Arrhythmogenicity of the Coronary Sinus

Katritsis, Demosthenes G (2004) Arrhythmogenicity of the Coronary Sinus. [Journal (Paginated)]

Full text available as:



The coronary sinus (CS) is the cardiac venous system that begins at its ostium in the right atrium and ends at the origin of the great cardiac vein. The major tributaries of the CS include the great cardiac vein (anterior cardiac vein), the left obtuse marginal vein, the posterior (or inferior) left ventricular vein, the middle cardiac vein, and the right coronary vein. In addition, atrial veins and, notably, the vein of Marshall (or oblique left atrial vein) also enter the coronary sinus. From the perspective of electrophysiologists, the CS represents an anatomical structure of particular interest. First, it provides access to epicardial atrioventricular pathways and arrhythmogenic foci of both atrial6 and ventricular arrhythmia. Second, it represents by itself a potential source of atrial arrhythmia. The arrhythmogenic potential of the thoracic veins in general has been recognised since the 1970s. Atrial arrhythmias can originate in the pulmonary veins, the superior vena cava, and the CS. Indeed, biatrial flutter,left atrial tachycardia, and atrial fibrillation, involving the distal CS have been well described. There is now evidence that the CS apart from participating in arrhythmia circuits, such as in the slow-slow form of atrioventricular nodal reentrant tachycardia and atrioventricular reentrant tachycardia due to accessory pathways,may itself be a source of apparently atrial arrhythmia. In patients with paroxysmal atrial fibrillation apparently originating from the left superior or inferior pulmonary vein, detailed epicardial mapping through the distal coronary sinus might identify epicardial location of the arrhythmogenic focus. Therefore, the search for foci of abnormal automaticity within the CS should be part of the electrophysiologic evaluation of left atrial arrhythmias.

Item Type:Journal (Paginated)
Keywords:coronary sinus
Subjects:JOURNALS > Indian Pacing and Electrophysiology Journal
ID Code:4182
Deposited By: Indian Pacing and Electrophysiology, Journal
Deposited On:14 Apr 2005
Last Modified:11 Mar 2011 08:55

References in Article

Select the SEEK icon to attempt to find the referenced article. If it does not appear to be in cogprints you will be forwarded to the paracite service. Poorly formated references will probably not work.

1. von Ludinghausen M. Clinical anatomy of cardiac veins, Vv. cardiacae. Surg Radiol Anat 1987;9:159-68

2. Marshall J. On the development of the great anterior veins in man and mammalia: including an account of certain remnants of foetal structure found in the adult, a comparative view of these great veins in the different mammalia, and an analysis of their occasional peculiarities in the human subject. Philos Trans R Soc Lond 1850: 140: 133-169.

3. Ortale JR, Gabriel EA, Iost C, Marquez CQ. The anatomy of the coronary sinus and its tributaries. Surg Radiol Anat 2001;23:15-21

4. Haissaguerre M, Gaita F, Fischer B, Egloff P, Lemetayer P, Warin JF. Radiofrequency catheter ablation of left lateral accessory pathways via the coronary sinus. Circulation. 1992;86:1464-8.

5. Giorgberidze I, Saksena A, Kroll RB, Mathew P. Efficacy and safety of radiofrequency catheter ablation of left-sided accessory pathways through the coronary sinus. Am J Cardiol 1995;76:359-65

6. Katritsis D, Ioannidis JPA, Giazitzoglou E, Korovesis S, Anagnostopoulos CE, Camm AJ. Epicardial origin of atrial ectopy apparently originating from the left pulmonary veins: implications for the treatment of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2002; 13: 319-323

7. Stellbrink C, Dien B, Schauerte P, et al. Transcoronary venous radiofrequency catheter ablation of ventricular tachycardia. J Cardiovasc Electrophysiol 1997;8:916-21.

8. de Paola AA, Melo WD, Tavora MZ, Martinez EE. Angiographic and electrophysiological substrates for ventricular tachycardia mapping through the coronary veins. Heart. 1998;79:59-63.

9. Pavin D, Boulmier D, Daubert JC, Mabo P. Permanent left atrial tachycardia: radiofrequency catheter ablation through the coronary sinus. J Cardiovasc Electrophysiol 2002;13:395-8

10. Volkmer M, Antz M, Hebe J, Kuck KH. Focal atrial tachycardia originating from the musculature of the coronary sinus. J Cardiovasc Electrophysiol 2002;13:68-71

11. Katritsis D, Ioannidis JPA, Giazitzoglou E, Korovesis S, Anagnostopoulos CE, Camm AJ. Conduction Delay Within the Coronary Sinus in Humans: Implications for Atrial Arrhythmias. J Cardiovasc Electrophysiol 2002;13:859-62.

12. Katritsis D, Ioannidis JP, Anagnostopoulos CE, et al. Identification and catheter ablation of extracardiac and intracardiac components of ligament of Marshall tissue for treatment of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2001;12:750-8

13. Eckardt L. Automaticity in the coronary sinus. J Cardiovasc Electrophysiol 2002; 13: 288-289.

14. Oral H, Ozaydin M, Chugh A, Scharf C, Tada H, Hall B, Cheung P, Pelosi F, Knight

BP, Morady F. Role of the Coronary Sinus in Maintenance of Atrial Fibrillation. J Cardiovasc Electrophysiol. 2003;14:1329-1336.

15. Zipes DP, Knope RF. Electrical properties of the thoracic veins. Am J Cardiol 1972;29:372-6 542.

16. Spach MS, Barr RC, Jewett PH. Spread of excitation from the atrium into thoracic veins in human beings and dogs. Am J Cardiol 1972;30:844-54.

17. Haissaguerre M, Shah DC, Jais P, Hocini M, Yamane T, Deisenhofer I, Chauvin M, Garrigue S, Clementy J. Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation 2000;102:2463-5

18. Tsai CF, Tai CT, Hsieh MH, Lin WS, Yu WC, Ueng KC, Ding YA, Chang MS, Chen SA. Initiation of atrial fibrillation by ectopic beats originating from the superior vena cava: electrophysiological characteristics and results of radiofrequency ablation. Circulation 2000;102:67-74

19. Olgin JE, Jayachandran JV, Engelstein E, Groh W, Zipes DP. Atrial macroreentry involving the myocardium of the coronary sinus: a unique mechanism for atypical flutter. J Cardiovasc Electrophysiol 1998; 9:1094-1099.

20. Ndrepera G, Zrenner B, Schneider MAE, et al. Dissociation between coronary sinus and left atrial conduction in patients wirth atrial fibrillation and flutter. J Cardiovasc Electrophysiol 2001; 12: 623-628.

21. Otomo K, Wang Z, Lazzara R, Jackman WM. Atrioventricular nodal re-entrant tachycardia: electrophysiological characteristics of four forms and implications for the re-entrant circuit. In ZipesDP, Jalife J Cradiac Electrophysiology. From Cell to Bedside. 3d Edition. WB Saunders. Pp 504-521. 2000.

22. Gerlis LM, Davies MJ, Boyle R, Williams G, Scott H. Pre-excitation due to accessory siniventricular connexions associated with coronary sinus aneurysms. A report of two cases. Br Heart J 1985; 53: 314-322.

23. Guiraudon GM, Guiraudon CM, Klein GJ, Sharma AD, Yee R. The coronary sinus diverticulum: a pathologic entity associated with the Wolff-Parkinson-White syndrome. Am J Cardiol. 1988;62:733-5.

24. Ho SY, Russell G, Rowland E. Coronary venous aneurysms and accessory atrioventricular connections. Br Heart J 1988;60:348-51.

25. Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J, Po S, Spector P, Lustgarten D, Herring L, Lazzara R, Jackman W. Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: incidence and electrophysiological identification. Circulation 2002;106:1362-7

26. Macle L, Shah DC, Jais P, Haissaguerre M. Accessory pathway automaticity after radiofrequency ablation. J Cardiovasc Electrophysiol 2002; 13: 285-287.

27. Hwang C, Karagueuzian HS, Chen PS. Idiopathic paroxysmal atrial fibrillation induced by a focal discharge mechanism in the left superior pulmonary vein. Possible role of the ligament of Marshall. J Cardiovasc Electrophysiol 1999: 10: 636-648.

28. Doshi RN, Wu TJ, Yashima M, Kim YH, Ong JJC, Cao JM, Hwang C, Yashar P, Fishbein MC, Karagueuzian HS, Chen P-S. Relation between ligament of Marshall and adrenergic atrial tachyarrhythmia. Circulation 1999: 100: 876-883.

29. Langman J. Medical Embryology. 3d Edition. Baltimore: Williams and Wilkins; 1975: 209-210.

30. Wilcox BR and Anderson RH. Surgical Anatomy of the Heart. 2nd Edition. London: Gower Medical Publishers; 1982: p220.

31. Hwang C, Wu TJ, Doshi RN, Peter CT, Chen PS. Vein of Marshall cannulation for the analysis of electrical activity in patients with focal AF. Circulation 2000; 101:1503-1505.

32. Kim DT, Lai AC, Hwang C, et al. The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias. J Am Coll Cardiol 2001;36:1324-1327.

33. Cox JL, Ad N. New surgical and catheter-based modifications of the Maze procedure. Semin Thorac Cardiovasc Surg 2000; 12:68-73.

34. Antz, M, Otomo K, Arruda M, et al. Electrical conduction between the right atrium and the left atrium via the musculature of the coronary sinus. Circulation 1998;98:1790-1795.

35. Chauvin M, Shah DC, Haissaguerre M, et al. The anatomic basis of connections between the coronary sinus musculature and the left atrium in humans. Circulation 2000;101:647-652.

36. Ho SY, Sánchez-Quintana D, Cabrera JA, Anderson RH: Anatomy of the left atrium: Implications for radiofrequency ablation of atrial fibrillation. J Cardiovasc Electrophysiol 1999;10:1525-33.

37. Lüdinghausen VM, Ohmachi N, Boot C. Myocardial coverage of the coronary sinus and related veins. Clinical Anatomy 1992;5:1-15.

38. Kasai A, Anselme F, Saoudi N. Myocardial connections between left atrial myocardium and coronary sinus musculature in man. J Cardiovasc Electrophysiol 2001; 12: 981-985.

39. Scanavacca MI, d’Avila A, Tondato F, Lara S, Sosa EA. Traansthoracic epicardial mapping of the ligament of Marshall. PACE 2001; 24(PtII): 586. Abstract.

40. Katritsis DG, Giazitzoglou E, Korovesis S, Karvouni E, Anagnostopoulos CE. Conduction Patterns in the Cardiac Veins: Electrophysiologic Characteristics of the Connections Between Left Atrial and Coronary Sinus Musculature. J Interv Cardiac Electrophysiol 2004; 10:1-8.

41. Goya M, Ouyang F, Ernst S, Volkmer M, Antz M, Kuck KH. Electroanatomic mapping and catheter ablation of breakthroughs from the right atrium to the superior vena cava in patients with atrial fibrillation. Circulation 2002;106:1317-20

42. von Ludinghausen M. Clinical anatomy of cardiac veins, Vv. cardiacae. Surg Radiol Anat 1987;9:159-68

43. Corcoran SJ, Lawrence C, McGuire MA. The valve of Vieussens: an important cause of difficulty in advancing catheters into the cardiac veins. J Cardiovasc Electrophysiol 1999;10:804-8

44. Ortale JR, Gabriel EA, Iost C, Marquez CQ. The anatomy of the coronary sinus and its tributaries. Surg Radiol Anat 2001;23:15-21


Repository Staff Only: item control page