Download A rare case: Coronary sinus thrombosis

A rare case: Coronary sinus thrombosis
Poster No.:
P-0085
Congress:
ESTI 2014
Type:
Educational Poster
Authors:
B. Özkul, N. Inan, Ö. Özkul, H. T. Sarisoy, G. Akansel, A. Akça, #.
Çam; Kocaeli/TR
Keywords:
Embolism / Thrombosis, Screening, CT-Angiography,
Cardiovascular system
DOI:
10.1594/esti2014/P-0085
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Learning objectives
1. To illustrate the venous anatomy of heart. The coronary system generally receives little
attention in the medical literature. Cardiologists mostly consantre on cardiac arteries but
venous system of heart must not to be neglected.
2. In this poster, our purpose is to present a case of coronary sinus thrombosis (CST)
with CT findings and to take attention on coronary system.
Background
Anatomy of cardiac venous system
The venous drainage of the heart consists of two separate systems draining the right and
left ventricular arterial flow. Normally the right ventricle is drained via the anterior cardiac
veins running along the anterior right ventricular surface and draining separately into the
right atrium; this accounts for approximately 15% of the total cardiac venous return. The
remainder of the cardiac venous return is via the coronary sinus, a large venous channel
running in the left atrio-ventricular sulcus. Fig. 1 on page 4
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Fig. 1: Anatomy of the coronary sinus
References: The McGraw-Hill Companies, Inc.
Tributaries with contribution to the coronary sinus include: the anterior interventricular
vein, also known as the great cardiac vein, running in the anterior interventricular sulcus
parallel to the left anterior descending coronary arterry; the posterior interventricular vein
(middle cardiac vein) running in the posterior interventricular sulcus parallel to te posterior
descending coronary artery; and the small cardiac vein running in the right atrioventricular
sulcus. Other venous channels entering either the great cardiac vein or directly into the
coronary sinus include: the oblique vein of the left atrium (oblique vein of Marshall); the
obtuse marginal vein running parallel to the obtuse marginal branch of the left circumflex
coronary artery; and the posterior left ventricular veins running parallel to the posterior
left ventricular branches of the left and right ventricles. Fig. 2 on page 5
Page 3 of 14
Fig. 2: Anterior view of heart
References: The McGraw-Hill Companies, Inc.
Although these two venous systems are anatomically distinct with separate entrances
into the right atrium, there are many anastomotic connections between the two allowing
diversion of flow from one to the other if resistance in one channel should increase for
any reason.
Images for this section:
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Fig. 1: Anatomy of the coronary sinus
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Fig. 2: Anterior view of heart
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Imaging findings OR Procedure details
A 79 years old male patient was evaluated for chest pain and breathlessness at the
emergency room. He has been chronic renal failure since 1996 and he had no history
of invasive cardiac procedures. Cardiac markers and D-dimer test, electrocardiography,
echocardiography and chest MDCT were performed.
MDCTA scanning protocol:
•
•
•
•
•
•
Aquilion 64 MDCT, Toshiba
Slice thickness: 2 mm
kVp: 120, mAs: 100
18G IV cannula placed in a distal arm vein
TM
Bolus track (OptiVantage ); 180 H.U.threshold, then 12-16 sec scan delay.
100 ml @ 4.5 ml/s di iodinated contrast medium (370 mgI/mL) + 50 ml @ 4.5
ml/s saline chase.
Examination revealed that no breath sound at the middle and lower zones of right lung
and increased blood d-dimer levels (1.83 ng/mL, normal: 0-0.5 ng/mL). The creatinin
was 3.88 mg/dL (normal: 0.6-1.3 mg/dL) and blood urea nitrogen was 34 mg/dL (normal:
7-25.7 mg/dL). A chest CT was performed because of the suspicious of pulmonary
embolism. Massive unilateral pleural effusion, atelectasis and CST were seen in the chest
CT (Fig. 3 on page 10, Fig. 4 on page 11 and Fig. 5 on page 12).
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Fig. 3: Axial view of chest CT
References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/
Turkey 2014
Also ST elevations in the ECG and increased cardiac markers were revealed (myoglobin:
355 ng/mL (normal: 0-107 ng/mL), Troponin I: 0.85 ng/mL (normal: 0-0.4 ng/mL)). Based
on these findings, a diagnosis of acute MI depending on CST was made.
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Fig. 4: Coronal view of chest CT
References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/
Turkey 2014
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Fig. 5
References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/
Turkey 2014
Images for this section:
Page 10 of 14
Fig. 3: Axial view of chest CT
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Fig. 4: Coronal view of chest CT
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Fig. 5
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Conclusion
CST is a rare acquired anomaly of the coronary sinus. It has been reported only as a
complication of cardiac transplantation and right heart catheterization in non infected
patients. In cardiac procedures that use access to the right atrium, such as insertion
of central venous lines, pacing wire, coronary sinus catheterisation for ventricular lead
placement during cardiac resynchronisation therapy, the CS is at risk of accidental trauma
and subsequent thrombosis. Our case had an acute coronary sinus thrombosis occurring
in the absence of these procedures.
References
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Vinayak NB, Ashutosh AH, Manish MP, Nandkishor BA, et al. Coronary
sinus thrombosis after cannulation during cardiopulmonary bypass. Ann
Thorac Surg. 1996;62:1506-7.
James, TN: Anatomy of the coronary arteries and veins. In Hurst, JW, et a1
(eds): "The Heart." New York: McGraw-Hill, 1978, p 26.
Ramsaran EK, Sadigh M, Miller D. Sudden cardiac death due to primary
coronary sinus thrombosis. South Med J. 1996;86:531-533.
O'Cochlain B, Delurgio D, Leon A. Biventricular pacing using two
pacemakers and the triggered VVT mode. Pacing Clin Electrophysiol. 2001;
24(8 Pt 1):1284-5.
Suarez-Penaranda JM, Rico-Boquete R, Munoz JI, Rodriguez-Nunez A,
Martinez Soto MI, et al. Unexpected sudden death from coronary sinus
thrombosis. An unusual complication of central venous catheterization. J
Forensic Sci. 200l;45:920-2.
Personal Information
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