Coronary venous anatomy and anomalies

Open AccessPublished:August 07, 2019DOI:https://doi.org/10.1016/j.jcct.2019.08.006

      Abstract

      Coronary venous anatomy can be divided into the greater cardiac venous system and the lesser cardiac venous system. With protocol optimization, including appropriate contrast bolus timing, coronary veins can be depicted with excellent detail on CT. Knowledge of variant coronary venous anatomy can sometimes play a role in pre-procedural planning. Analysis of the coronary venous anatomy on CT can detect coronary venous anomalies that cause right to left shunts with risk of stroke, left to right shunts, and arrhythmias.

      Keywords

      1. Introduction

      Procedures such as left ventricular pacing, targeted drug therapy, delivery of stem cells to infarcted myocardium, and arrhythmia ablation require knowledge of coronary venous anatomy and anomalies.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      • Sanders P.
      • Jais P.
      • Hocini M.
      • Haissaguerre M.
      Electrical disconnection of the coronary sinus by radiofrequency catheter ablation to isolate a trigger of atrial fibrillation.
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      Coronary venous anatomy can be variable and coronary veins can even regress and disappear after myocardial infarction.
      • Boonyasirinant T.
      • Halliburton S.S.
      • Schoenhagen P.
      • Lieber M.L.
      • Flamm S.D.
      With protocol optimization including appropriate contrast bolus timing, ECG gated multidetector computed tomography (CT) can noninvasively show coronary venous anatomy with excellent detail. This can be useful for pre-procedural planning of some cardiac interventions. Adequate depiction of the coronary venous system can be achieved by modifying the CT coronary angiography technique such that data acquisition occurs 2–3 s later than normal. Magnetic resonance imaging has also been advocated as a tool for evaluating coronary venous anatomy but remains inferior to CT regarding image quality and resolution.
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      • Plein S.
      • Crean A.
      • Ball S.G.
      • Greenwood J.P.
      Visualization of coronary venous anatomy by cardiovascular magnetic resonance.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      In this article, we review both normal and variant coronary venous anatomy.

      2. Coronary venous system: anatomy overview

      The coronary venous system can be divided into two groups of veins: the greater cardiac venous system and the lesser cardiac venous system.

      2.1 Greater cardiac venous system

      • I.
        Coronary sinus and tributary veins
        • a.
          Coronary sinus
        • b.
          Great cardiac vein
        • c.
          Anterior interventricular vein
        • d.
          Left marginal vein
        • e.
          Left posterior veins
        • f.
          Oblique vein of Marshall
        • g.
          Posterior interventricular vein
        • h.
          Small cardiac vein
        • i.
          Ventricular septal veins
      • II.
        Veins draining the right ventricle
        • a.
          Right marginal vein
        • b.
          Anterior cardiac veins
        • c.
          Infundibular veins
          • i.
            Vein of Zuckerkandl
          • ii.
            Vein of Cruveilhier
      • III.
        Veins draining the atria

      2.2 Lesser cardiac venous system

      • I.
        Thebesian veins
        • a.
          Small vascular channels
        • b.
          Venous sinusoids
      While the greater cardiac venous system is much larger than the lesser cardiac venous system, both play an important role in the venous drainage of the heart. The greater cardiac venous system is illustrated in Fig. 1.
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      • Ho S.Y.
      • Sanchez-Quintana D.
      • Becker A.E.
      A review of the coronary venous system: a road less travelled.
      Fig. 1
      Fig. 1The greater cardiac venous system. Illustrations showing coronary venous anatomy of the greater cardiac venous system on coronal (A) and posterolateral (B) views of the heart.

      3. The greater coronary venous system

      3.1 Coronary sinus

      The coronary sinus (CS) is a tubular venous structure sitting in the inferior portion of the left atrioventricular groove that receives blood from many tributary veins before emptying into the posteromedial right atrium (Fig. 2). It is the largest cardiac venous structure, with a diameter measuring up to 12 mm and length ranging from 30 to 63 mm. A CS length of 20 mm or less is considered a short CS.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Saremi F.
      • Krishnan S.
      Cardiac conduction system: anatomic landmarks relevant to interventional electrophysiologic techniques demonstrated with 64-detector CT.
      • Isaacs D.
      • Hazany S.
      • Gamst A.
      • Stark P.
      • Mahmud E.
      Evaluation of the coronary sinus on chest computed tomography in patients with and without pulmonary artery hypertension.
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      Landmarks that externally demarcate the length of the CS include the right atrium distally and the oblique vein of Marshall proximally.
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      • de Oliveira I.M.
      • Scanavacca M.I.
      • Correia A.T.
      • Sosa E.A.
      • Aiello V.D.
      Anatomic relations of the Marshall vein: importance for catheterization of the coronary sinus in ablation procedures.
      A muscular sleeve surrounding the CS has been associated with arrhythmias, however this is not well visualized on CT. The muscular sleeve of the CS is contiguous with the muscle of the right and left atria and the muscular sleeve around the oblique vein of Marshall.
      • Sun Y.
      • Arruda M.
      • Otomo K.
      • et al.
      Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: incidence and electrophysiological identification.
      • Chauvin M.
      • Shah D.C.
      • Haissaguerre M.
      • Marcellin L.
      • Brechenmacher C.
      The anatomic basis of connections between the coronary sinus musculature and the left atrium in humans.
      • Haissaguerre M.
      • Hocini M.
      • Takahashi Y.
      • et al.
      Impact of catheter ablation of the coronary sinus on paroxysmal or persistent atrial fibrillation.
      • Saremi F.
      • Thonar B.
      • Sarlay T.
      • et al.
      Posterior interatrial muscular connection between the coronary sinus and left atrium: anatomic and functional study of the coronary sinus with multidetector CT.
      Fig. 2
      Fig. 2Coronary sinus. A: Axial CT image shows the coronary sinus (arrow) posterior to the left ventricle in the left atrioventricular groove and draining into the right atrium. B: Double oblique curved reformatted CT image from a CT angiogram through the level of the atria shows the coronary sinus draining into the right atrium. RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle, IVC = inferior vena cava, CS = coronary sinus.
      The CS has two valves: the Thebesian valve and the valve of Vieussens, which are shown in Fig. 2.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      The Thebesian valve, present up to 86% of the time, is located at the junction of the coronary sinus and the right atrium. It is visualized on CT in approximately 72% of individuals as a thin, hypodense linear structure at the junction of the CS and the right atrium. Image noise and heart failure can make it difficult to visualize the Thebesian valve the remainder of the time.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      Thebesian valve morphology varies.
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      Typically it is a thin semilunar fold with fenestrations and a height of 2–9 mm.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      ,
      • Biffi M.
      • Bertini M.
      • Ziacchi M.
      • et al.
      Clinical implications of left superior vena cava persistence in candidates for pacemaker or cardioverter-defibrillator implantation.
      In approximately 16% of people the Thebesian valve has features that make cannulation of the CS during cardiac procedures difficult. These features include: fibromuscular or muscular composition, covering over 75% of the ostium, and lack of fenestrations. Of these features, CT can detect when the Thebesian valve covers more than 75% of the CS ostium.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Mak G.S.
      • Hill A.J.
      • Moisuic F.
      • Krishnan S.C.
      Variations in Thebesian valve anatomy and coronary sinus ostium: implications for invasive electrophysiology procedures.
      The valve of Vieussens is located at the junction of the CS and the great cardiac vein, adjacent to where the oblique vein of Marshall enters the CS. It is present up to 87% of the time.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      When visible on CT, it may appear as a slight indentation at the junction of the great cardiac vein and the CS.
      • Saremi F.
      • Thonar B.
      • Sarlay T.
      • et al.
      Posterior interatrial muscular connection between the coronary sinus and left atrium: anatomic and functional study of the coronary sinus with multidetector CT.
      A prominent valve of Vieussens can make it difficult to advance a catheter into the great cardiac vein.
      • Corcoran S.J.
      • Lawrence C.
      • McGuire M.A.
      The valve of Vieussens: an important cause of difficulty in advancing cathetrs into the cardiac veins.
      Anomalies of the CS are uncommon and include enlargement, hypoplasia, and absence of the CS. A persistent left superior vena cava is an uncommon anomaly occurring in 0.3–0.5% of individuals and can result in enlargement of the coronary sinus (Fig. 3). A persistent left superior vena cava results from failure of the left common and left anterior cardinal veins to regress. The persistent left superior vena cava forms from the confluence of the left internal jugular and left subclavian veins and courses caudally, draining into the CS.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Goyal Sandeep K.
      • Punnam Sujeeth R.
      • Verma Gita
      • Ruberg Frederick L.
      Persistent left superior vena cava: a case report and review of literature.
      Fig. 3
      Fig. 3Persistent left superior vena cava (SVC). Axial CT image shows a left SVC present lateral to the aortic arch (thick arrow). Note there is also a smaller caliber right SVC present (thin arrow).
      Enlargement of the CS can also occur secondary to an unroofed CS, another rare anomaly. An unroofed CS consists of communication between the superior portion of the CS and the left atrium, resulting in a left to right shunt or sometimes a bidirectional shunt placing the individual at risk for cerebral embolus (Fig. 4).
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Hahm J.K.
      • Park Y.W.
      • Lee J.K.
      • et al.
      Magnetic resonance imaging of unroofed coronary sinus: three cases.
      Unroofed CS is strongly associated with a persistent left superior vena cava and other congenital heart disease.
      • Ootaki Y.
      • Yamaguchi M.
      • Yoshimura N.
      • Oka S.
      • Yoshida M.
      • Hasegawa T.
      Unroofed coronary sinus syndrome: diagnosis, classification, and surgical treatment.
      Fig. 4
      Fig. 4Unroofed coronary sinus. Curved reformatted CT image from a CT angiogram shows a connection between the superior portion of the coronary sinus and the left atrium (arrow). CS = coronary sinus, LV = left ventricle, LA = left atrium. Image courtesy of Jeffrey P. Kanne (Madison, WI).
      Additional rare causes of CS enlargement include coronary artery fistulae, partial and total anomalous pulmonary venous return (PAPVR and TAPVR), and interrupted inferior vena cava. Fistulae between the coronary arteries and the CS are usually congenital and result in enlargement of both the coronary artery and the CS (Fig. 5).
      • Mirmohammadsadeghi M.
      • Salimi-Jazi F.
      • Rabbani M.
      Multiple right coronary artery fistulas to coronary sinus: a case report and literature review.
      In PAPVR/TAPVR, pulmonary veins may anomalously drain into the CS which also has an association with unroofed CS.
      • Laux D.
      • Houyel L.
      • Bajolle F.
      • Bonnet D.
      Total anomalous pulmonary venous connection to the unroofed coronary sinus in a neonate.
      ,
      • Bo I.
      • Carvalho J.S.
      • Cheasty E.
      • Rubens M.
      • Rigby M.L.
      Variants of the scimitar syndrome.
      Interruption of the inferior vena cava with drainage of the hepatic veins directly to the CS as well as hemiazygous continuation of a left inferior vena cava with drainage into the CS via a persistent left superior vena cava can also lead to CS dilation.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      Fig. 5
      Fig. 5Coronary artery fistula to the coronary sinus. A tortuous right coronary artery (arrows) connects to the coronary sinus (*), resulting in dilation of both the right coronary artery and the coronary sinus. RA = right atrium, RV = right ventricle, IVC = inferior vena cava, LV = left ventricle, CS = coronary sinus, DA = descending aorta.
      A rare condition associated with absence of the CS is Raghib syndrome. In Raghib syndrome, the CS is absent and a persistent left superior vena cava drains directly into the left atrium resulting in a right to left shunt (Fig. 6). An atrial septal defect is commonly although not invariably present in the posterior/inferior portion of the interatrial septum. Patients may present with paradoxical stroke. Veins that would normally empty into the CS may drain into the superior vena cava or left atrium.
      • Daruwalla V.J.
      • Parekh K.
      • Tahir H.
      • Collins J.D.
      • Carr J.
      Raghib syndrome presenting as a cryptogenic stroke: role of cardiac MRI in accurate diagnosis.
      ,
      • Okumori M.
      • Hyuga M.
      • Ogata S.
      • Akamatsu T.
      • Otomi S.
      • Ota S.
      Raghib's syndrome: a report of two cases.
      Fig. 6
      Fig. 6Raghib syndrome. Curved reformatted oblique CT image from a CT angiogram shows a right superior vena cava (SVC) draining into the right atrium and a persistent left SVC draining into the left atrium. No coronary sinus is present. RA = right atrium, LA = left atrium, PA = pulmonary artery, AA = ascending aorta.

      3.2 Coronary sinus tributary veins

      The CS receives bloodflow from many coronary veins. Some veins drain directly into the CS while others contribute to the venous return to the CS indirectly by draining into other coronary veins that drain into the coronary sinus. Coronary veins that directly or indirectly contribute to the venous return of the CS are commonly referred to collectively as CS tributary veins and include: the great cardiac vein, the anterior interventricular vein, the left marginal vein, left posterior veins, oblique vein of Marshall, posterior interventricular vein, small cardiac vein, and ventricular septal veins.

      3.2.1 Great cardiac vein and anterior interventricular vein

      The anterior interventricular vein travels in the anterior interventricular groove with the left anterior descending coronary artery (LAD) (Fig. 7). It typically arises at the left ventricular apex, but occasionally in the mid portion of the anterior interventricular groove.
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      Its relationship to the LAD is variable as it can be located right, left, superficial, or deep relative to the LAD. Crossing into the left antrioventricular groove, it creates a characteristic triangle with the left anterior descending and left circumflex coronary arteries known as the trigone of Brocq and Mouchet.
      • Pejkovic B.
      • Bogdanovic D.
      The great cardiac vein.
      Once in the left atrioventricular groove, it is referred to as the great cardiac vein (Fig. 8).
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      Fig. 7
      Fig. 7Anterior interventricular vein. Curved reformatted maximum intensity projection CT angiogram image shows the anterior interventricular vein traveling in the anterior interventricular groove with the left anterior descending coronary artery. SVC = superior vena cava, AA = ascending aorta, RVOT = right ventricular outflow tract, LA = left atrium, LM = left main coronary artery, LAD = left anterior descending artery.
      Fig. 8
      Fig. 8Great cardiac vein. Curved reformatted maximal intensity projection CT image shows the anterior interventricular vein (AIV) traveling in the anterior interventricular groove with the left anterior descending coronary artery (LAD). The AIV then crosses the LAD and the left circumflex artery to enter the left atrioventricular groove where it becomes the great cardiac vein. PA = pulmonary artery, AA = ascending aorta, LA = left atrium, SVC = superior vena cava, LAD = left anterior descending coronary artery, LM = left main coronary artery, LCX = left circumflex artery.
      The great cardiac vein continues within the left atrioventricular groove alongside the left circumflex artery, empyting into the CS. Similar to the anterior interventricular vein, the relationship of the great cardiac vein to the left circumflex artery is highly variable. It may be located left, right, superficial, or deep to the left circumflex coronary artery.
      • Shah S.S.
      • Teague S.D.
      • Lu J.C.
      • Dorfman A.L.
      • Kazerooni E.A.
      • Agarwal P.P.
      Imaging of the coronary sinus: normal anatomy and congenital abnormalities.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      ,
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      ,
      • Bales G.S.
      Great cardiac vein variations.
      The transition point between the great coronary vein and the CS is demarcated internally by the valve of Veiussens and externally by the oblique vein of Marshall.
      • Saremi F.
      • Krishnan S.
      Cardiac conduction system: anatomic landmarks relevant to interventional electrophysiologic techniques demonstrated with 64-detector CT.
      ,
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      The anterior interventricular vein and great cardiac vein drain the left ventricular apex, anterior interventricular septum, anterior portions of both ventricles, and part of the left atrium.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      Anomalies of these two cardiac veins are uncommon and include myocardial bridging of the anterior interventricular vein, anomalous course through the transverse sinus empyting into the superior vena cava or right atrium (Fig. 9), and aneurysmal dilation of the great cardiac vein.
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      ,
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      ,
      • Loukas M.
      • Tubbs R.S.
      • Jordan R.
      Aneurysm of the great cardiac vein.
      Fig. 9
      Fig. 9Anomalous course of the great cardiac vein. Maximum intensity projection CT angiogram image shows an anomalous course of the great cardiac vein which courses through the transverse sinus to drain into the superior vena cava (SVC). LAD = left anterior descending coronary artery, AA = ascending aorta, PA = pulmonary artery, LA = left atrium, RA = right atrium. Image courtesy of Cheng Ting Ling (Baltimore, MD).

      3.2.2 Left marginal vein

      The left marginal vein, also known as the left obtuse marginal vein, travels alongside the lateral border of the left ventricle with one of the obtuse marginal arterial branches of the left circumflex artery and drains the lateral wall of the left ventricle (Fig. 10). It is present in up to 85% of individuals and usually drains into the great cardiac vein. Approximately 20% of the time it drains into the CS.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      ,
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      ,
      • Loukas M.
      • Bilinksy S.
      • Bilinsky E.
      • el-Sedfy A.
      • Anderson R.H.
      Cardiac veins: a review of the linterature.
      Fig. 10
      Fig. 10Left marginal vein. Axial CT angiogram image shows the left marginal vein coursing along the lateral border of the left ventricle alongside an obtuse marginal artery branch and then draining into the great cardiac vein. PA = pulmonary artery, AA = ascending aorta, SVC = superior vena cava, LA = left atrium, LV = left ventricle, OM1 = first obtuse marginal artery branch, OM2 = second obtuse marginal branch, DA = descending aorta.

      3.2.3 Left posterior veins

      The left posterior veins, also known as the posterolateral veins, range from one to three in number, course along the lateral and inferior walls of the left ventricle, and typically drain into the CS (Fig. 11).
      • Singh J.P.
      • Houser S.
      • Seist E.K.
      • Ruskin J.N.
      The coronary venous anatomy: a segmental approach to aid cardiac resynchronization therapy.
      ,
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      Approximately 15% of the time they drain into the great cardiac vein. Approximately 5% of the time, there is no left posterior vein and the left marginal vein drains the left ventricular posterolateral wall by itself.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      Fig. 11
      Fig. 11Left posterior veins. Maximum intensity projection CT angiogram image shows two left posterior veins draining into the coronary sinus. RV = right ventricle, LV = left ventricle, RA = right atrium, CS = coronary sinus.

      3.2.4 Oblique vein of Marshall

      The oblique vein of Marshall, also known as the oblique vein of the left atrium, is present in up to 95% of individuals and is a remnant of the left superior vena cava. It is a short vein of approximately 2–3 cm that courses between the left atrial appendage and left pulmonary veins to join the CS at its junction with the valve of Vieussens (Fig. 2B). It can be completely fibrotic with only a ligament of Marshall remaining. The ligament of Marshall appears as a thin band of soft tissue on CT.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      ,
      • de Oliveira I.M.
      • Scanavacca M.I.
      • Correia A.T.
      • Sosa E.A.
      • Aiello V.D.
      Anatomic relations of the Marshall vein: importance for catheterization of the coronary sinus in ablation procedures.
      ,
      • Kim D.T.
      • Lai A.C.
      • Hwang C.
      • et al.
      The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias.
      The oblique vein of Marshall is surrounded by a muscular sleeve called the Marshall bundle. The Marshall bundle connects to the musculature surrounding the pulmonary veins and the coronary sinus. The Marshall bundle is associated with various arrhythmias.
      • Hwang C.
      • Wu T.J.
      • Doshi R.N.
      • Peter C.T.
      • Chen P.S.
      Vein of Marshall cannulation for the analysis of electrical activity in patients with focal atrial fibrillation.
      ,
      • Chauvin M.
      • Shah D.C.
      • Haissaguerre M.
      • Marcellin L.
      • Brechenmacher C.
      The anatomic basis of connections between the coronary sinus musculature and the left atrium in humans.
      Rarely, the oblique vein of Marshall persists as a left superior vena cava.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.

      3.2.5 Posterior interventricular vein

      The posterior interventricular vein is also known as the inferior interventricular vein and the middle cardiac vein. The posterior interventricular vein arises at the left ventricular apex and travels in the posterior interventricular groove with the posterior descending artery and drains into the coronary sinus (Fig. 12).
      • Genc B.
      • Solak A.
      • Sahin N.
      • gur S.
      • Kalaycioglu S.
      • Ozturk V.
      Assessment of the coronary venous system by using cardiac CT.
      It drains a portion of the apex, the posterior interventricular septum, and the posterior walls of the ventricles. The posterior interventricular vein can become aneurysmal or have a diverticulum at its junction with the CS, both of which have been associated with cardiac arrhythmias.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • Sun Y.
      • Arruda M.
      • Otomo K.
      • et al.
      Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: incidence and electrophysiological identification.
      Fig. 12
      Fig. 12Posterior interventricular vein. Maximum intensity projection CT image shows the posterior interventricular vein coursing in the posterior interventricular groove with the posterior descending coronary artery and then draining into the coronary sinus. LV = left ventricle. CS = coronary sinus.

      3.2.6 Small cardiac vein

      The small cardiac vein, sometimes referred to as the right coronary vein in older literature, travels in the right atrioventricular groove with the right coronary artery and usually empties into the CS (Fig. 13). Less commonly it may empty into the posterior interventricular vein or occasionally into the right atrium. It drains the inferior wall of the right ventricle and is present in approximately 50% of people.
      • Ortale Jr.,
      • Gabriel E.A.
      • Iost C.
      • Marquez C.Q.
      The anatomy of the coronary sinus and its tributaries.
      ,
      • Cendrowska-Pinkosz M.
      The variability of the small cardiac vein in the adult human heart.
      Fig. 13
      Fig. 13Small cardiac vein. The small cardiac vein travels with the right coronary artery (RCA) in the right atrioventricular groove and then empties into the coronary sinus. RV = right ventricle, LV = left ventricle.

      3.2.7 Ventricular septal veins

      The ventricular septal veins are parallel sets of veins draining the interventricular septum. They empty into the anterior interventricular vein and the posterior interventricular vein (Fig. 14).
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      Fig. 14
      Fig. 14Ventricular septal veins. Axial CT image shows septal veins draining into the anterior interventricular vein (A) and into the posterior interventricular vein (B). PA = pulmonary artery, AA = ascending aorta, RA = right atrium, LA = left atrium, LM = left main coronary artery, LCX = left circumflex coronary artery, LAD = left anterior descending coronary artery, AIV = anterior interventricular vein, RCA = right coronary artery, PDA = posterior descending artery, RV = right ventricle.

      3.3 Veins draining the right ventricle

      The veins draining the right ventricle consist of the right marginal vein, the anterior cardiac veins, and the infundibular veins. The right marginal vein travels along the lateral wall of the right ventricle alongside the right marginal artery and drains directly into the right atrium (Fig. 15). Approximately one-third of the time, the right marginal vein drains into the small cardiac vein.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      ,
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      Fig. 15
      Fig. 15Right marginal vein. Axial CT image shows the right marginal vein traveling alongside the right acute marginal artery along the lateral right ventricle. RA = right atrium, RV = right ventricle, LV = left ventricle, LA = left atrium, DA = descending aorta.
      Anterior cardiac veins vary in number. They drain up to two-thirds of the right ventricle and empty directly into the right atrium just above the right atrioventricular groove (Fig. 16).
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      The infundibular veins consist of the vein of Zuckerkandl and vein of Cruveilhier, which drain the anterior and posterior portions of the infundibulum respectively.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.
      Fig. 16
      Fig. 16Coronal oblique maximum intensity projection CT image shows the anterior cardiac veins and theinfundibular vein. RCA = right coronary artery, RV = right ventricle.

      3.4 Veins draining the atria

      The left atrium is drained by many small caliber coronary veins that empty into a variety of structures depending on their proximity: coronary sinus, great cardiac vein, superior pulmonary vein, mediastinal veins, and right atrium.
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.
      The right atrium is drained by the thebesian vessels of the lesser coronary venous system, as detailed in the next section.
      • Saremi F.
      • Muresian H.
      • Sanchez-Quintana D.
      Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.

      4. The lesser coronary venous system

      4.1 Thebesian vessels

      The thebesian vessels are a complex network of small vascular channels and sinusoids that drain the inner third of the myocardium. They empty directly into the four cardiac chambers, and are most prevalent in the right atrium and right ventricle.
      • von Lüdinghausen M.
      The venous drainage of the human myocardium.

      5. Conclusion

      Coronary venous anatomy can be depicted with excellent detail using CT. Knowledge of coronary venous anatomy and anomalies can play a part in the planning various procedures such as left ventricular pacing. Analysis of the coronary venous anatomy on CT can detect coronary venous anomalies causing right to left shunts with risk of stroke, left to right shunts, and arrhythmias.

      Funding and conflicts of interest

      This work was supported by the Intramural Research Program of the National Heart, Lung, and Blood Institute , National Institutes of Health, USA . Andrew E. Arai is a principal investigator on a US government Cooperative Research and Development Agreement (CRADA) with Siemens Healthineers, Bayer Healthcare Pharmaceuticals, and Circle Cardiovascular imaging. Marcus Y. Chen has a research agreement with Canon Medical Systems. Other coauthors have no conflicts of interest relevant to this publication to declare.

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