again in distilled water. The remnants of the tissues were removed in a 3% solution of trichloroacetic acid. Next the casts were analyzed and documented. Statistical analysis was based on Kruskal-Wallis test, t-student test, Mann-Whitney test, Spearman test.ResultsIn all 80 hearts the coronary sinus was found and it emptied into the right atrium of the heart. The vessel was located within posterior part of the coronary sulcus, between left ven-tricle and the left atrium.Brygida Wandzel-Loch, Małgorzata Mazur et al.7Using electronic caliper the length of the coronary sinus was measured, assuming that it is the distance between the orifice of the oblique vein of the left atrium into coronary sinus and the orifice of the coronary sinus into the right atrium of the heart. In 78 specimens the beginning of the coronary sinus was seen evidently, as a significant dilatation of the vessel comparing to the great cardiac vein. In two hearts (one male aged 38 and one female aged 45) it was difficult to establish the beginning of the coronary sinus, since the dilatation was ab-sent. In these cases the orifice of the oblique vein of the left atrium was decisive. The length of the coronary sinus measured from the orifice of the oblique vein of the left atrium until the orifice into the right atrium varied from 15 mm (minimal length till 50 mm (maximal length). In all age groups the shortest coronary sinus measured 15 mm. The longest coronary sinus was found in the III group (50 mm); in the group I and II it was equal and measured 37 mm; in group IV it was 46 mm (Table 2).Table 2. Length of the coronary sinus in particular age groups.Age (years) N important Mean value Minimum Maximum Standard  deviation17–40 16 27.94 15.00 37.00 5.9541–50 24 28.54 15.00 37.00 5.9951–60 28 30.14 15.00 50.00 9.1861–70 12 30.17 15.00 46.00 10.78The mean value of the length of the coronary sinus in particular age groups was similar and varied from 28–30 mm.Fig. 1. Mean length of the coronary sinus in age groups.Morphometric parameters of human coronary sinus — based on study of 80 human hearts8In majority of the hearts studied (14 specimens) the coronary sinus measured 25 mm. Only in one heart the length was 44 mm. The longest vessels was found in two male hearts — 50 mm. We analyzed the length of the coronary sinuses considering the sex: in male hearts the length of the vessel varied from 15–50 mm, while in female hearts it measured 15–37 mm respectively (Table 3).Table 3. The length of the coronary sinus considering the sex.Sex N important Mean value |Minimum Maximum Standard deviationMale 64 30.17 15.00 50.00 8.05Female 16 25.44 15.00 37.00 6.39The mean length of the coronary sinus in males was 30 mm, while in females it was 25 mm (Fig. 2).Fig. 2. The mean length of the coronary sinus in males and females.To study the relevance of the differences between the length of the coronary sinus in females and males we applied t-student test for independent variables. Its result (p = 0.0320) indicates that differences are statistically significant. In the males the coronary sinus is sig-nificantly longer than in the females.The width of the coronary sinus was measured in the midlength. The results varied from 7 to 13 mm. The most frequent (18 hearts — 16 male and 2 female) caliber was 10 mm. The results of measurements are presented in Table 4.Brygida Wandzel-Loch, Małgorzata Mazur et al.9Table 4. The width of the coronary sinus in particular age groups.Age (years) N important Mean value Minimum Maximum Standard deviation17–40 16 10.06 7.00 13.00 2.1141–50 24 10.50 7.00 13.00 1.9851–60 28 10.71 7.00 13.00 1.9061–70 12 10.08 7.00 13.00 2.19Fig. 3. Relationship between the mean width of the coronary sinus and age of individuals.The width of the coronary sinus was included into the frames between 7 and 13 mm, although the mean width in male hearts was slightly bigger (10.45 mm), while in females it measured 10.31 mm (Table 5).Table 5. The width of the coronary sinus in male and female hearts.Sex N important Mean value Minimum Maximum Standard deviationMale 64 10.45 7.00 13.00 1.93Female 16 10.31 7.00 13.00 2.30Thus obtained results were next analyzed, to study the differences in the mean length of the coronary sinus in particular age groups, using Kruskal-Wallis test. Its results indi-cate lack of differences statistically important considered to the mediana of the legth of the coronary sinuses (p = 0.8910). Medianae in the following age groups are: group I, II and Morphometric parameters of human coronary sinus — based on study of 80 human hearts10III — 28; IV — 28.5. This is why one can state that the length of the coronary sinus in in-dependent on the age.Fig. 4. Medianae of the length of coronary sinuses in groups studied.The study of the mean width of the coronary sinuses in different age groups was carried out using Kruskal-Wallis test — its result (p = 0.7271) indicates lack of statistically signifi-cant differences in the medianane of the width of coronary sinus : in group I and IV — 10; in group III — 10.5; and in group II — 11.Fig. 5. The width of the coronary sinus in groups studies (medianae).Brygida Wandzel-Loch, Małgorzata Mazur et al.11To study the relevance of the differences between the width of the coronary sinuses in the males and females we used Mann-Whitney test. Its result (p = 0.9233) indicates lack of statistical significance of the differences between width of male and female coronary sinuses.Fig. 6. The width of the female and male coronary sinuses (medianae).We tried to calculate the dependency between the length and the width of the coronary sinus, using Spearman rank correlation factor. Based on the results we established relatively strong correlation between the length and the width of the coronary sinus. This dependency is positive, what means that increase of one of the features causes increase of another one (R = 0.4625, p = 0.0000) — Fig. 7.Fig. 7. Width and length of the coronary sinus.Morphometric parameters of human coronary sinus — based on study of 80 human hearts12DiscussionIn the literature quite different descriptions of the coronary sinus were found. Based on the study of 160 hearts, Adachi found coronary sinus emptying into the right atrium of the heart in all cases studied [5]. Also studies carried out on 200 human hearts aged 18–97 by Grzybiak proved that coronary sinus was a single vessel [6]. The coronary sinus did not al-ways open into right atrium. Ratajczyk-Pakalska et al. described abnormal opening of the coronary sinus into the left atrium in 39-year old female. This anomaly was accompanied by abnormal course of the great cardiac vein. This malformation did not disturb heart action and were disclosed accidentally during autopsy, while the death was caused by car accident [7]. Our knowledge on the coronary sinus is enriched by observation made during invasive pro-cedures on hearts. During an implantation of electrodes for biventricular stimulation Anh et al. found coronary sinus in 98 out of 100 patients [8]. In 2 patients they did not manage to visualize the vessel. Donal et al. and Luik et al. described three cases of coronary sinus atresia in patients subjected to ablation. Catheterization was ineffective and the cause was the blockage of the vessel. The venous flow occurred through the persistent left superior vena cava [9, 10]. Yamada et al. found double coronary sinus in 48-year old female [11]. Interesting are the studies of Blendea et al. who found coronary sinus in 100% of studied hearts, but noticed that it is bigger in males than in females, both in patients with coro-nary and cardiac insufficiency, more than in patients suffering from cardiomyopathy [12]. It seems also that diseases affecting the arterial blood supply may have influence on venous coronary tree. In our material, consisted of 80 hearts, we found coronary sinus in all cases studied. It was placed in the posterior fragment of the coronary sulcus, enveloped by connective (fat) tissue. In all cases it emptied into the right atrium of the heart. It is interesting however that different anomalies of the coronary sinus are predominantly found in individuals subjected to invasive cardiologic procedures. It doesn’t seem to be a rule however since this malfor-mations are usually clinically asymptomatic [13]. There are some controversies regarded to designation of the beginning and the end of the vessel. Adachi [5] initially established the border between the great cardiac vein and the coronary sinus based on the caliber of these two vessels. He found that in 33% of studied hearts the caliber of coronary sinus was bigger than that of the great cardiac vein, but only in 3% the difference was large enough to serve as orientation point. This is why he accepted that the length of the coronary sinus will be measured from the orifice of the oblique vein of the left atrium until the orifice of the coronary sinus into the right atrium of the heart. Thus measured coronary sinus varied in length from 5 to 45 mm [5]. Koźluk et al. accepted that length of the coronary sinus is the distance between two points: one is the orifice of the left marginal vein into the great cardiac vein and the second is the orifice of the coro-nary sinus into the right atrium. His results varied from 26–93 mm [14]. In our study we accepted Adachi’s criteria, since the presence of the left marginal vein is not confirmed in all hearts. Our results varied from 15–50 mm so they were similar to other results [5, 14, 15]. The width of the coronary sinus measured in the middle of the vessel agreed with Bleandea’s observation [12]. Brygida Wandzel-Loch, Małgorzata Mazur et al.13ConclusionsThe length of the coronary sinus in independent on the age, but males have statistically longer vessels than females, so the parameter is sex-dependent. Probably this is a result of a trend of generally bigger male hearts than female. The width of the coronary sinus is both age- and sex-independent. A strong correlation between length and the width of the vessels was shown. The longer coronary sinus is, the wider it is. It seemed that males should have wider coronary sinus than females — and this is truth, however differences in the width of the vessels are not so well visible as seen concerning the length, and for this reason they are statistically insignificant.Conflict of interestNone declared.References1\1. Swartz J., Tracy C., Fletcher R.: Radiofrequency endocardial catheter ablation of accessory atrioven-tricular pathway atrial insertion sites. Circ. 1993; 87: 487–499. 12. Taka-aki M., Hatsue I., Yoshiko I., Yuko Y.: The positional relathionship between the coronary sinus musculature and the atrioventricular septal junction. Europace. 2010; 12: 719–725. 13. Tracy C., Swartz J., Fletcher R., Wetson L., Soloman A., Karasik K.: Atrial endocardial radiofrequency ablation of accessory pathways. J Am Coll Cardiol. 1991; 17: 368–368.14. Van de Vire N.R., Schuijf J.D., Bleeker G.B., Schalij M.J., Bax J.J.: Magnetic resonance imaging and computed tomography in assessing cardiac veins and scar tissue. Europace. 2008; 10: 110–113. 15. Adachi B.: Das Venesystem der Japaner. Druckanstalt Kenkyusha, Tokyo, 1933; 41–64. 16. Grzybiak M.: Morphology of the coronary sinus and contemporary cardiac electrophysiology. Folia Morph (Warsz.). 1996; 55: 272–273. 17. Ratajczyk-Pakalska E., Błoch P., Kulig A.: Termination of the coronary sinus in the left atrium Folia Morph (Warsz.). 1980; 48: 151–155. 18. Anh D.J., Eversull C.S., Chen H.A., Mofrad P., Mourlas N.J., Mead R.H., Zei P.C., Hsia H.H., Wang P.J., Al-Ahmad A.: Characterization of human coronary sinus valves by direct visualization during biven-tricular pacemaker implantation. Pacing Clin Electrophysiol. 2008; 1: 78–82. 19. Donal E., de Chillou C., Magnin-Poull I., Leclercq C.: Imaging in cardiac resynchronization therapy: what does the clinical need? Europace. 2008; 3: 70–72. 10. Luik A., Deisenhofer I., Estner H., Ndrepepa G., Pflaumer A., Zrenner B., Schmitt C.: Atresia of the coro-nary sinus in patients with supraventricular tachycardia. Pacing Clin Electrophysiol. 2006; 29: 171–174. 11. Yamada T., McElderry H.T., Plumb V.J., Doppalapudi H., Epstain A.E.: Duplicated coronary sinus with a connecting branch. Europace. 2008; 7: 880–889. 12. Blendea D., Shah R.V., Auricchio A., Namdigam V., Orencole M., Heist E.K., Reddy V.Y., Mc Pherson C.A., Ruskin J.N., Singh J.P.: Variability of coronary venous anatomy in patients undergoing cardiac resynchro-nization therapy: a high-speed rotational venography study. Heart Rhythm. 2007; 49: 1155–1162. 13. Chou M.C., Wu M.T., Chen C.H., Lee M.H., Tzeng W.S.: Multidetector CT findings of a congenital coronary sinus anomaly: a report of two cases. Korean J Radiol. 2008; 9: 1–6. 14. Koźluk E., Kozłowski D., Adamowicz M., Walczak E.: Coronary sinus topography and its dependency from weight and diameters of the heart. Pace. 1995; 18: 2–5. 15. Loukas M., Bilinsky S., Bilinsky E., el-Sedfy A., Anderson R.H.: Cardiac veins: a review of the literature. Clin Anat. 2009; 22 (1): 129–145.Morphometric parameters of human coronary sinus — based on study of 80 human hearts

Morphometric parameters of human coronary sinus : based on study of 80 human hearts

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Morphometric parameters of human coronary sinus : based on study of 80 human hearts

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