MORPHOLOGICAL STUDY OF CORONARY SINUS IN HUMAN CADAVERIC HEARTS

(1)

Int J Anat Res 2015, 3(3):1415-18. ISSN 2321-4287 1415 Original Article

M ORPHOLOGICAL STUDY OF CORONARY SINUS IN HUM AN

CADAVERIC HEARTS

R. M anoranjitham *

1

_{, R. Shalini}

2

_{, Suresh R. Gosai}

3

_{, C. Ravi Varman}

4

_.

ABSTRACT

Address for Correspondence: Dr. R. M anoranjit ham, M S (Anat omy), Professor, Depart ment of Anat omy, Dhanalakshmi Srinivasan M edical College and Hospital, Siruvachur, Perambalur, Tamil nadu- 621212. E-M ail: liniram80@yahoo.com

Background: The cor onar y sinus is a dilat ed venous channel opening int o t he right at rium of t he heart . The cor onary venous syst em has gained im por t ance in r ecent years f or elect r ophysiological procedures lik e arr hyt hm ia ablat ion, bivent ricular pacing and im plant at ion of cardiac pacem akers. The present st udy aim s t o st udy t he for m at ion and t ribut ar ies of coronar y sinus and also t he m or phology of t hebesian valve.

M aterials and M et hods: 30 for m al in f ixed cad aver ic hear t s avai l able i n t he depar t m ent o f Anat om y, Dhanalakshm i Srinivasan M edical College and Hospit al, Peram balur, Tam il nadu, w as used for t he st udy. The form at ion and t r ibut aries of cor onary sinus w ere not ed. The lengt h of coronary sinus in m illim et er s w as m easured from t he union of great car diac vein and left m arginal vein upt o t he opening of t he coronary sinus in t he right at r ium w it h vernier caliper s. The w idt h of t he coronary ost ium in t he r ight at rium w as m easured in m illim et ers w it h vernier calipers.

Results: In 93.33% specim ens t he coronar y sinus w as f orm ed by t he union of gr eat cardiac vein and left m ar ginal vein. In 3.33% specim ens it w as form ed by t he union of great car diac vein and post erior vein of left vent ricle, and in 3.33% specim ens it w as form ed by t he union of gr eat cardiac vein and oblique vein of left at r ium . The left m arginal vein w as absent in 2 specim ens and sm all cardiac vein w as absent in 1 specim en. The m ean lengt h of cor onary sinus w as 54.98 + 12.2m m . The m ean w idt h of coronary sinus ost ium w as 9.35 + 3.24m m . The Thebesian valve w as present in 93.33% specim ens and it w as sem ilunar in shape.

Conclusion: The know ledge of coronary sinus anat om y w ill be helpful dur ing elect rophysiological procedur es.

KEY W ORDS: Coronary Sinus, Cardiac Veins, Thebesian Valve, Coronary Ost ium , Elect rophysiological Procedures.

INTRODUCTION

Int ernat ional Journal of Anatomy and Research, Int J Anat Res 2015, Vol 3(3):1415-18. ISSN 2321- 4287 DOI: ht t p:/ / dx.doi.org/10.16965/ ijar.2015.250

Access this Article online

Quick Response code Web site:

Received: 24 Aug 2015 Accept ed: 14 Sep 2015 Peer Review : 24 Aug 2015 Published (O): 30 Sep 2015 Revised: None Published (P): 30 Sep 2015

Int ernat ional Journal of Anat omy and Research ISSN 2321-4287

ww w.ijmhr.org/ ijar.htm

DOI: 10.16965/ ijar.2015.250

* 1 _{Professor, Depart ment of Anat omy, Dhanalakshmi Srinivasan M edical College and Hospital, Tamil}

nadu, India.

2_{Assist ant Professor, Depart ment of Anat omy, Dhanalakshm i Srinivasan M edical College and}

Hospital, Tamil nadu, India.

3_{Professor & Head, Depart ment of Anat omy, Dhanalakshmi Srinivasan M edical College and Hospital,}

Tamil nadu, India.

4_{M DS (Conservat ive Dent ist ry and Endodont ics), Adhiparasakt hi M elmaruvat hur Dent al college,}

M elmaruvat hur, Tamil nadu, India.

except for t he ant erior region of right vent ricle and small variable part s of bot h at ria and t he left vent ricle. The coronary sinus is 2 or 3 cm The coronary sinus and it s t ribut aries ret urn

(2)

Int J Anat Res 2015, 3(3):1415-18. ISSN 2321-4287 1416

R. M anoranjit ham et al. M ORPHOLOGICAL STUDY OF CORONARY SINUS IN HUM AN CADAVERIC HEARTS.

M ATERIALS AND M ETHODS

l on g an d li es in t he p ost er i o r par t o f t h e at riovent r icular groove. The coronar y sinus opens int o the right at rium betw een the opening of IVC and t he right at riovent ricular orifice. The opening is guarded by an endocardial f old-Thebesian valve. The t ribut aries of coronary sinus are – great , small and middle cardiac veins, post erior vein of left vent ricle and oblique vein of left at rium [1].

M any st udies have focused mainly on coronary art eries. Wit h t he advent of many invasive and in t er v en t i on al car diac pr oced ur es f or t he m anagem ent of cardiac ai lm ent s li ke heart f ailur e, ar r hyt hm ias, t he under st anding of coronary sinus anat omy is import ant [2,3]. The coronary venous syst em is import ant in many elect r o p hy si ol o gi cal p r o ced ur es i n cl ud in g arrhyt hmia ablat ion, bivent ricular pacing and for deployment of an array of cardiac devices like pacemakers [4,5,6].

There are anat omic variat ions of t he orifice of t he hum an cor onar y sinus. It has pract ical significance since t he advent of cat het erizat ion o f t h e co r on ar y si nu s. Th e di f f icu l t i es encount ered in t he cat het erizat ion of coronary sinus are probably due t o obst ruct ion offered by large membranes, bars and net w orks [7].

Hence t he present st udy aim s t o st udy t he format ion and t ribut aries of coronary sinus. The lengt h of coronary sinus and w idt h of coronary sinus at it s t erminat ion int o right at rium w ere measured. The morphology of Thebesian valve w as also st udied.

This st udy w as conduct ed in 30 formalin fixed h u m an cad aver i c h ear t s av ai lab l e i n t h e d epar t m en t o f An at o m y, Dh an al ak sh m i Sr i n i vasan M edi cal Co ll ege an d Ho sp i t al , Perambalur, Tamil nadu.

The right at rium w as opened by dissect ion t o st udy t he opening of t he coronary sinus. The w idt h of the coronary sinus orifice in right at rium w as m easu r ed u si n g Ver ni er Cal ip er s i n m i ll i m et er s. The p r esence an d sh ap e o f t hebesian valve w ere not ed. The coronary sinus orifice w as examined for t he presence of any ridges, net w orks or membranes.

The lengt h of coronary sinus was measured wit h

vernier calipers from t he point w here t he great cardiac vein and left marginal vein opened int o t he cor o n ar y si n u s i n t h e l ef t p o st er io r at riovent ricular groove upt o t he opening of coronary sinus in right at rium in millimet ers.

All t he t ribut aries of coronary sinus w ere t raced by dissect ion. The veins forming t he coronary si nu s w er e n o t ed . An y v ar i at i o n s i n t h e format ion and t ribut aries of coronary sinus w ere n ot ed. Al l t he par am et er s w er e car ef u ll y t abulat ed and st at ist ically analysed by Epi Info version 3.4.3.

RESULTS

Formation of coronary sinus: In 28 specimens t he coronary sinus w as formed by t he union of great cardiac vein w it h left marginal vein. In one specimen it w as formed by t he union of great cardiac vein and post erior vein of left vent ricle and in anot her specimen, it w as formed by union of great cardiac vein and oblique vein of left at rium (Table 1).

Table 1: Form at ion of coronary sinus.

S.no. Veins forming coronary sinus

No. of specimens

Percentage of specimens

1 Great cardiac vein w ith

left marginal vein 28 93.33%

3

Great cardiac vein w ith oblique vein of left

atrium

1 3.33%

2

Great cardiac vein w ith posterior vein of left

ventricle

1 3.33%

Tributaries of coronary sinus: Left marginal vein w as absent in 2 specim ens and small cardiac vein was absent in 1 specimen (Table 2).

Table 2: Tri butar ies of coronar y sinus.

S.no. Tributaries of coronary sinus

Present in number of specimens

Absent in number of specimens

1 Great cardiac vein 30 0

2 Left marginal vein 28 2

3 Posterior vein of left

ventricle 30 0

4 Oblique vein of left

atrium 30 0

5 M iddle cardiac vein 30 0

(3)

Length of coronary sinus:

Table 3: Lengt h of coronar y sinus in m illim et ers.

1

Great cardiac vein w ith left marginal vein (28 specimens)

54.98 + 12.2

2

Great cardiac vein w ith posterior vein of left

ventricle (1 specimen)

53.06

3

Great cardiac vein w ith oblique vein of left atrium

(1 specimen)

34.52

Length of coronary sinus in millimeters M ean

+ standard deviation S.no. Formation of coronary sinus

Valve of coronary sinus:

Table 4: Valve of coronar y sinus.

Valve of coronary sinus –present

Valve of coronary sinus – absent

28 specimens (93.33%)

2 specimens (6.66%)

M orphology of thebesian valve: The t hebesian valve w as semilunar in all t he 28 specimens in w hich t he valve w as present . In one specimen, a net w ork of fibres w as found in t he ost ium of coronary sinus.

Fig. 1: Int erior of right at rium - A- Coronary sinus ost ium show ing net w or k of f ibr es, B- r ight at r iovent r icular or ifice.

W idth of coronary sinus ostium:

The mean w idt h of t he coronary sinus ost ium w as 9.35 + 3.24mm.

DISCUSSION

Formation of coronary sinus: The coronary sinus is described as being formed by oblique vein of left at rium joining wit h great cardiac vein by most of t he aut hors [8]. According t o some aut hors t he great cardiac vein it self cont inues as coronary sinus at t he left end of t he post erior cor onar y sulcus [ 9]. These aut hors did not consider t he left marginal vein and post erior vein of left vent ricle as t ribut aries of coronary sinus, t herefore t he am biguit y arises regarding t he format ion of coronary sinus.

In t h e p r esen t st u dy, w e h ave n ot ed t h e

format ion of coronary sinus under t he follow ing

t ypes: (Table 1)

Type I- w hen t he great cardiac vein joins w it h left marginal vein to form coronary sinus (present in 93.33% of our specimens)

Type II- w hen t he great cardiac vein joins w it h post er ior vein of lef t vent r icle t o for m t he co r o n ar y sin u s (p r esen t i n 3.33% o f o u r specimens)

Type III- w hen t he great cardiac vein joins w it h oblique vein of left atrium t o form coronary sinus (present in 3.33% of our specimens)

Type IV- w hen t he great cardiac vein does not

end in t he coronary sinus and ends direct ly int o right at rium or int o ant erior cardiac vein [9,10] ( not found in our st udy)

Tributaries of coronary sinus: The great cardiac vein and middle cardiac vein are t he 2 m ost consist ent ly present t ribut aries of coronary sinus [11]. The great cardiac vein has been r epor t ed t o vary consider ably in it s course [12,13]. Lat eral and post erior venous branches are seen in <50% of human heart unlike the great cardiac vein and middle cardiac vein w hich are seen in >90% [14]. Ort ale JR et al. [8] have indicat ed t hat t he left marginal vein may vary in it s course in relat ion t o t he lat eral w all of t he heart and drain eit her int o great cardiac vein or int o t he coronary sinus, but t his m ay not be definit ive [14]. In the present study, left marginal vein w as absent in 2 specim ens and sm all cardiac vein w as absent in 1 specimen (Table 2).

(4)

CONCLUSION

coronary sinus ranged from 2- 3.8cm and t he mean was 2.8cm. In t he present st udy, the mean lengt h of coronary sinus in 28 specimens w as 54.98 + 12.2 mm w here t he coronary sinus w as formed by t he union of great cardiac vein and left marginal vein (Table 3).

In t he specim en in w hich coronary sinus w as formed by t he union of great cardiac vein and post erior vein of left vent ricle- t he lengt h w as 53.06mm. In another specimen in which coronary sinus w as formed by t he union of great cardiac vein and oblique vein of left at rium – t he lengt h was 34.52mm (Table 3).

W idth of coronary sinus ostium: The available lit erat ure indicat es t hat t he coronary sinus is a w ide venous channel and describes t he w idt h of coronary sinus at t he t erminat ion measuring 9.6m m[7]. In t he present st udy t he coronary ost ium m easured 9.35 + 3.24mm and it is in conformit y w it h available lit erat ure.

Valve o f co ro na r y sin us: Acco rd i n g t o Hellerst ein HK and Orbison JL,[7]t he orifice of coronary sinus appeared most ly oval in shape and w as guarded by t he t hebesian valve. M ainly 6 t ypes of variat ions in t he valve of coronary sinus have been report ed by t hem:

- Absent in 14.7%

- Small and crescent in 38%

- Lar ge an d co ver i ng t he ent ir e or if ice of coronary sinus in 30.7%

- Bars and bands in 5.7% - Threads and net w orks in 5.3%

- Common Eust achian and t hebesian valves in 6%

In t he present st udy, t he t hebesian valve was present in 28 specimens – 93.33% and it w as semilunar in shape (Table 4). In 1 specimen t here w as a netw ork of fibres in the ost ium of coronary sinus (Figure 1) and in anot her specimen, t he valve w as absent .

The coronary sinus has now begun t o at t ract more at t ent ion because of t he development of lat est int ervent ional t echniques li ke cardiac cat het erizat ion, select ive cat het erizat ion of car d iac v ei ns an d im p lant at i on o f car di ac pacem aker s. Hence t he know led ge of t he morphology of coronary sinus, w ill add value before and during electrophysiological procedures.

Conflicts of Interests: None

REFERENCES

[1]. Gat zoulis AM . Heart and great vessels. In: St andring S. Gray’s Anat om y- The Anat om ical Basis of Clinical Pract ice. 40t h_{edn. Churchill Livingst one Elsevier,} London, 2008:981-982.

[2] . Abraham WT, Fisher W G, Sm it h AL, Delurgio DB, Leon AR, Loh E et al. Cardiac resynchronizat ion in chronic heart failure. N Engl J M ed 2002;346:1845– 53.

[3] . Cleland JG, Daubert JC, Erdm ann E, Freem ant le N, Gras D, Kappenber ger L et al. The CARE-HF st udy (CArdiac REsynchronisat ion in Heart Failure st udy): rat ionale, design and end-point s. Eur J Heart Fail 2001; 3:481–9.

[4] . Alonso C, Leclercq C, d’Allonnes FR, Pavin D, Vict or F, M abo P et al. Six year experience of t ransvenous lef t vent ricular lead im plant at ion f or perm anent bivent r icular pacing in pat ient s w it h advanced heart failure: t echnical aspects. Heart 2001;86:405– 10.

[5]. Gerber TC, Kant or B, Keelan PC, Hayes DL, Schw art z RS, Holm es DR. The coronary venous Syst em : an alt ernat e por t al t o t he m yocardium for diagnost ic and t herapeut ic procedures in invasive cardiology. Cur r Int erv Cardiol Rep 2000;2:27–37.

[6] . Grzybiak M . M orphology of t he CS and cont em -porar y cardiac elect rophysiology. Folia M orphol (Warsz) 1996;55:272–3.

[7] . Hellerst ein HK, Orbison JL. Anat om ic variat ions of t h e o r i f i ce o f t h e h u m an co r o n ar y si n u s. Cir culat ion. 1951;3:514-523

[ 8] . Ort ale JR, Gabriel EA, Iost C, M arquez CQ. The anat om y of coronary sinus and it s t ribut aries. Surg Radiol Anat .2001;23(1):15-21.

[9] . Iyer PB. Great cardiac vein draining direct ly int o t he right at r ium - a case report . J Anat Soc India. 2006;55:60-64.

[10]. Loukas M , Bilinsky S, Bilinsky E, El-Sedfy A, Anderson RH. Cardiac veins: a r eview of lit er at ure. Clin Anat . 2009;22:129-145.

[11]. Gilard M , M ansourat i J, Et ienne Y, Laslet JM , Truong B, Boschat J, et al. Angiographic anat om y of t he co r on ar y sin us and it s t r ibu t ar i es. Pacing Cl in Elect r ophysiol. 1998;21:2280-4.

[12]. Kaw ashim a T, Sat o K, Sat o F, Sasaki H. An anat om ical st udy of t he hum an car d iac veins w it h special reference t o t he drainage of t he great cardiac vein. Ann Anat .2003;185:535-542.

[13]. Bales GS. Great cardiac vein variat ions. Clin Anat . 2004;17:436-43.

[14]. Gerber TC, Sheedy PF, Bell M R, et al. Evaluat ion of t he coronary venous syst em using elect ron beam com put ed t om ography. Int J Cardiovasc Im aging. 2001;17:65-75.

[ 15] .Kavim ani , Jebakan i C.F. Coro nar y Sinu s. Wor ld Journal of M edical Sciences. 2014;10(1):61-64.