Pradhan Akshyaya, Bajaj Vrishank, Vishwakarma Pravesh, Bhandari Monika, Sharma Akhil, Chaudhary Gaurav, Chandra Sharad, Sethi Rishi, Narain Varun Shankar, Dwivedi Sudhanshu
Department of Cardiology, King George Medical University, Lucknow 226003, Uttar Pradesh, India.
World J Cardiol. 2022 Jun 26;14(6):372-381. doi: 10.4330/wjc.v14.i6.372.
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.
To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.
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.
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.
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.
由于心脏再同步治疗（CRT）期间对电生理心律失常进行标测和消融以及左心室（LV）起搏的需求不断增加，冠状窦（CS）成像最近变得越来越重要。逆行静脉造影是目前用于CS及其分支成像的标准方法。
评估常规冠状动脉造影左前斜位时CS的解剖结构，以辅助CRT期间LV导联植入。
在这项前瞻性观察研究中，纳入了164例因各种适应症接受常规冠状动脉造影的患者（慢性稳定型心绞痛-44.5%，急性冠状动脉综合征-39.5%，扩张型心肌病-11%，非典型胸痛-5%）。在左前斜位-头位和右前斜位-头位视图中记录左冠状动脉注射的静脉期（左前斜位）。记录冠状静脉的可视性、CS口的宽度和形状、近端CS与CS体的夹角。还记录了后外侧静脉（PLV）、前室间静脉（AIV）和心中静脉（MCV）的存在、大小、起始角度和迂曲情况。
在左前斜位期间，74%的病例冠状静脉的可视性分级（Muhlenbruch分级）为3级，26%的病例为2级。CS的可视性与体重指数无关。CS口直径<10 mm、10 - 15 mm和>15 mm的患者分别占48%、42%和10%。136例（83%）患者的近端CS呈管状，28例（17%）患者呈漏斗状。16例（10%）患者的CS口与CS体之间有锐角起始夹角。8例患者有两条或更多PLV，52例（32%）患者无PLV。65例（40%）患者PLV与CS体的起始角度有利（0°-45°）。36例患者角度为45°-90°，8例患者起始角度困难（>90°）。84例患者PLV长度到达心肌远端三分之一，11例患者到达中间三分之一。79例无迂曲，29例有单个弯曲，4例有两个以上弯曲。39例（24%）患者有其他静脉供应LV后壁/侧壁。31例（19%）患者有一条静脉供应侧壁/后壁。与有PLV的患者相比，无PLV的患者MCV和AIV直径明显更大。
左冠状动脉注射的左前斜位研究对几乎所有接受冠状动脉造影的患者的CS可视化有效，对于LV功能障碍或左束支传导阻滞（LBBB）患者可能是逆行静脉造影的有效替代方法。
