Takenaka S Coronary sinus morphology in patients with accessory pathways Original Article Coronary Sinus Morphology in Patients with Posteroseptal Atrioventricular Accessory Pathways Sou Takenaka MDÃ1 , Yukiko Nakano MDÃ2 , Hidekazu Hirao MDÃ3 , Hiroki Teragawa MDÃ2 , Tetsuji Shingu MDÃ2 , Kazuaki Chayama MDÃ2 Ã1 Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan Department of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan Ã3 Department of Cardiology, Tsuchiya General Hospital, Hiroshima, Japan Ã2 Background: There have been numerous reports about coronary sinus (CS) anomalies related to posteroseptal accessory pathways (APs) The purpose of this study was to explore the diameter and morphology of CS in patients with posteroseptal APs Methods: We performed direct CS angiography in 105 patients with 22 posteroseptal APs and 83 APs in other regions, and 25 control subjects We compared the diameter of the CS ostium in all subjects, and assessed the correlation of the local activation time in the patients with posteroseptal APs Results: The proximal size (diameter) of the CS in the patients with posteroseptal APs (13:6 Ỉ 1:1 mm) was larger than that in the patients with other types of APs (10:2 Ỉ 1:8 mm [p < 0:001]) and that in the control subjects (9:6 Ỉ 1:5 mm [p < 0:001]) Dilatation of the CS in the patients with posteroseptal APs extended up to 20 mm inside the CS In 15 (68%) of the patients with posteroseptal APs, the proximal site of the CS demonstrated a windsock appearance Conclusions: We concluded that the larger size and the wind cone appearance of proximal CS were unique structural characteristics in most patients with posteroseptal APs (J Arrhythmia 2006; 22: 149–154) Key words: Wolff-Parkinson-White syndrome, Radiofrequency catheter ablation Introduction There have been numerous reports1–9) about coronary sinus (CS) anomalies related to posteroseptal accessory pathways (APs) Chiang CE et al.1) reported that some patients with APs in the left-free wall and posteroseptal area have CS abnormalities, such as an angulation, hypoplasia or diverticulum Sun et al.9) showed that CS diverticula were found in 21% of patients with posteroseptal and epicardial Received 5, January, 2006: accepted in final form 12, September, 2006 Address for correspondence: Sou Takenaka MD, Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 7108602, Japan Tel: 086-422-0210 Fax: 086-422-9351 E-mail: soutakenaka@yahoo.co.jp 149 J Arrhythmia Vol 22 No 2006 APs In addition, in patients with atrioventricular nodal reentrant tachycardia, the CS ostium is prone to be larger than in those with other types of supraventricular tachycardias.10,11) The purpose of this study was to explore the diameter and morphology of the CS in patients with posteroseptal APs Methods Patient selection The subjects of this study consisted of 105 patients (mean age 44 Ỉ 18 years; 67 males and 38 female) with a single AP Of these 105 patients, 22 had an AP located in the posteroseptal region (PSAP group) The posteroseptal accessory pathway location was defined as the pathway located around the CS over the inferoposterior one-third of Koch’s triangle, within cm adjacent to the CS ostium over the inferomedial aspect of the right atrium or cm to the left of the CS ostium at the crux area over the posterior medial mitral annulus.12–14) The other 83 patients (other AP group) was comprised of 63 patients with APs in the left free wall, 13 in the right free wall, and in the anteroseptal wall Twenty-five control subjects (control group; 15 males and 10 females; mean age: 45 Æ 17 years) consisted of patients admitted for the evaluation of chest pain, or ventricular tachycardia Written informed consent for participation was obtained from all patients before the procedure, and all procedures were carried out according to the protocol approved by the Ethics Committee of the Hiroshima University Faculty of Medicine CS morphology Direct CS angiography was performed prior to the electrophysiological study The CS was cannulated with a Fr RESPONSEÔ decapolar CS electrode catheter with a lumen (St Jude Medical, Daig Division, MN, USA) or a Fr Goodale-Lubin catheter (Medtronic, MA, USA) via the right subclavian vein or right jugular vein About ml of contrast medium was injected into the CS Images of the CS were obtained in the projections (30 right anterior oblique and 50 left anterior oblique views) during sinus rhythm and stored on cine film The size and shape of the CS were measured in all patients with APs and in the control subjects.15) We analyzed and compared the shape and diameter of the CS (1) Shape of the CS: We closely investigated the presence of CS abnormalities, such as an angulation, hypoplasia, or diverticulum of the CS1 In addition, the shape of the CS was classified 150 into the groups (windsock and tubular appearance), previously described by Doig et al.10) (2) CS diameter: We measured the diameter at mm and 10 mm locations inside the CS ostium and subsequently at 10-mm intervals along the rest of the CS and great cardiac vein, up to the origin of the anterior interventricular vein, based on previous published criteria.13) The orifice of the CS was defined as the point at the atrial septum above and below the ostium, which was outlined by contrast flowing out of the vessel and the long axis of the proximal portion of the CS as it entered the right atrium Measurements were made in a frame that provided the clearest image of the CS ostium at the ventricular end-systolic phase of the angiogram Electrophysiological study An electrophysiological study was performed in all patients during the baseline, drug-free and unsedated state Under local anesthesia, four standard electrode catheters were placed at the high right atrium, His bundle region, and the right ventricular apex, and into the CS Intracardiac electrograms were simultaneously recorded and stored digitally on a Cardiolab systemÔ (Prucka Engineering Inc., TX, USA) We then performed the diagnostic electrophysiologic study Intravenous isoproterenol, atropine, or both were used to facilitate the induction of tachyarrthythmias if necessary Paradoxical capture, parahisian pacing and/or an ATP injection were used to rule out atrioventricular nodal tachycardia.11,15) We also collected and compared the antegrade/ retrograde effective refractory periods and the local activation time The local activation time was defined as the atrioventricular or ventriculoatrial conduction time at the successful site Radiofrequency catheter ablation Radiofrequency catheter ablation (RFCA) was conducted immediately after the diagnostic electrophisiologic study Successful results were defined as the disappearance of the AP conduction The successful ablation sites were stored on cine film, and the AP location was classified Statistical analysis All values are expressed as mean Ỉ SD The CS diameter was compared by using the unpaired t test The baseline characteristics and comparisons of the shape of the CS among the PSAP group, other AP group and control group were performed with the chi-square test P values less than 0.05 were considered statistically significant Takenaka S Table Coronary sinus morphology in patients with accessory pathways Clinical characteristics Table CS angiographic measurements PSAP other AP control n ¼ 22 n ¼ 83 n ¼ 25 Male/Female 17/5 50/33 15/10 Age (years) 41 Ỉ 18 45 Ỉ 18 52 Æ 20 Height (cm) 165 Æ 10 167 Æ 10 163 Ỉ 14 Weight (kg) 72 Ỉ 15 73 Ỉ 12 76 Ỉ 20 Left Ventricular Ejection Fraction (%) 62 Æ 61 Æ 53 Æ 10 Coronary artery disease 15 Hypertrophic cardiomyopathy Atrial septal defect 17 78 — Atrial fibrillation 15 Atrial flutter Atrial tachycardia Preexcited Atrial Fibrillation Ventricular tachycardia 0 Syncope Orthodromic reentrant tachycardia CS CS CS CS CS CS CS Ã os (mm) mm (mm) 10 mm (mm) 20 mm (mm) 30 mm (mm) 40 mm (mm) 50 mm (mm) PSAP n ¼ 22 other APs n ¼ 83 control n ¼ 25 13:6 Ỉ 1:1Ã 10:5 Ỉ 1:0Ã 8:7 Ỉ 1:2Ã 6:9 Ỉ 1:2Ã 5:8 Ỉ 1:2 5:2 Ỉ 0:9 5:0 Ỉ 0:6 10:2 Ỉ 1:8 8:4 Ỉ 1:7 7:2 Æ 1:5 6:0 Æ 1:4 5:2 Æ 0:9 5:2 Æ 1:0 5:0 Ỉ 0:7 9:6 Ỉ 1:5 8:1 Ỉ 1:8 7:1 Ỉ 1:5 6:0 Ỉ 1:3 5:4 Ỉ 1:0 5:4 Æ 0:8 5:1 Æ 0:5 ; p < 0:05 vs other APs and control CS morphology The CS morphology is shown in Figures and In 15 patients (68%) in the PSAP group, the proximal CS had a windsock appearance (Figure 2A and 2B) This morphology was found in 16% of subjects in the other AP group (p < 0:001) In 96% of the control subjects, the CS was tubular (p < 0:001) Electrophysiological study Results Clinical characteristics The clinical characteristics of the patients with APs is shown in Table There were no significant differences between the PSAP group and other AP group In the control subjects, 15 patients had angina pectoris, hypertrophic cardiomyopathy, idiopathic ventricular tachycardia, and the others chest pain syndrome CS anomaly Major CS anomalies were identified in (6%) of all patients with APs Two patients had an angulation of the CS, localized narrowing, a CS-left atrial fistula, and a diverticulum of the CS, all of which had a nice correlation between their locations and the successful ablation site Five of those patients had left lateral APs and had a posteroseptal AP In this study, the control subjects had no CS anomalies CS diameter The CS angiographic measurements are shown in Table The proximal CS in the PSAP group was larger than that in the other AP group and control (13:6 Ỉ 1:1 mm vs 10:2 Ỉ 1:8 mm [p < 0:001], and 9:6 Ỉ 1:5 mm [p < 0:001], respectively) The dilatation of the CS in the PSAP group extended up to 20 mm inside the CS There were no differences in these distal diameters (more than 20 mm inside the CS ostium, Table 2) Four patients of the PSAP group and patients of the other AP group had multiple (more than components) APs During electrophysiological study, orthodromic reentrant tachycarida was induced in 13 patients of the PSAP group and in 78 of the other AP group (Table 1) The angegrade/retrograde effective refractory period of accessory pathway (327 Ỉ 64 ms vs 330 Ỉ 50 ms; 296 Ỉ 53 ms vs 305 Ỉ 82 ms) and the antegrade local activation time (45 Ỉ 12 ms vs 38 Ỉ 13 ms) were no different between the groups The retrograde local conduction time was longer in the PSAP group than in the other AP group (39 Ỉ 22 ms vs 25 Ỉ 10 ms, p ¼ 0:02) Radiofrequency catheter ablation Successful ablation was achieved from CS diverticulum in patient with posteroseptal AP, and from the endocardial approach in the other patients Correlation between the diameter of CS ostium and the local activation time In the PSAP group, there was no correlation between the diameter of CS ostium and the antegrade (r ¼ À0:13) and retrograde (r ¼ 0:26) local activation time (Figure 3) Discussion The present study revealed a unique morphology of the CS in the patients with posteroseptal APs The 151 J Arrhythmia Vol 22 No 2006 100% Tubular appearance Wind-sock appearance 68% 17% 0% PS LL 15% RL 29% AS 4% Control A B C D Figure Coronary sinus (CS) morphology In 68% of the PSAP group, the proximal CS had a windsock appearance This morphology was found in 16% of the other AP group (p < 0:001) In 96% of the control subjects, the CS was tubular (p < 0:001) Figure Coronary sinus (CS) angiography (A, B) A case with a posteroseptal accessory pathway The CS ostium had a windsock appearance (C, D) A case with a left lateral accessory pathway The CS ostium had a tubular appearance (A, C) 30 right anterior oblique (B, D) 50 left anterior oblique proximal CS in those patients was significantly larger than in those with other types of APs and the control In addition, those patients were prone to having a CS with a windsock appearance There have been several reports2–7,16) about cases of Wolff-Parkinson-White syndrome with posteroseptal APs associated with CS diverticula Those anomalies included an angulation, hypoplasia, localized narrowing, fistula and diverticula, but did not include dilatation (windsock appearance) of the CS In this study, we first demonstrated the relationship between the dilatation of the CS and the posteroseptal APs 152 CS diameter and morphology Recent studies1,2,10,17–19) have reported the relationship between the pathogenesis of arrhythmias and the structural characteristics of the human heart Ebstein’s anomaly is often associated with APs Chiang et al.1) reported that 2.9% of patients with supraventricular tachycardias had major CS abnormalities In our study, 6% of the patients had major CS abnormalities All of them had left lateral or posteroseptal APs This finding suggested that some disarrangement during cardiogenesis might have created the CS abnormalities and/or the APs APs are vestigial remnants of embryonic structures.20) In Takenaka S Coronary sinus morphology in patients with accessory pathways (A) posteroseptal APs may be related to the dilatation of the CS ostium 100 r=−0.26 Clinical implications 80 60 Local activation time (ms) 40 20 10 12 14 16 18 (B) 100 r=0.13 80 60 40 20 10 12 14 16 18 CS ostial diameter (mm) Figure Correlation between the diameter of coronary sinus ostium and the antegrade (A) and retrograde (B) local activation time in the PSAP group mammals, the right extension of the primitive sinus venosus, or cuvierian duct, becomes the cardiac end of the superior vena cava, and the left extension becomes the CS When the CS progresses into an intimate anatomical relation with the ventricles, it remains possible that extensions of the sinus venosus muscle could be responsible for a physiological connection.20) Not only CS abnormalities, but also CS dilatation, as shown in the present study, could occur during this development In atrioventricular nodal reentrant tachycardia (AVNRT), the CS ostium was found to be larger and to remain more dilated to at least 10 mm from the ostium.10,11) The appearance of the CS is like a windsock in AVNRT patients In our study the CS ostium in patients with posteroseptal APs was also large and remained dilated to at least 20 mm from the ostium and had a windsock appearance These findings were similar to those of AVNRT patients In an anatomical study, Davis et al.13) reported that APs located in the proximal 15 mm of the CS were almost always in the posteroseptum In our study, for at least 10 mm from the CS ostium, the diameter of the CS was larger in the patients with posteroseptal APs than in the other AP group This suggested that In the patients with posteroseptal APs, the ostium of the CS is large and shaped like a windsock These findings mean that the RFCA catheter can drop easily into the CS Not only chest pain22) during the application, but also complications following RFCA in the coronary venous system, such as an occlusion18) or thrombosis formation, have been reported.22) The posteroseptal accessory pathway location included the area around and into the CS CS angiography could be useful to understand the catheter position in this area During RFCA in the right posteroseptal region, especially into CS and the coronary venous system, we should carefully control the catheter and check the impedance and power output23) to avoid damaging the coronary venous system Study limitations This study had several limitations First, the twodimensional measurements of the CS diameter may not have accurately presented the true distance of the three-dimensional structure of the CS However, this is the first important study to characterize the morphology of the CS ostium in patients with APs Second, the criteria for the CS abnormalities were not available in the past We defined them ourselves more appropriately for the patients with supraventricular tachycardias and the control population Takenaka et al.24) reported that a longer local activation time is characteristics of left free-wall epicardial APs There was only one patient with epicardial AP in this study, and we could not characterize the electrophysiological difference between the endocardial and epicardial APs In conclusion, the larger size of the proximal CS was a unique structural characteristic in patients with posteroseptal APs The appearance of proximal CS was like a wind cone in these patients These findings may give some clues to trace arrthythmic pathogenesis to its origin Acknowledgment We wish to thank Fumiharu Miura, MD, Togo Yamagata, MD, and Hideo Matsuura, MD for their continued and invaluable assistance, and Yuko Omura for her secretarial assistance References 1) Chiang CE, Chen SA, Yang CR, et al: Major coronary sinus abnormalities: Identification of occurrence and 153 J Arrhythmia 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 154 Vol 22 No 2006 significance in radiofrequency ablation of supraventricular tachycardia Am Heart J 1994; 127: 1279–1289 Omran H, Pfeiffer D, Tebbenjohanns J, et al: 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A, Shah DC, Jais P, et al: Specific electrocardiographic features of manifest coronary vein posteroseptal accessory pathways J Cardiovasc Electrophysiol 1998; 9: 1015–1025 24) Takenaka S, Yeh SJ, Wen MS, et al: Characteristics and radiofrequency ablation in posteroseptal and left freewall subepicardial accessory pathways J Electrocardiol 2005; 38: 69–76 ... structures.20) In Takenaka S Coronary sinus morphology in patients with accessory pathways (A) posteroseptal APs may be related to the dilatation of the CS ostium 100 r=−0.26 Clinical implications... performed with the chi-square test P values less than 0.05 were considered statistically significant Takenaka S Table Coronary sinus morphology in patients with accessory pathways Clinical characteristics... is like a windsock in AVNRT patients In our study the CS ostium in patients with posteroseptal APs was also large and remained dilated to at least 20 mm from the ostium and had a windsock appearance