Cardiac venous system

CARDIAC VENOUS SYSTEM

1. SURGICAL ANATOMY OF VENOUS SYSTEM OF HEART CORONARY SINUS,LSVC By- Dr.Jyotindra Singh NIMS,HYDERABAD

2. PLAN INTRODUCTION EMBRYOLOGY VENOUS ANATOMY SURGICAL IMPLICATIONS CORONARY SINUS LSVC RECENT UPDATES TAKE HOME MESSAGE

3. Umbilical Vitelline The Developing Venous System Sinus Venosus Cardinal

4. Umbilical Vitelline The Developing Venous System Sinus Venosus Cardinal Subcardinal Supra cardinal Supra-Subcardinal Anastomosis

5. EMBRYOLOGY Formed 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

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

7. 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

8. . VENOUS ANATOMY CORONARY SINUS ANTERIOR CARDIAC VEINS VENAE CORDIS MINIMI

9. . 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

10. 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 arch Ascending aorta Brachiocephalic veins Brachiocephalic trunk Lt. common carotid A. Lt. subclavian A.

11. Inferior vena cava Rt. Coronary A Posterior interventricular A. Middle cardiac vein Posterior cardiac vein Coronary sinus Lt. pulmonary vein Left ventricle Right ventricle

12. Overview of venous drainage

13. 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

14. . 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

15. GREAT CARDIAC VEIN Introducing 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

16. 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,

17. 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

18. Interatrial septum

19. Opening of IVC

20. . a TRIANGLE OF KOCH CORONARY 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.

21. . 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.

22. 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 ,

23. 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.

24. 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

25. 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.

26. 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.

27. ROOFING THE CORONARY SINUS

28. 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

29. 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

30. LSVC PLSVC, 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 .

31. 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  

32. Questions to be asked Is there a right superior vena cava? Is the Inno m inate vein   present Is the PLSVC associated with any other cardiac m alfor m ations?   Where does the PLSVC drain? And does the surgery involve the   right atriu m ?

33. LSVC CONNECTIONS LEFT ATRIUM CORONARY SINUS WITH OSTIAL ATRESIA WITHOUT OSTIAL ATRESIA - INTACT CORONARY SINUS - UNROOFED CORONARY SINUS - COMPLETE UNROOFING - PARTIAL UNROOFING

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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.

43. 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.

44. RECENT ADVANCES Clinical 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 .

45. Take home message Indications 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.

46. Eyes see what the mind knows!!