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Hypoplasia of the Coronary Sinus with Coronary Venous Drainage into the Left Ventricle by Way of the Thebesian System
Hypoplasia of the Coronary Sinus with Coronary Venous Drainage into the Left Ventricle by Way of the Thebesian System Sam A. Kinard, M.D."
A 60-year-old woman with recent onset of exertional chest pain, left anterior hemiblock and negative stress electrocardiogram was found to have hypoplasia of the coronary sinus with drainage of the major coronary venous blood by way of the Thebesian system into the left ventricle. This abnormality appeared to be of no great functional significance.
functional importance of the Thebesian venous T hesystem is only slightly understood. In cases in which anomalies of the coronary sinus result in obstruction of venous return, the Thebesian system of the atria and the right ventricle usually carries most of the blood supply from the heart. Occasionally, however, the venous drainage exits by way of the le ft ventricular Thebesian system.'- 4 The present study represents an unusual example of almost total coronary venous drainage by the left ventricular Thebesian route . CASE REPORT
Two weeks prior to admission in March, 1973, the patient, a 60-year-old woman, had noted a dull substernal ache lasting one to two minutes. This was precipitated by exertion and relieved with rest, although some tiredness did seem to be associated with it. She had a history, from September, 1972, of elevated blood pressure and choles terol level, for which she had been treated with thiazide, reserpine, hydralazine "Chief of Cardiology, Arizon a Heart Institute, St. Joseph's H ospital and Medical Center, Phoenix. Reprint requests: Dr. Kinard, 350 West Thomas Road, Phoenix 85013
FIGURE 2. An arteriogram in th e left anterior oblique view reveals an irregular right coronary artery. There are dilated vascular channels within th e ventricular sephun . mixture ( Ser-ap-es ) once daily and clofibrate 500 mg twice daily, until the present admission. Physical examination revealed blood pressure of 150/ 70. There was a grade 2 high-pitch ed midsystolic murmur at the· apex without radiation. The e le ctrocardiogram showed l eft axis deviation, left anterior hemiblock and poor R-wave progression in leads v, through Vs. Laboratory studies gave normal findings, including cholesterol level, which was 230, with triglycerides of 62 and a normal lipoprotein pattern. Chest x-ray fihn showed m ild cardiom egaly with a suggestion of left ventricular enlargement. An echocardiogram demonstrated a markedly thickened interventricular septum with reduction in · the internal di ameter of the right ventricle (Fig 1 ). Following treadmill exercise, during which the patient went 24 seconds into stage 3 with a heart rate of 122 b eats per minute, there was no chest pain, and ST -segment changes were not noted on the e le ctrocardiogram. Left heart catheterization revealed normal left heart pressures and normal left ventricular cavity size, with no mitral regurgitation. The right coronary artery (Fig 2 ) was irregu-
Anterior wall Right ventricle Septum
Left ventricle
Posterior wall
normal
384 SAM A. KINARD
FrGURE 1. The echocardiogram shows an enlarged interventricular septum with a reduced size of the right ventricle .
CHEST, 68: 3, SEPTEMBER, 1975
by way of the Thebesian system, through the ventricular septum and thence into the left ventricle. No coronary vein could he seen draining the right coronary artery. The left coronary arterial system (Fig 3 and 4) also contained areas of irregularity without significant stenosis. The vessels appeared somewhat tortuous, and the major egress of blood from the left coronary artery was observed to be by way of Thebesian veins draining directly into the left ventricle from which the contrast material could he seen to pass into the aorta. In the very late angiographic phase, one posterior and two lateral cardiac veins were visualized converging into a common chamber near the site of termination of the coronary sinus. A lesser degree of myocardial straining was also noted in the distribution of the circumflex coronary artery. In the late phase following left ventricular injection, a dilated vein was revealed on the surface at the apex. The oxygen saturation in the ascending aorta was measured by oximeter at 96 percent. At least two-thirds of the arterial inflow drains by way of the Thebesian system into the left ventricle. The remainder probably drains normally by way of coronary veins through a FIGURE 3. An arteriogram of the left coronary artery in the left anterior oblique view shows the artery to be irregular and tortuous. Numerous small vascular channels within the left ventricular myocardium are indicated by the mass of dye in the left ventricle.
common egress leading to the right atrium. Dilation of a cardiac vein at the left ventricular apex following ventricular injection suggests that the vein was obstructed or narrowed. CoNCLUSION
lar without significant stenosis. Branches of the posterior descending portion, however, appeared to be more numerous than usual, with dilated channels in the ventricular septum. Egress of blood from this vessel was observed to take place
Atresia of the right atrial coronary sinus ostium is frequently associated with a functionally persistent left superior vena cava.' In the absence of both a functional left superior vena cava and a coronary sinus ostium in the left atrium, drainage occurs through enlarged Thebesian veins. Also, when hypoplastic cardiac veins fail to join the coronary sinus, they empty individually into the atrial chambers through dilated Thebesian channels. The described patient appears to have a combination of partial atresia of the coronary sinus and hypoplasia of some of the cardiac veins. Consequently, venous drainage takes place via the Thebesian system into the left ventricular chamber. REFERENCES
1 Mantini E, Grondin CM, Lillehei CW, et al: Congenital anomalies involving the coronary sinus. Circulation 33 :319327, 1966
FIGURE 4. An arteriogram in the right anterior oblique view of the left coronary artery reveals dilated intermyocardial vessels beneath the anterior descending coronary artery, with one very dark area just beneath the endocardium. This represents a concentration of contrast material within the left ventricular chamber prior to its egress with the next systole. There are very few of the normal va~cular channels within the myocardium in the basal distribution of the circumflex coronary artery.
CHEST, 68: 3, SEPTEMBER, 1975
2 Raghib G, Bloemendaal RD, Kanjuh Fl, et al : Aortic atresia and premature closure of foramen ovale: Myocardial sinusoids and coronary arteriovenous fishtla serving a< outflow channel. Am Heart J 70:476, 1965 3 Falcone MW, Roberts WC, et al: Atresia of the right atrial ostium of the coronary sinus unassociated with persistence of the left superior vena cava : A clinicopathologic study of four adult patients. Am Heart J 5:604-611, 1972 4 Reddy K, Gupta M, Hamby R: Mttltiple coronary arteriosystemic fistulas. Am J Cardiol33:304, 1974
HYPOPLASIA OF CORONARY SINUS 385
A 60-year-old woman with recent onset of exertional chest pain, left anterior hemiblock and negative stress electrocardiogram was found to have hypoplasia of the coronary sinus with drainage of the major coronary venous blood by way of the Thebesian system into the left ventricle. This abnormality appeared to be of no great functional significance.
functional importance of the Thebesian venous T hesystem is only slightly understood. In cases in which anomalies of the coronary sinus result in obstruction of venous return, the Thebesian system of the atria and the right ventricle usually carries most of the blood supply from the heart. Occasionally, however, the venous drainage exits by way of the le ft ventricular Thebesian system.'- 4 The present study represents an unusual example of almost total coronary venous drainage by the left ventricular Thebesian route . CASE REPORT
Two weeks prior to admission in March, 1973, the patient, a 60-year-old woman, had noted a dull substernal ache lasting one to two minutes. This was precipitated by exertion and relieved with rest, although some tiredness did seem to be associated with it. She had a history, from September, 1972, of elevated blood pressure and choles terol level, for which she had been treated with thiazide, reserpine, hydralazine "Chief of Cardiology, Arizon a Heart Institute, St. Joseph's H ospital and Medical Center, Phoenix. Reprint requests: Dr. Kinard, 350 West Thomas Road, Phoenix 85013
FIGURE 2. An arteriogram in th e left anterior oblique view reveals an irregular right coronary artery. There are dilated vascular channels within th e ventricular sephun . mixture ( Ser-ap-es ) once daily and clofibrate 500 mg twice daily, until the present admission. Physical examination revealed blood pressure of 150/ 70. There was a grade 2 high-pitch ed midsystolic murmur at the· apex without radiation. The e le ctrocardiogram showed l eft axis deviation, left anterior hemiblock and poor R-wave progression in leads v, through Vs. Laboratory studies gave normal findings, including cholesterol level, which was 230, with triglycerides of 62 and a normal lipoprotein pattern. Chest x-ray fihn showed m ild cardiom egaly with a suggestion of left ventricular enlargement. An echocardiogram demonstrated a markedly thickened interventricular septum with reduction in · the internal di ameter of the right ventricle (Fig 1 ). Following treadmill exercise, during which the patient went 24 seconds into stage 3 with a heart rate of 122 b eats per minute, there was no chest pain, and ST -segment changes were not noted on the e le ctrocardiogram. Left heart catheterization revealed normal left heart pressures and normal left ventricular cavity size, with no mitral regurgitation. The right coronary artery (Fig 2 ) was irregu-
Anterior wall Right ventricle Septum
Left ventricle
Posterior wall
normal
384 SAM A. KINARD
FrGURE 1. The echocardiogram shows an enlarged interventricular septum with a reduced size of the right ventricle .
CHEST, 68: 3, SEPTEMBER, 1975
by way of the Thebesian system, through the ventricular septum and thence into the left ventricle. No coronary vein could he seen draining the right coronary artery. The left coronary arterial system (Fig 3 and 4) also contained areas of irregularity without significant stenosis. The vessels appeared somewhat tortuous, and the major egress of blood from the left coronary artery was observed to be by way of Thebesian veins draining directly into the left ventricle from which the contrast material could he seen to pass into the aorta. In the very late angiographic phase, one posterior and two lateral cardiac veins were visualized converging into a common chamber near the site of termination of the coronary sinus. A lesser degree of myocardial straining was also noted in the distribution of the circumflex coronary artery. In the late phase following left ventricular injection, a dilated vein was revealed on the surface at the apex. The oxygen saturation in the ascending aorta was measured by oximeter at 96 percent. At least two-thirds of the arterial inflow drains by way of the Thebesian system into the left ventricle. The remainder probably drains normally by way of coronary veins through a FIGURE 3. An arteriogram of the left coronary artery in the left anterior oblique view shows the artery to be irregular and tortuous. Numerous small vascular channels within the left ventricular myocardium are indicated by the mass of dye in the left ventricle.
common egress leading to the right atrium. Dilation of a cardiac vein at the left ventricular apex following ventricular injection suggests that the vein was obstructed or narrowed. CoNCLUSION
lar without significant stenosis. Branches of the posterior descending portion, however, appeared to be more numerous than usual, with dilated channels in the ventricular septum. Egress of blood from this vessel was observed to take place
Atresia of the right atrial coronary sinus ostium is frequently associated with a functionally persistent left superior vena cava.' In the absence of both a functional left superior vena cava and a coronary sinus ostium in the left atrium, drainage occurs through enlarged Thebesian veins. Also, when hypoplastic cardiac veins fail to join the coronary sinus, they empty individually into the atrial chambers through dilated Thebesian channels. The described patient appears to have a combination of partial atresia of the coronary sinus and hypoplasia of some of the cardiac veins. Consequently, venous drainage takes place via the Thebesian system into the left ventricular chamber. REFERENCES
1 Mantini E, Grondin CM, Lillehei CW, et al: Congenital anomalies involving the coronary sinus. Circulation 33 :319327, 1966
FIGURE 4. An arteriogram in the right anterior oblique view of the left coronary artery reveals dilated intermyocardial vessels beneath the anterior descending coronary artery, with one very dark area just beneath the endocardium. This represents a concentration of contrast material within the left ventricular chamber prior to its egress with the next systole. There are very few of the normal va~cular channels within the myocardium in the basal distribution of the circumflex coronary artery.
CHEST, 68: 3, SEPTEMBER, 1975
2 Raghib G, Bloemendaal RD, Kanjuh Fl, et al : Aortic atresia and premature closure of foramen ovale: Myocardial sinusoids and coronary arteriovenous fishtla serving a< outflow channel. Am Heart J 70:476, 1965 3 Falcone MW, Roberts WC, et al: Atresia of the right atrial ostium of the coronary sinus unassociated with persistence of the left superior vena cava : A clinicopathologic study of four adult patients. Am Heart J 5:604-611, 1972 4 Reddy K, Gupta M, Hamby R: Mttltiple coronary arteriosystemic fistulas. Am J Cardiol33:304, 1974
HYPOPLASIA OF CORONARY SINUS 385