Author + information
- Received May 27, 2016
- Revision received June 22, 2016
- Accepted June 29, 2016
- Published online November 1, 2016.
- Hampton A. Crimm, MS, MD∗ (, )
- Sun Mee Paik, MD,
- Matthew Needleman, MD and
- Todd C. Villines, MD
- Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
- ↵∗Reprint requests and correspondence:
Dr. Hampton Crimm, Cardiology Service, Walter Reed National Military Medical Center, 8930 Brown Drive, Building 9A, 2nd Floor, Bethesda, Maryland 20889.
A 57-year-old woman with recurrent, symptomatic, paroxysmal atrial fibrillation, refractory to multiple cardioversions and oral antiarrhythmic therapy, was referred for pulmonary vein isolation. To evaluate pulmonary vein anatomy and assist with 3-dimensional mapping, pre-procedural cardiac computed tomography angiography was performed. The computed tomography revealed a rare coronary venous anomaly: atresia of the right atrial coronary sinus ostium and direct communication of the coronary sinus with the posterior left atrium (Figure 1). The pulmonary vein anatomy and cardiac chamber sizes were otherwise normal.
Knowledge of this rare anomaly of the coronary venous return helped avoid the potential pitfall of cannulating (and risk perforating) the blind pouch emanating from the right atrium. Ablation of the 4 pulmonary veins was performed in a standard fashion using an irrigated contact force catheter. Although no typical “pulmonary vein” electrical potentials were identified within the anomalous left atrial coronary sinus ostium, this ostium was ablated using a wide area circumferential ablation (Figure 2). Despite having daily episodes of atrial fibrillation prior to ablation, the patient has remained free from symptomatic atrial fibrillation. A previous case report involving a patient with anomalous coronary sinus drainage to the left and right atria demonstrated successful ablation of atrial fibrillation, at short interval follow-up, without isolation of the anomalous ostium (1). Thus, given the lack of potentials and prior report, the utility of isolating the aberrant coronary sinus ostium remains unclear.
Anomalies of coronary venous anatomy are infrequently encountered but are important to consider in advance of intracardiac instrumentation. The additional blood flow of the coronary sinus draining into the left atrium may have contributed to adverse left atrial remodeling, representing a possible etiology of atrial fibrillation in this patient.
The opinions or assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Department of Defense or the United States Government. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 27, 2016.
- Revision received June 22, 2016.
- Accepted June 29, 2016.
- American College of Cardiology Foundation