Cardiac venous system

SURGICAL ANATOMY OF VENOUS SYSTEM OF HEART

CORONARY SINUS,LSVC

By- Dr.Jyotindra Singh

NIMS,HYDERABAD

PLANINTRODUCTION

EMBRYOLOGY

VENOUS ANATOMY

SURGICAL IMPLICATIONS

CORONARY SINUS

LSVC

RECENT UPDATES

TAKE HOME MESSAGE

Umbilical

Vitelline

The Developing Venous System

SinusVenosus

Cardinal

Umbilical

Vitelline

The Developing Venous System

SinusVenosus

Cardinal

Subcardinal

Supra cardinal

Supra-SubcardinalAnastomosis

EMBRYOLOGYFormed by vasculogenesis.

3 vital systemic venous drainage - VITELLINE/ UMBILICAL/ CARDINAL

SINUS VENOSUS - RIGHT AND LEFT HORNS - Provide bilateral connection

The connection of 3 veins on left side regress- CORONARY SINUS

When sinus venosus fail to regress- Persistent left superior vena cava

Remodeling of Abdominal Venous System Occurs through Obliteration of the Left Supracardinal Vein

Failure of Left Cardinal Veins to Undergo Normal Regression Leads to Venous Anomalies

LSVC occurs in 0.3% to 0.5% of the normal population

In 65% of cases, left brachiocephalic vein is also missing

4% of patients with CHD have an LSVC

Usually drains to the coronary sinus

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VENOUS ANATOMY

CORONARY SINUS

ANTERIOR CARDIAC VEINS

VENAE CORDIS MINIMI

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TRIBUTARIES TO CORONARY SINUS

1. The Great Cardiac Vein (v. cordis magna; left coronary vein)

2. The Small Cardiac Vein (v. cordis parva; right coronary vein)   

 3. The Middle Cardiac Vein (v. cordis media)

 4. The Posterior Vein of the Left Ventricle (v. ventriculi sinistri)

 5. The Oblique Vein of the Left Atrium(oblique vein of Marshall)

6. The Right Marginal vein

Ligamentum arteriosum

Pulmonary trunk

Left pulmonary artery

Left pulmonary veins

Left coronary artery

Circumflex artery

Great cardiac vein

Anterior interventricular (left anterior descending) artery

Superior vena cava

Right coronary artery

Marginal artery

Small cardiac vein

Aortic archAscending aorta

Brachiocephalic veinsBrachiocephalic trunk Lt. common carotid A.

Lt. subclavian A.

Inferior vena cava

Rt. Coronary A

Posterior interventricular A.

Middle cardiac vein

Posterior cardiac vein

Coronary sinus

Lt. pulmonary vein

Left ventricle

Right ventricle

Overview of venous drainage

GREAT CARDIAC VEIN The GCV curves to the left as it leaves the anterior interventricular groove, to form the base of the triangle of

‘‘ Brocq and Mouchet ”

Left anterior descending and the left circumflex arteries form other sides.

GCV related internally to the anterolateral commissure of the mitral valve.

The latter part lay in close relationship to the left circumflex artery

After crossing the left circumflex artery, the great cardiac vein ended at the Vieussens valve and continued as the coronary sinus

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GREAT CARDIAC VEIN

 Patent SVGs and a patent LIMA to the 1st diagonal branch of the LAD.

Inadvertent insertion of the LIMA skip graft into the Great cardiac vein, instead of the distal LAD

GREAT CARDIAC VEINIntroducing the cardioplegic solution via the coronary sinus will not perfuse the entire left side of the heart.

Post operatively there will be some myocardial dysfunction due to non perfusion of the area drained by Great cardiac vein.

Since the opening of the great cardiac vein in the right atrium is very close to the interatrial septum it may be mistaken as an atrial septal defect during cardiac catheterization

Selective arterialization of coronary venous system

CVBG – Therapeutic option in patients with diffuse coronary artery disease.

Arterial blood can perform retrograde perfusion through it and nourish ischemic myocardium.

It helps to ensure sufficient blood flow, reduced thrombosis and improved graft patency.

Another reason to select middle cardiac vein for arterialization was that left coronary artery trunk or its branches may lie on the surface of great cardiac vein for nearly 50% patients.

It means that, when coronary atherosclerosis happens, great cardiac vein may be oppressed by sclerotic left coronary artery trunk or its branches,

THEBESIAN VENOUS SYSTEM

In the absence of both LSVC and a Coronary sinus ostium in the left atrium, drainage occurs through enlarged Thebesian veins.

Also, when hypoplastic cardiac veins fail t o join t h e coronary sinus, they empty individually into the atrial chambers through dilated Thebesian channels

Interatrial septum

Opening of IVC

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a

TRIANGLE OF KOCHCORONARY SINUS DILATATION

1. Cardiac arrhythmia due to stretching of the

atrioventricular node and bundle of His.

2. Obstruction of the left atrioventricular flow

because of partial occlusion of the mitral valve.

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CORONARY SINUS

The coronary sinus is defined as the blood conduit that is a continuation of the great cardiac vein from the valve of the great cardiac vein to the ostium of the coronary sinus.

The length varies from 3 to 5.5 cm. CS lies in the sulcus between the left atrium and ventricle

Begins proximally at the right atrial orifice and ends distally at the valve of Vieussen's.

The CS receives blood from the ventricular veins during ventricular systole and empties into the right atrium during atrial systole.

The wall of the CS is made up of striated myocardium that is continuous with the atria, forming a myocardial sleeve around the venous system

The Thebesian valve is a crescent shaped structure often found guarding the mouth of the CS as it opens to the right atrium.

THEBESIAN VALVE

(1) absent, 14.7%; (2) small and crescentric, 38%; (3) large and covering the entire orifice of the coronary sinus, 30.7%; (4) bars and bands, 5.3%; (5) threads and networks, 5.3%; (6) common Eustachian and Thebesian valves,

RETROGRADE CARDIOPLEGIA(1) the provision of a relatively uniform distribution of cardioplegia even in the presence of severe coronary artery  disease

2) it is effective in the presence of aortic regurgitation 

(3) Redo – CABG antegrade cardioplegia is associated with a high risk of atheromatous embolization from patent grafts

(4) RCP may be an effective method for treating coronary air embolism 

(5) it can be given without interrupting the surgical procedure.

Coronary Sinus ANOMALIES An Absent coronary sinus is always associated with a persistent left superior vena cava (PLSVC) connecting to the left atrium.

A Hypoplastic coronary sinus occurs when one or more of the cardiac veins drain directly into the atria.

Atresia or stenosis of the coronary sinus ostium may occur alone or with associated cardiac anomalies

Enlargement of the coronary sinus can be divided into two groups

- with left to right shunt

- without left to right shunt

Unroofed coronary sinus anomaly

CORONARY SINUS ASD Located – posteriorly and inferiorly in the interatrial septum.

INTERATRIAL SEPTAL TISSUE – separates AV valve annulus.

May be associated SECUNDUM ASD.

CLEFT MITRAL VALVE- confluent PRIMUM ASD

PULMONARY VEINS – enter left atrium more superiorly than usual – when LSVC present with coronary sinus ASD.

Left to right or right to left shunt depending on relative ventricular compliance/ right atrial pressure.

Unroofed coronary sinus ASD in the adult -2D and 3D Echo - YouTube.flv

Figure 1. Transesophageal echocardiography revealed both atrial and right ventricular enlargement (left), a defect of the partial coronary sinus (middle), and shunt of the left atrium

to the dilated coronary sinus (right) at the near longitudinal plane.

ROOFING THE CORONARY SINUS

REPAIR OF CORONARY SINUS ASD Goal – separate systemic & pulmonary return

- eliminate shunting at atrial level

Caution – close to conduction system and pulmonary veins.

ROOFING PROCEDURE - BICAVAL VENOUS CANNULATION

- STANDARD RIGHT ATRIOTOMY

IF ATRIAL SEPTUM INTACT- FOSSA OVALIS IS INCISED

UNROOFED CS- MEDIAL TO PULMONARY VEINS

PERICARDIAL PATCH USED TO COVER THE DEFECT

ATRIAL SEPTUM REPAIRED EITHER PRIMARILY OR WITH SECOND PERICARDIAL PATCH

UNROOFED CORONARY SINUS SYNDROME

LSVC to left atrium with coronary sinus ASD

LSVC to left atrium with COMMON ATRIUM

Complete unroofing without LSVC

Partial unroofing –mid portion without LSVC

Partial unroofing –distal portion ,no LSVC

Partial unroofing –distal portion ,intact

corsinus ostium with coronary sinus ASD

LSVCPLSVC, is a result of a residual left anterior cardinal vein.

It occurs in 0.1% to 0.3% of the general population.

PLSVC is 3% to 8%, and up to 40% when such patients have abnormal situs  

A PLSVC originates from the junction of the left innominate vein and the left jugular vein.

More than 90% of cases of PLSVC drain through a coronary sinus.

The rest drain into the coronary sinus through a window into the left atrium, directly into the left atrium or into the left pulmonary vein .

In 60% of cases, the innominate vein bridges the two superior venae cavae;

In the other 40%, the cavae drain the right and left brachiocephalic regions separately.

If there is no innominate vein the PLSVC must persist; however, the converse is not true.

A PLSVC with an absent right superior vena cava is found in 14% of cases 

Questions to be askedIs there a right superior vena cava?

Is the Innominate vein present

Is the PLSVC associated with any other cardiac malformations? 

Where does the PLSVC drain?

And does the surgery involve the right atrium?

LSVC CONNECTIONS

LEFT ATRIUM

CORONARY SINUS WITH OSTIAL ATRESIA

WITHOUT OSTIAL ATRESIA

- INTACT CORONARY SINUS

- UNROOFED CORONARY SINUS

- COMPLETE UNROOFING

- PARTIAL UNROOFING

LSVC with CS Ostial atresia Physiologically benign

Grave hazard- for cardiac surgeon if not identified

Permanent/temporary occlusion or vigorous manipulation – cause myocardial congestion/ischemia

Patency should be sought – preoperatively/intraop

LSVC TO CS WITHOUT ATRESIA If large left innominate vein is present – tourniquet.

Small/absent innominate vein-

Cardiac catheterisation – occlusion pressure less than 18 mm hg- temporarily occluded.

Third angled venous cannula – cannulated directly

When temporarily occlusion not advisable

Flexible venous cannula retrograde through CS

Use of cardiotomy sucker.

Single right atrial venous cannula + profound hypothermia and total circulatory arrest

LSVC TO LA without CS LSVC can be ligated below innominate vein.

LSVC to RIGHT ATRIUM

- direct implantation

- left atrial tubular flap creation

- right atrial tubular extension

- PTFE graft

limitation – stenosis /occlusion of rerouted LSVC

COMMON ATRIUM Repositioning the ATRIAL SEPTUM

-- Interatrial septum- completely excised

-- autologous pericardium/ prosthetic patch used

Goal – systemic venous orifice lie on right side

- pulmonary venous orifice lie on left side

- optimal baffle placement

Biderectional Cavopulmonary connection

Extracardiac repair

LSVC detached from heart – cardiac end oversewn

LSVC sutured to superior aspect of –

LEFT PULMONARY ARTERY

Avoids complication like-

baffle leaks/baffle stenosis /atrial arrythmia

ATRIAL ISOMERISM When b/l morphologically Right atria present

Lsvc enters the left sided Right atrium

Not an example of Unroofed coronary sinus.

Right isomerism – CS usually absent

Minor venous channel open directly into RA/RV

RAGHIB SYNDROME INCLUDES – LSVC to left atrium

- Absence of coronary sinus

- Low lying ASD

Simple closure – Persistent desaturation

Correction - ASD repair + ligation of LSVC

- Excision of septum primum

- Placement of intra atrial baffle

HEART LUNG TRANSPLANT Recipient LSVC is divided near its entrance into left atrium during recipient cardiectomy

It is sutured end to end to donor left inominate vein

SUPERIOR ROOFING – defect made in interatrial septum

Superior wall of left atrium is used to make left atrial tunnel from LSVC orifice to interatrial defect

Cor Triatriatum Pathogenesis - Impingement of a left superior vena cava on the developing left atrium.

Left and right pulmonary veins may enter the left atrium more superior than usual.

Mild to moderate narrowing- left atrium to which pulmonary veins are attached.

Partially unroofed CS condition can be easily overlooked

suspicious- when no asd or pulmonary vein anomaly seen in RA with documented oxygen step up

Diagnosis – pass a probe in CS orifice

- View defect through separate incision in interatrial septum

FONTAN REPAIR - When it co exists with tricuspid atresia – marked RIGHT to left shunt that incorporates coronary sinus into systemic venous pathway.

RECENT ADVANCESClinical trials investigating treatment with angiogenesis factors and gene therapy have been

goin on

New devices for creating cardiac arteriovenous fistulas percutaneously have been deviced

Radionuclide cardioangiography.

Three different systems of percutaneous mitral annuloplasty are currently under evaluation: the Edwards Monarc system, the Carillon Mitral Contour System and the PTMA implant system.

They are inserted into the coronary sinus and the great cardiac vein and all

work on the same principle: they shrink the mitral annulus, increasing leaflet coaptation and thus reducing the regurgitation .

Take home messageIndications of selective CVBG include the patients with tenuous right coronary artery or with diffuse lesions. It is fit for the patients who need secondary CABG operation.

Partially unroofed coronary sinus should not be over looked

Close relation between LAD and GCV should be kept in mind.

Eyes see what the mind knows!!

Blood supply of the heart - YouTube.flv