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FOCUS ISSUE: CARDIAC IMAGING: CLINICAL RESEARCH

In Vivo Analysis of the Anatomical Relationship of Coronary Sinus to Mitral Annulus and Left Circumflex Coronary Artery Using Cardiac Multidetector Computed Tomography

Implications for Percutaneous Coronary Sinus Mitral Annuloplasty

Arti J. Choure, MD^_*, Mario J. Garcia, MD, FACC^_*, Barbara Hesse, MD^_*, Matthew Sevensma, DO^_*, George Maly, MD, Neil L. Greenberg, PhD^_*, Lynn Borzi, RN, MBA^_*, Stephen Ellis, MD, FACC^_*, E. Murat Tuzcu, MD, FACC^_* and Samir R. Kapadia, MD, FACC^_*,,_*

^_* Cardiovascular Medicine
Radiology, Cleveland Clinic, Cleveland, Ohio

Manuscript received January 30, 2006; revised manuscript received June 13, 2006, accepted July 3, 2006.

^_* Reprint requests and correspondence: Dr. Samir Kapadia, Department of Cardiovascular Medicine, Associate Professor of Medicine, Cleveland Clinic, 9500 Euclid Avenue/F25, Cleveland, Ohio 44195 (Email: kapadis{at}ccf.org).

OBJECTIVES: We sought to determine the in vivo anatomical relationships between mitral annulus (MA) and coronary sinus (CS) as well as CS and left circumflex coronary artery using cardiac computed tomography.

BACKGROUND: Percutaneous treatment of mitral regurgitation (MR) by annuloplasty via CS is under development. Success of such treatment depends on the close anatomical proximity of the MA to the CS. The in vivo data regarding this anatomical relationship in humans are scant. We investigated this relationship using contrast multidetector computed tomography.

METHODS: We studied 25 normal individuals and 11 patients with severe MR (3 to 4+) due to mitral valve prolapse. Separation between MA and CS was measured in standard planes, in 4-chamber (4C), 2-chamber (2C), and 3-chamber views. Distance from ostium of CS to the intersection with left circumflex (LCX), and anatomical relation of LCX and CS were determined using 3-dimensional mapping (Philips Brilliance, Philips Medical Systems, Amsterdam, the Netherlands).

RESULTS: There was significant variance of CS to MA separation at all planes. Separation of CS and MA was increased in lateral location (4C) and decreased in posterior location (2C) in the MR group with increase in MA size. Left circumflex artery crossed between CS and MA in 80% of patients. The LCX crossed CS at a variable distance from the ostium of CS (86.5 ± 21 mm, range 37 to 123 mm)

CONCLUSIONS: There is significant variability in the relation of CS to MA in humans. Coronary sinus to MA distance increases in patients with severe MR and annular dilation, mainly in the posterolateral location. The left circumflex crosses under the CS the majority of times, but with a significant variability in the location where it crosses the CS. These anatomical features should be taken into consideration while selecting percutaneous treatment strategies for mitral valve repair.

Abbreviations and Acronyms   CS = coronary sinus   CT = computed tomography   LCX = left circumflex coronary artery   MA = mitral annulus   MDCT = multidetector computed tomography   MR = mitral regurgitation   MVP = mitral valve prolapse   MVR = mitral valve repair   2C = 2 chamber   3C = 3 chamber   4C = 4 chamber

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