A rare case: Coronary sinus thrombosis

Transcription

1 A rare case: Coronary sinus thrombosis Poster No.: P-0085 Congress: ESTI 2014 Type: Educational Poster Authors: B. Özkul, N. Inan, Ö. Özkul, H. T. Sarisoy, G. Akansel, A. Akça, #. Çam; Kocaeli/TR Keywords: Embolism / Thrombosis, Screening, CT-Angiography, Cardiovascular system DOI: /esti2014/P-0085 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Learning objectives 1. To illustrate the venous anatomy of heart. The coronary system generally receives little attention in the medical literature. Cardiologists mostly consantre on cardiac arteries but venous system of heart must not to be neglected. 2. In this poster, our purpose is to present a case of coronary sinus thrombosis (CST) with CT findings and to take attention on coronary system. Page 2 of 15

3 Background Anatomy of cardiac venous system The venous drainage of the heart consists of two separate systems draining the right and left ventricular arterial flow. Normally the right ventricle is drained via the anterior cardiac veins running along the anterior right ventricular surface and draining separately into the right atrium; this accounts for approximately 15% of the total cardiac venous return. The remainder of the cardiac venous return is via the coronary sinus, a large venous channel running in the left atrio-ventricular sulcus. Fig. 1 on page 5 Fig. 1: Anatomy of the coronary sinus References: The McGraw-Hill Companies, Inc. Tributaries with contribution to the coronary sinus include: the anterior interventricular vein, also known as the great cardiac vein, running in the anterior interventricular sulcus Page 3 of 15

4 parallel to the left anterior descending coronary arterry; the posterior interventricular vein (middle cardiac vein) running in the posterior interventricular sulcus parallel to te posterior descending coronary artery; and the small cardiac vein running in the right atrioventricular sulcus. Other venous channels entering either the great cardiac vein or directly into the coronary sinus include: the oblique vein of the left atrium (oblique vein of Marshall); the obtuse marginal vein running parallel to the obtuse marginal branch of the left circumflex coronary artery; and the posterior left ventricular veins running parallel to the posterior left ventricular branches of the left and right ventricles. Fig. 2 on page 5 Fig. 2: Anterior view of heart References: The McGraw-Hill Companies, Inc. Although these two venous systems are anatomically distinct with separate entrances into the right atrium, there are many anastomotic connections between the two allowing diversion of flow from one to the other if resistance in one channel should increase for any reason. Page 4 of 15

5 Images for this section: Fig. 1: Anatomy of the coronary sinus The McGraw-Hill Companies, Inc. Page 5 of 15

6 Fig. 2: Anterior view of heart The McGraw-Hill Companies, Inc. Page 6 of 15

7 Imaging findings OR Procedure details A 79 years old male patient was evaluated for chest pain and breathlessness at the emergency room. He has been chronic renal failure since 1996 and he had no history of invasive cardiac procedures. Cardiac markers and D-dimer test, electrocardiography, echocardiography and chest MDCT were performed. MDCTA scanning protocol: Aquilion 64 MDCT, Toshiba Slice thickness: 2 mm kvp: 120, mas: G IV cannula placed in a distal arm vein TM Bolus track (OptiVantage ); 180 H.U.threshold, then sec scan delay ml/s di iodinated contrast medium (370 mgi/ml) ml/s saline chase. Examination revealed that no breath sound at the middle and lower zones of right lung and increased blood d-dimer levels (1.83 ng/ml, normal: ng/ml). The creatinin was 3.88 mg/dl (normal: mg/dl) and blood urea nitrogen was 34 mg/dl (normal: mg/dl). A chest CT was performed because of the suspicious of pulmonary embolism. Massive unilateral pleural effusion, atelectasis and CST were seen in the chest CT (Fig. 3 on page 11, Fig. 4 on page 11 and Fig. 5 on page 12). Page 7 of 15

8 Fig. 3: Axial view of chest CT References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/ Turkey 2014 Also ST elevations in the ECG and increased cardiac markers were revealed (myoglobin: 355 ng/ml (normal: ng/ml), Troponin I: 0.85 ng/ml (normal: ng/ml)). Based on these findings, a diagnosis of acute MI depending on CST was made. Page 8 of 15

9 Fig. 4: Coronal view of chest CT References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/ Turkey 2014 Page 9 of 15

10 Fig. 5 References: Department of Radiology, Kocaeli University School of Medicine, Kocaeli/ Turkey 2014 Page 10 of 15

11 Images for this section: Fig. 3: Axial view of chest CT Department of Radiology, Kocaeli University School of Medicine, Kocaeli/Turkey 2014 Page 11 of 15

12 Fig. 4: Coronal view of chest CT Department of Radiology, Kocaeli University School of Medicine, Kocaeli/Turkey 2014 Page 12 of 15

13 Fig. 5 Department of Radiology, Kocaeli University School of Medicine, Kocaeli/Turkey 2014 Page 13 of 15

14 Conclusion CST is a rare acquired anomaly of the coronary sinus. It has been reported only as a complication of cardiac transplantation and right heart catheterization in non infected patients. In cardiac procedures that use access to the right atrium, such as insertion of central venous lines, pacing wire, coronary sinus catheterisation for ventricular lead placement during cardiac resynchronisation therapy, the CS is at risk of accidental trauma and subsequent thrombosis. Our case had an acute coronary sinus thrombosis occurring in the absence of these procedures. Page 14 of 15

15 References Vinayak NB, Ashutosh AH, Manish MP, Nandkishor BA, et al. Coronary sinus thrombosis after cannulation during cardiopulmonary bypass. Ann Thorac Surg. 1996;62: James, TN: Anatomy of the coronary arteries and veins. In Hurst, JW, et a1 (eds): "The Heart." New York: McGraw-Hill, 1978, p 26. Ramsaran EK, Sadigh M, Miller D. Sudden cardiac death due to primary coronary sinus thrombosis. South Med J. 1996;86: O'Cochlain B, Delurgio D, Leon A. Biventricular pacing using two pacemakers and the triggered VVT mode. Pacing Clin Electrophysiol. 2001; 24(8 Pt 1): Suarez-Penaranda JM, Rico-Boquete R, Munoz JI, Rodriguez-Nunez A, Martinez Soto MI, et al. Unexpected sudden death from coronary sinus thrombosis. An unusual complication of central venous catheterization. J Forensic Sci. 200l;45: Page 15 of 15