The Coronary Venous Anatomy
A Segmental Approach to Aid Cardiac Resynchronization Therapy
Jagmeet P. Singh, MD, PhD*,*,
Stuart Houser, MD ,
E. Kevin Heist, MD, PhD* and
Jeremy N. Ruskin, MD*
* Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Cardiac Pathology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
View larger version (165K):
[in a new window]
|
Figure 1 Coronary sinus angiogram of a cadaveric human heart. This heart is splayed out in an anterior view to show the entire length of the atrioventricular venous ring on the left side of the heart. The dotted lines depict the near-equal segmental divisions along the horizontal (short) axis. The horizontal line extends from the coronary sinus ostium (origin of MV) to the point where the AV terminates into the great cardiac vein. Each of the segments are defined as follows: A = anterior segment; B = lateral segment; C = posterior segment. The segment refers to the region under the respective letters A, B, and C. Conventional branches are labeled as follows: AV = anterior interventricular vein; LV = lateral marginal vein; PV = posterior cardiac vein; MV = middle cardiac vein. This figure highlights the second- and third-order tributaries and collateral circulation.
|
|
View larger version (167K):
[in a new window]
|
Figure 2 Coronary sinus angiogram of a cadaveric human heart. This is a vertical-axis (longitudinal) look at the heart. The dotted lines depict the segmentation of the heart into three equal parts, i.e., the basal, mid, and apical regions. This is a lateral view showing the area between the lateral marginal vein (LV) and the anterior interventricular vein (AV).
|
|
View larger version (147K):
[in a new window]
|
Figure 3 Coronary sinus angiogram in a patient with ischemic cardiomyopathy (right anterior oblique 30° view). This angiogram highlights lateral segmental branch and the multiple second-order tributaries originating in the basal (B), mid (M), and apical (A) regions, coursing in the anterior (apical branch) and posterior direction (i.e., branches from the basal and mid-region). LV = lateral marginal vein; GV = great cardiac vein; AV = anterior interventricular vein.
|
|
View larger version (130K):
[in a new window]
|
Figure 4 Volume computed tomography image of the coronary veins in a cadaveric heart. Double balloon occlusive venography was performed to isolate the lateral segment of the coronary venous tree. The lateral vein (LV) and its tributaries can be seen in great detail. 1 = the LV, which is the first-order tributary; 2 = second-order tributary; 3 = third-order tributary.
|
|
View larger version (122K):
[in a new window]
|
Figure 5 Rotational venous angiogram, with still frames in anteroposterior (A) and left anterior oblique 30° (B). PV = posterior vein; MV = middle cardiac vein; GV = great cardiac vein; AV, anterior cardiac vein. Alongside are three-dimensional reconstructed images of the coronary venous tree, facilitating segmental visualization of the coronary venous anatomy. The coronary venous ring is divisible into three segments: posterior (C), lateral (B), and anterior (A), in both views. (B) The mid-ventricular position of a lateral segmental branch (1), closely corresponding to the second-order lateral tributary from an anterior segmental branch, extending over the mid-ventricular region (2).
|
|
View larger version (145K):
[in a new window]
|
Figure 6 Standard multidetector computed tomography angiogram (Brilliance 16P scanner) delineating the coronary venous branches in close proximity to the coronary arteries. No appreciable posterior or posterolateral vein. The lateral marginal vein seems to be diminutive. Conventional branches are labeled as follows: LV = lateral marginal vein; MV = middle cardiac vein; CS = coronary sinus; PDA = posterior descending coronary artery.
|
|
|
