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Advances in Vein Therapies
Coronary Sinus Anatomy: Ajmer Working Group Classification
R.K. Gokhroo, MD, DM, Devendra Singh Bisht, MD, DM, Deepak Padmanabhan, MD, DM, Sajal Gupta, MD, DM
tools for common disorders like heart failure has made understanding the coronary sinus (CS) anatomy necessary.8-10
We made an attempt to classify CS anatomy depending upon
the size, branching pattern, location of posterolateral vein (PLV),
and other parameters. This classification is intended to guide the
cardiologist for successful cannulation of the CS and LV lead.
Methods
In this single-center, non-randomized, observational study,
we analyzed the levophase angiograms of 100 patients undergoing routine coronary angiography in the right anterior oblique
(RAO) view, and classified these observations on the basis of
predetermined parameters; a working classification was produced for the ease of the operator and to predict the bottlenecks
of the procedure. All patients gave written informed consent.
Patients allergic to radiographic contrast agent were excluded.
Coronary angiography. Coronary angiography was performed with Judkins technique via the radial route using a 5 Fr
TIG catheter. Venograms were analyzed in the levophase after
injection of contrast in the coronary artery ostia. Coronary sinus visualization was observed 8-12 cycles after contrast injection. A non-ionic contrast agent with low osmolarity was used.
Terminology and coronary venous anatomy. We used
the same terminology as used in previous studies to identify
the coronary veins.11-13 The myocardium drains mainly by two
groups of veins: the tributaries of the greater and smaller cardiac veins, or the Thebesian veins. The main vein of the greater
venous system is the CS, which runs in the posterior aspect of
the coronary groove. The anterior wall of the left ventricle and
the interventricular septum are drained by branches of the anterior interventricular (AIV) vein, known as the great cardiac vein
on the annulus.14-16 The course of the anterior interventricular
vein is similar to the adjacent left anterior descending artery
in the interventricular groove. In a study using electron-beam
computed tomography (CT), the anterior interventricular vein
was visualized in up to 100% of subjects scanned.17
In addition, the diameter of the anterior interventricular
vein was seen to be similar to the neighboring artery for the
length of its course. The great cardiac vein in turn joins the
main posterior lateral vein to form the CS. Other major tributaries entering the CS include the inferior left ventricular vein
and the middle cardiac vein (MCV), which originates close to
the apex of the heart and follows the posterior interventricular
groove toward the base. Usually, the MCV drains into the CS
close to its ostium in the right atrium. The atrial myocardium
also drains into the CS via the various atrial veins and the vein
of Marshall. The vein of Marshall is a remnant of the left superior vena cava; it runs along the posterior aspect of the left
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Abstract: Background. Coronary sinus (CS) anatomy is a major predictor of successful implantation of left ventricular (LV) lead
and procedural outcome. We therefore made an attempt to look at the
CS anatomy and possible feasibility to classify them into categories depending upon their size, branching pattern, location of posterolateral
vein (PLV), and other parameters in order to guide the cardiologist for
successful cannulation of the CS and LV lead implantation. Methods.
We analyzed the levophase angiograms of patients (n = 100) undergoing routine coronary angiography in the right anterior oblique view.
We have made an attempt to classify these observations on the basis
of predetermined parameters and a working classification was brought
out for the ease of the operator and to predict the bottlenecks of the
procedure. Observations. On the basis of predetermined parameters,
venograms obtained from 100 patients were analyzed and findings
were divided into three groups depending upon the ease of cannulation of posterolateral vein for LV lead placement. These 3 groups were
further classified as type I, type II, and type III coronary sinuses. Conclusions. This observational study proposes a new anatomical working
classification for CS for purposes of successful LV lead placement and
optimal operative success.
J INVASIVE CARDIOL 2014;26(2):71-74
Key words: coronary sinus,
cardiac resynchronization therapy, angiography
The coronary venous system is increasingly used for biventricular pacing in patients with chronic refractory heart failure.
The present study investigated the structure of the coronary
veins, and assessed the availability of veins for possible left ventricular (LV) lead placement. A further attempt to classify the
coronary venous anatomy on the basis of successful left ventricular lead implantation was made.
Background. The coronary venous system is used for various
electrophysiological purposes. Cardiac resynchronization therapy
(CRT) incorporating an LV lead may profoundly improve the
condition of patients with severe heart failure.1,2 The coronary
venous system has also been used for various electrophysiological procedures, eg, arrhythmia ablation,3 electroanatomical mapping,4 and implantation of various cardiac devices.5-7
Historically, cardiac vascular studies have focused mainly
on the coronary artery circulation. The advent of advanced invasive and interventional cardiac treatment and management
From the Department of Cardiology, Institute of Cardiology, JLN Medical College
& Associated Group of Hospitals, Ajmer, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest
regarding the content herein.
Manuscript submitted July 1, 2013, provisional acceptance given August 1, 2013,
final version accepted August 6, 2013.
Address for correspondence: Devendra Singh Bisht, MD, DM, Postgraduate Department of Cardiology, JLN Medical College & Associated Group of Hospitals, Ajmer
305 001, Rajasthan (India). Email: [email protected]
Vol. 26, No. 2, February 2014
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GOKHROO, et al.
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Figure 1. Hypothetical representation of three types of coronary sinus in right anterior oblique view depending upon predefined parameters and
angiographic findings of patients analyzed.
PLV); and (9) other findings
such as valves, CS diverticula,
muscle sleeves in CS, and obstructed CS.
Since the sole purpose of
the present study was to assess
the potential availability and
ease of cannulation of posterolateral veins for placement of
LV lead of CRT device, predetermined parameters were
chosen keeping the above fact
Figure 2. Coronary venogram analysis in right anterior oblique view from three patients showing 3 types of coro- in mind.
nary sinus. Venograms show that LV lead placement is easiest in type I and most difficult in type III coronary sinus.
Observations. On the basis of predetermined paramatrium and is formed by the junction of the great cardiac vein eters, venograms obtained from 100 patients were analyzed and
and the posterolateral vein.18 The right atrium and the posterior findings were divided into three groups (Table 1) depending
and posterolateral portions of the right ventricle are drained by upon the ease of cannulation of posterolateral vein for LV lead
the small cardiac vein into the CS at the ostium of the right placement. These 3 groups were further classified as type I, type
atrium. The smaller cardiac venous system is the Thebesian ve- II, or type III coronary sinuses (Figures 1 and 2). Our working
nous network. This system is responsible for draining the inner experience suggests that type I coronary sinus has the easiest
layers of the myocardium of the right ventricular venous system cannulation rate, whereas type III is the most difficult.
and portions of the interventricular septum directly into the
right ventricle via orifices that are often 0.5 mm in diameter.
Discussion
Venogram analysis. Four experienced cardiologists anaThe high degree of variability in coronary venous anatomy
lyzed the venogram under the following predetermined param- makes it important to have a uniform segmental classification
eters: (1)diameter of CS ostium; (2) diameter of posterolateral system for cannulating these vessels. It will be helpful for the
vein; (3)mean diameter of CS before posterolateral vein; (4) electrophysiologist to classify coronary sinus tributaries by their
number of lateral vein branches; (5) tortuosity of coronary ve- epicardial location in addition to their anatomic classification.
nous system between optimal lead implantation site (usually
Further approaches to epicardial lead placement may inPLV) and CS ostium; angle between axis of body of CS and hori- volve a non-invasive definition of the coronary venous anatozontal plane passing through the ostium of the CS; (7) tortuosity my prior to procedure, followed by more selective angiographic
of the vein that is the ideal site for lead implantation (usually techniques to enable better definition of the coronary venous
PLV); (8) distance between the CS ostium and the ostium of anatomy for LV lead placement. Recognition of the venous
the vein that is the ideal site for implantation of LV lead (usually tributaries in terms of their distribution, angulation, tortuosity,
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The Journal of Invasive Cardiology®
Coronary Sinus Anatomy: Ajmer Working Group Classification
Table 1. Findings on venogram analysis.
Parameters (n = 100)
Type I
Type II
Size of ostium
>10 mm (30%)
5-10 mm (63%)
<5 mm (7%)
Mean size of CS before PLV
>10 mm (8%)
5-10 mm (67%)
<5 mm (25%)
Mean size of PLV
>4 mm (7%)
2-4 mm (53%)
<2 mm (40%)
Ratio of mean CS size/PLV size
<2 (40%)
2-4 (53%)
>4 (7%)
Total number of lateral branches
>2 (27%)
2 (39%)
<2 (34%)
Total number of veins between anterior
interventricular vein and middle
cardiac vein
>2 (52%)
2 (36%)
<2 (12%)
2 curves <75° or
1 curve >75°(68%)
2 curves >75° (31%)
3 curves >75° (1%)
Angle between axis of body of CS and
horizontal plane passing through the
ostium of the CS
<45° (28%)
45°-90° (66%)
>90° (6%)
Tortuosity of the vein that is the ideal
site for lead implantation
Absent/<2 curves (65%)
2 curves (30%)
>2 curves (5%)
<10 mm (0%)
11-40 mm (71%)
>40 mm (29%)
no valves (51%)
valves in the anterior/middle
or posterior veins (22%)
Thebesian valve and
valve of Vieussens (27%)
separate opening of the
posterior vein and middle
cardiac vein (67%)
common opening of posterior
vein and middle cardiac vein
(33%)
obstructed CS (3%)
muscle Sleeve in CS (33%)
CS diverticula (0%)
Tortuosity between optimal lead
implantation site and CS ostium
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Distance between the CS ostium and the
ostium of the vein that is the ideal site
for implantation of LV lead
Other findings
Type III
Values in parentheses signify the number or percentage of patients having the same observation. It is evident that type II is the most common among the patients
studied. CS = coronary sinus; PLV = posterolateral vein.
and dimensions will enable the development of lead positioning tailored to each individual patient.
We therefore proposed a new anatomical working classification for CS for purposes of successful LV lead placement and
optimal operative success (Table 1).
The venous drainage of the left ventricle is variable and typically gives multiple options for the implanter.19,20 The posterolateral vein is the ideal vein to attempt cannulation because it
drains the free wall of the left ventricle; however, in cases of difficult CS anatomy, lateral tributaries of anterior interventricular
vein, posterior ventricular vein, or middle cardiac veins can be
used to pace the LV free wall.21
The MCV can be specifically targeted for placing an LV
lead.21 Although the MCV lies in the posterior interventricular
septum, various branches/tributaries drain the lateral wall toward
this vein. Being perpendicular to the main access of the CS, cannulation is not straightforward. Once entered, the pacing lead
can then be placed in this vein and carefully maneuvered to the
LV free wall.22-24 Often, the posterior vein can be cannulated.
Sometimes, a common ostium for the posterior and MCV
occurs and may need specific cannulation either for placement of pacing leads or ablation of posterior epicardial accessory pathways.21
Sixty-four slice or dual-source computed tomography may
be a valuable tool to evaluate coronary venous anatomy prior
to invasive procedures. Performing multidetector computed
Vol. 26, No. 2, February 2014
tomography (MDCT) has been recommended to non-invasively evaluate the coronary vein map before attempting
biventricular pacemaker implantation.25 The venous diameters, courses, and relationships to other cardiac structures
may be examined in detail using multiplanar reconstructions and volume-rendering technique images. The main
problem encountered during evaluation of coronary venous
system using electrocardiographic-gated MDCT is to select
the optimal phase for reconstruction.26,27 Further imaging
of the coronary venous system using routine coronary CT
angiography protocol may not always be feasible in heart
failure patients due to heightened heart rate, various cardiac arrhythmias, and an inability to hold breath because
of respiratory symptoms. It is also possible to evaluate the
coronary venous system using electron-beam CT. However,
many patients may not be adequately assessed by this modality because of suboptimal image quality and not all parts of
the heart come under examination.28,29
Study limitations. The transverse diameter of the epicardial veins remains constant during systole and diastole, with
flow occurring as a bolus during each cardiac cycle. Therefore,
uniform opacification of the entire cardiac venous system including tributaries is difficult with a single bolus of contrast
delivered at the proximal end.30 Further single-frame analysis
of coronary angiogram doesn’t provide sufficient information
about coronary sinus anatomy.
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GOKHROO, et al.
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Conclusion
The presence, diameter, angulation, and tortuosity of coronary veins determine their acceptability for the placement of
an LV lead in a predetermined location. Despite the considerable variability of the coronary venous system among patients,
a lateral vein for lead implantation is available in the majority
of patients. Furthermore, this classification system attempts not
to supplant, but rather adds information to the conventional
coronary venous anatomy, which is of particular relevance to
the electrophysiologist.
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We did not perform conventional balloon occlusion venography31 because this may lead to raised backpressure, which
may cause distension of the venous system and values may get
overestimated. Furthermore, unlike anterograde coronary arteriography, balloon occlusion coronary venography is often limited by the vigorous backwash of the injected contrast, which
impairs the ability to define the detailed anatomy of the tributaries and collateral circulation.
We analyzed the angiograms in only the right anterior
oblique view to avoid excessive contrast and radiation exposure,
whereas coronary venous angiography should be performed in
at least two different views with the necessary caudal or cranial
angulations to separate the branches and display the course of
the main branches, which is key to the segmental approach. We
know that a left anterior oblique view is necessary to perfectly
define the lateral position of a CS vein.
All of our patients are not suffering from cardiomyopathy,
whereas patients receiving cardiac resynchronization therapy
devices have an underlying cardiomyopathy and may have had
extensive remodeling and rotation of the heart. Hence, subselective angiography of the main branches is often important
to clearly define the pattern of distribution of the second- and
third-order tributaries for optimal lead placement.
We have classified coronary sinus into three categories, but
an individual CS could have characteristics of all three types, eg,
a type I ostium, a type II mean size of the PLV, and a type III
number of lateral branches, etc.
The success rate for placement of a transvenous cardiac resynchronization system has ranged from approximately 88% to
92% in clinical trials.32 We do not consider type III coronary
sinus to be a contraindication to device implantation; however;
we consider that in type III coronary sinus, the technique of the
procedure is challenging and cannulation of the coronary sinus
and subsequent manipulation within its tributaries remain difficult despite substantial improvements in hardwares. Dissection of the coronary sinus is one of the major complications of
type III coronary sinus, especially for the beginner operators.
Currently, the data from our center to justify this hypothesis are
limited and further research is needed for validation.
The Journal of Invasive Cardiology®