Unroofed coronary sinus,left-sided superior vena cava and mitral insufficiency:A case report and review of the literature

BACKGROUND Unroofed coronary sinus(UCS)is a rare subtype of atrial septal defect.It is frequently associated with a persistent left superior vena cava and is often part of a more intricate cardiac malformation.CASE SUMMARY This report describes a rare case of an adolescent patient with UCS featuring atrial situs solitus,absence of the right superior vena cava and a persistent left superior vena cava draining into the left atrium consistent with total unroofing of the coronary sinus.This was associated with concurrent severe mitral insufficiency secondary to redundant and prolapsing leaflets,and a substantial left-to-right shunt across the coronary sinus orifice.A comprehensive examination of the existing literature is included,shedding light on the diagnostic challenges of UCS and describing the available surgical options within the context of mitral valve surgery.CONCLUSION UCS is a complex condition requiring careful consideration of associated anomalies and a tailored surgical approach.

Misdiagnosis of unroofed coronary sinus syndrome as an ostium primum atrial septal defect by echocardiography:A case report

BACKGROUND Unroofed coronary sinus syndrome(UCSS)is a rare congenital heart disease,which has variable morphologic features and is strongly associated with persistent left superior vena cava(PLSVC).However,it is often difficult to visualize the left-to-right shunt pathway through the CS by transthoracic echocardiography(TTE).CASE SUMMARY A 37-year-old female was admitted to the hepatological surgery department of a hospital with complaint of subxiphoid pain that had started 1 wk prior.Physical examination revealed a grade 3/6 systolic murmur at the left margin of the sternum,between the 2nd and 3rd intercostal cartilage.The patient underwent echocardiography and was diagnosed with ostium primum atrial septal defect(ASD);thus,she was subsequently transferred to the cardiovascular surgery department.A second TTE evaluation before surgery showed type IV UCSS with secundum ASD.Right-heart contrast echocardiography(RHCE)showed that the right atrium and right ventricle were immediately filled with microbubbles,but no microbubble was observed in the CS.Meanwhile,negative filling was observed at the right atrium orifice of the CS and right atrium side of the secundum atrial septal.RHCE identified UCSS combined with secundum ASD but without PLSVC in this patient.CONCLUSION This rare case of UCSS highlights the value of TTE combined with RHCE in confirming UCSS with ASD or PLSVC.

Coronary sinus endocarditis in a hemodialysis patient:A case report and review of literature

BACKGROUND Infective endocarditis is more common in hemodialysis patients than in the general population and is sometimes difficult to diagnose.Isolated coronary sinus(CS)vegetation is extremely rare and has a good prognosis,but complicated CS vegetation may have a poorer clinical course.We report a case of CS vegetation accidentally found via echocardiography in a hemodialysis patient with undifferentiated shock.The CS vegetation may have been caused by endocardial denudation due to tricuspid regurgitant jet and subsequent bacteremia.CASE SUMMARY A 91-year-old man with dyspnea and hypotension was transferred from a nursing hospital.He was on regular hemodialysis and had a history of severe grade of tricuspid regurgitation.There was no leukocytosis or fever upon admission.Repetitive and sequential blood cultures revealed absence of microorganism growth.Chest computed tomography showed lung consolidation and a large pleural effusion.A mobile band-like mass on the CS,suggestive of vegetation,was observed on echocardiography.We diagnosed him with infective endocarditis involving the CS,pneumonia,and septic shock based on echocardiographic,radiographic,and clinical findings.Infusion of broad-spectrum antibiotics,fluid resuscitation,inotropic support,and ventilator care were performed.However,the patient died from uncontrolled infection and septic shock.CONCLUSION CS vegetation can be fatal in hemodialysis patients with impaired immune systems,especially when it delays the diagnosis.

Temporary coronary sinus pacing to improve ventricular dyssynchrony with cardiogenic shock: A case report

BACKGROUND Temporary transvenous pacing through the coronary sinus is a novel approach rarely used in treating unstable bradycardia.This modality could provide cardiac pacing while achieving better ventricular synchrony.We present a case who received cardiac pacing through the coronary sinus and provide a summary of evidence in the current literature.CASE SUMMARY A 55-year-old woman with a history of advanced heart failure was admitted to the rehabilitation ward after a recent stroke.During hospitalization,she had paroxysmal atrial fibrillation with rapid ventricular response resulting from fluid overload.While atrial fibrillation was spontaneously reversed to sinus rhythm after diuresis,she developed multiple episodes of polymorphic ventricular tachycardia along with sinus bradycardia and prolonged QTc interval.She became hypotensive despite appropriate medical management.Pacing through her implantable cardioverter-defibrillator was attempted but worsened her hypotension.Ventricular dyssynchrony was suspected.Temporary transvenous atrial pacing through the coronary sinus was performed,which stabilized her blood pressure and improved end-organ perfusion.A permanent biventricular pacemaker was later implanted,and she was safely discharged to a nursing home.CONCLUSION Temporary transvenous pacing through the coronary sinus,a novel approach to treat unstable bradycardia,may reduce ventricular dyssynchrony.

Value of Coronary Sinus During Computed Tomography Pulmonary Angiography for Predicting Pulmonary Hypertension in Patients with Acute Pulmonary Embolism

Objective:Computed tomography pulmonary angiography(CTPA)parameters are valuable for predicting pulmonary hypertension(PH)in patients with pulmonary embolism(PE).However,few studies have used the coronary sinus ostium area(CSOA),derived from CTPA,to detect PH.This study aimed to compare the prognostic values of the CSOA,coronary sinus ostium diameter(CSOD),and right ventricular(RV)/left ventricular(LV)ratio for PH.Methods:This study retrospectively analyzed 78 patients(mean age,(51.94±12.33)years;53.8%male)with acute PE confirmed by CTPA at the Sixth and Eighth Medical Centers of the People’s Liberation Army General Hospital between June 2018 and June 2020.Patients were categorized into 2 groups using a pulmonary artery systolic pressure(PASP)cut-off of 30 mmHg.CTPA parameters were compared between these groups.Results:Patients with PASP>30 mmHg(n=22)had a larger CSOA,CSOD,RV diameter,RV/LV ratio,and inferior vena cava diameter compared with patients with PASP≤30 mmHg(n=56).The CSOA had an area under the receiver-operating characteristic curve(AUC,0.84;95%confidence interval(CI),0.74–0.94;P<0.001)similar to that of the RV/LV ratio(AUC,0.85;95%CI,0.73–0.99;P<0.001),while that of the CSOD was smaller(AUC,0.66;95%CI,0.51–0.81;P<0.05).Conclusion:Both CSOA and CSOD demonstrated a good ability to predict PH,while CSOA better predicted PASP>30 mmHg.

Results of transvenous lead extraction of coronary sinus leads in patients with cardiac resynchronization therapy

Background The need for transvenous lead extraction procedures of coronary sinus （CS） leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade. Methods From January 2009 to June 2013, 27 CS leads were scheduled for extraction in 27 patients （mean age （63.1±14.6） years）. Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases. Isolated extraction of CS leads was performed in eight, extraction of multiple leads in 19 cases. Among leads with an implant time of 〉12 months （n=19） mean implant duration （MID） was （46.4±15.2） （12-76） months. Groups were formed depending on infectious or non-infectious indications （INF vs. Non-INF）, and the use or non-use of extraction tools （ET1 vs. ET0）. Results Among patients with an implant duration of 〉12 months, complete procedural success was 94.7% and clinical success 100%. Operative mortality was zero. In the INF versus NON-INF groups complete procedural success （100% vs. 91.7%, P=0.43）, mean number of required extraction tools （0.7 （0-2） vs. 0.9 （0-3）, P=0.65） and MID （49.1±15.0 vs. 44.7±15.8, P=0.83） did not differ significantly. Comparing the groups ET1 and ET0 showed no significant differences in complications （n=l vs. n=l, P=-0.81） and MID （47.0±17.5 vs. 45.5±12.6, P=0.71）. Conclusions In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively. Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure.

Reposition of coronary sinus lead dislocation only using pre-shaped stylet and guidewire： a case report

Technologies associated with cardiac resynchronization therapy （CRT） devices and lead systems have progressed.However, dislocation after coronary sinus （CS） lead placement continues to be a problem. We reported on the patient treated with CRT, in whom dislocation of CS lead occurred. In the case, we tried to reposition the CS lead without the left heart delivery system only using pre-shaped stylet and guidewire, and the dislocated CS lead could be successfully repositioned by the method. The method of only using a pre-shaped stylet and guidewire is easier than the conventional way, and it can shorten procedure duration and fluoroscopy time, as well as reduce the cost of treatment, but it is not always feasible.

Coronary sinus： an important target of catheter ablation of atrial fibrillation

The pulmonary veins have been demonstrated to be the major source of atrial fibrillation （AF）. Isolation of the pulmonary veins is effective in curing patients with paroxysmal AE However, this strategy is associated with limited success in some patients with paroxysmal AF and in most patients with persistent and permanent AF It requires more widespread ablation targeting most parts of the left atrial and thoracic veins and may include some discrete sites, which, if missed or neglected, can lead to persistence of fibrillation. In recent years, other AF origins have also been reported in addition to some types of atrial tachycardia and AF originating from the coronary sinus （CS） musculature. The CS appears to be a major element perpetuating persistent AF.

UNRUPTURED ANEURYSM OF THE LEFT CORONARY SINUS OF VALSALVA ASSOCIATED WITH ANEURYSM OF THE INTERVENTRICULAR SEPTUM

Aneurysms of the coronary sinus of Valsalva are commonly seen in the oriental people.Their clinical courses and prognosis depend on the location,size and propensity to rupture.They often occur in the right coronary sinus and tend to rupture to the

The anatomic and electrophysiological characters of the coronary sinus

With the development of the technology of electrophysiological study and radiofrequency catheter ablation, electrophysiologists realized that the coronary sinus (CS) was involved in several types of arrhythmias due to its special anatomic and histological characteristics. In this article we review the anatomy, histology and electrophysiology of the CS and the relation between the CS and selected types of arrhythmias.

Cardiac tamponade as a rare complication after giant coronary fistula percutaneous closure

We present the case of an unusual complication after percutaneous closure of a giant coronary artery fis-tula. A 76-year-old man with previous admissions due to right heart failure and previous history of atrial fibrillation under acenocumarol, was admitted to our hospital for new onset of symptoms, characterized by progressive dyspnoea and peripheral edema. Physical examination revealed signs of congestive heart failure and a continuous murmur loudest along the lower sternal border. X-Ray showed cardiomegaly due to right chambers dilatation. Transthoracic echocardiography showed right chambers pressure and volume overload, with right ventricular enlargement and dysfunction, tricuspid annulus dilatation and severe tricuspid regurgitation. Cardiac catheterization showed significant elevation of right atrial pressure, as well as significant step-up of oxygen saturation in this chamber. Coronary angiography revealed the presence of a large fistula between the circumflex coronary artery (CCA) and coronary sinus (CS), with severe dilation of the CCA (maximum diameter20 mm). An Amplatzer? PDA was implanted in a distal elbow of the fistula with initailly good results. Anticoagulant therapy was then reinitiated, and a few days later, the patient developed clinical worsening of heart failure and dyspnoea. Echocardiogram showed significant pericardial effusion. Pleuropericardial window was then made draining a500 cm3 of bloody pericardial effusion. The postoperative outcome was excellent, with symptomatic relief and no signs of heart failure.

Accidental venous port placement via the persistent left superior vena cava:Two case reports

BACKGROUND Breast cancer poses a great threat to females worldwide.There are various therapies available to cure this common disease,such as surgery,chemotherapy,radiotherapy,and immunotherapy.Implantable venous access ports(IVAP,referred to as PORT)have been widely used for breast cancer chemotherapy.Venous malformations are possible conditions encountered during PORT implantation.Persistent left superior vena cava(PLSVC)is a common superior vena cava malformation.Most patients have normal right superior vena cava without affecting hemodynamics,so patients often have no obvious symptoms.CASE SUMMARY We incidentally found that two patients had PLSVC while a PORT was implanted via the internal jugular vein.Due to chemotherapy for breast cancer,PORT was successfully implanted under the guidance of ultrasound into these 2 patients.Positive chest X-ray examination after the operation showed that the catheter ran beside the left mediastinum and the end was located in the seventh thoracic vertebra.The patients had no catheter-related complications and successfully completed the course of chemotherapy.Ultrasonography found that the ratio of PORT outer diameter to PLSVC inner diameter was less than 0.45,which was in line with the recommendations of relevant literature and operating guidelines.The purpose of this article is to introduce two rare cases and review the relevant literature.CONCLUSION Correct assessment of PLSVC status and ultrasound-guided PORT placement generally does not affect breast cancer patients chemotherapy.