The technique of sinus catheterization in
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Postgraduate Medical Journal (October 1972) 48, 599-602. The technique of coronary sinus catheterization in man BRIAN LIVESLEY* M.B.(Leeds), M.R.C.P.(U.K.) Department of Cardiology, King's College Hospital, London, S.E.5 Summary A simple method for catheterization of the coronary sinus in man has been described. It has been used successfully in more than ninety patients. Introduction Although a technique for catheterization of the coronary sinus in the intact dog was reported in 1948 (Goodale et al.) elective catheterization of the coronary sinus in man has been regarded as a difficult procedure because either the Eustachian ridge or a prominent Thebesian valve is apt to over- lie the entrance of the sinus (Bing, 1951). The diffi- culty in finding the ostium has been one of the most serious obstacles to broader applications of this technique in man. Only a few previous workers have reported their results and these have been reviewed (Bing & Castellanos, 1959). The highest incidence of successful catheterization has been reported to be 75%°. It is perhaps because of the previously 'hit-or- miss' nature of the procedure that a satisfactory technique in man has not been described when catheterization has been successful (Bing et al., 1947; Goodale et al., 1949; Banfield, Hackle & Goodale, 1950; Bing & Daley, 1951; Miller, Kaplan & Katz, 1953; Harris & Summerhayes, 1955; Lancaster et al., 1965; Yum & Miller, 1969). However, fortuitous and inadvertent catheterization of the coronary sinus in man has been recorded (Bing et al., 1947; Sosman, 1947; Culbertson, Halperin & Wilkins, 1949; McMichael & Mounsey, 1951; Smith, Albert & Rader, 1951; Meyer & Millar, 1969; Castellanos & Castillo, 1970) and on occasion has resulted in perforation of the sinus (McMichael & Mounsey, 1951; Smith et al., 1951). Although deep catheteriza- tion of the sinus has been performed without hazard (Harris & Summerhayes, 1955) it is obviously potentially dangerous (Miller et al., 1953). This is especially so when, after inadvertent catheterization, the operator believes the catheter is positioned in the pulmonary artery and then tries to pass it on to the pulmonary 'wedge' position. This danger should * Supported by a Research Grant from Pfizer Ltd, Sandwich, Kent. be anticipated whenever the catheter is being viewed in the sagittal plane during a right heart study and can be avoided either by performing a retrograde venogram (Yum & Miller, 1969; Fig. le), or an intracardiac electrogram; (Fig. 2f). To enable myocardial metabolism to be investi- gated in man (Livesley, Catley & Oram, 1972) a reliable and simple method of coronary sinus catheterization had to be devised. As a result of personal experience in earlier unpublished studies in the dog, a new technique was developed which was immediately successful in man. In more than ninety patients, on no occasion was there failure to locate the coronary ostium and catheterize the sinus when this simple method was used, despite an earlier suggestion that the presence of the Thebesian valve would make this unlikely in 25% of cases (Heller- stein & Orbison, 1951). Materials and methods Using an aseptic technique and local anaesthesia, a No. 6 or 7F Zucker bipolar sampling catheter (Zucker, Rothfield & Bernstein, 1965) is passed via a left or right antecubital vein previously isolated through a small skin incision. This catheter allows simultaneous pacing and sampling from the coro- nary sinus which is convenient for both the patient and the operator. To prevent clotting, the catheter is filled with normal saline containing 500 IU heparin/ml, some 30 min prior to the procedure. The whole period of radiographic screening leading up to positioning of the catheter in the coronary sinus usually occupies less than 4 min. Once in the superior vena cava (Fig. la) the cath- eter is advanced into the right atrium and then rotated along the posterior atrial wall (Fig. Ib) to a site just above the septal leaflet of the tricuspid valve (Fig. Ic) as indicated by a slight resistance to the forward direction of the catheter. The ostium of the coronary sinus is located when atrial premature beats with inverted P-waves occur on the electrocardio- gram. At this stage, gentle advancement of the cathe- ter allows it to enter the coronary sinus where it is placed in a non-obstructing mid-position (Fig. ld). copyright. on April 4, 2022 by guest. Protected by http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/pgmj.48.564.599 on 1 October 1972. Downloaded from
Transcript of The technique of sinus catheterization in
Postgraduate Medical Journal (October 1972) 48, 599-602.
The technique of coronary sinus catheterization in man
BRIAN LIVESLEY*M.B.(Leeds), M.R.C.P.(U.K.)
Department of Cardiology, King's College Hospital, London, S.E.5
SummaryA simple method for catheterization of the coronarysinus in man has been described. It has been usedsuccessfully in more than ninety patients.
IntroductionAlthough a technique for catheterization of the
coronary sinus in the intact dog was reported in1948 (Goodale et al.) elective catheterization of thecoronary sinus in man has been regarded as adifficult procedure because either the Eustachianridge or a prominent Thebesian valve is apt to over-lie the entrance of the sinus (Bing, 1951). The diffi-culty in finding the ostium has been one of the mostserious obstacles to broader applications of thistechnique in man. Only a few previous workers havereported their results and these have been reviewed(Bing & Castellanos, 1959). The highest incidence ofsuccessful catheterization has been reported to be75%°. It is perhaps because of the previously 'hit-or-miss' nature of the procedure that a satisfactorytechnique in man has not been described whencatheterization has been successful (Bing et al., 1947;Goodale et al., 1949; Banfield, Hackle & Goodale,1950; Bing & Daley, 1951; Miller, Kaplan & Katz,1953; Harris & Summerhayes, 1955; Lancaster et al.,1965; Yum & Miller, 1969). However, fortuitousand inadvertent catheterization of the coronary sinusin man has been recorded (Bing et al., 1947; Sosman,1947; Culbertson, Halperin & Wilkins, 1949;McMichael & Mounsey, 1951; Smith, Albert &Rader, 1951; Meyer & Millar, 1969; Castellanos &Castillo, 1970) and on occasion has resulted inperforation of the sinus (McMichael & Mounsey,1951; Smith et al., 1951). Although deep catheteriza-tion of the sinus has been performed without hazard(Harris & Summerhayes, 1955) it is obviouslypotentially dangerous (Miller et al., 1953). This isespecially so when, after inadvertent catheterization,the operator believes the catheter is positioned inthe pulmonary artery and then tries to pass it on tothe pulmonary 'wedge' position. This danger should
* Supported by a Research Grant from Pfizer Ltd,Sandwich, Kent.
be anticipated whenever the catheter is being viewedin the sagittal plane during a right heart study andcan be avoided either by performing a retrogradevenogram (Yum & Miller, 1969; Fig. le), or anintracardiac electrogram; (Fig. 2f).To enable myocardial metabolism to be investi-
gated in man (Livesley, Catley & Oram, 1972) areliable and simple method of coronary sinuscatheterization had to be devised. As a result ofpersonal experience in earlier unpublished studies inthe dog, a new technique was developed which wasimmediately successful in man. In more than ninetypatients, on no occasion was there failure to locatethe coronary ostium and catheterize the sinus whenthis simple method was used, despite an earliersuggestion that the presence of the Thebesian valvewould make this unlikely in 25% of cases (Heller-stein & Orbison, 1951).
Materials and methodsUsing an aseptic technique and local anaesthesia, a
No. 6 or 7F Zucker bipolar sampling catheter(Zucker, Rothfield & Bernstein, 1965) is passed viaa left or right antecubital vein previously isolatedthrough a small skin incision. This catheter allowssimultaneous pacing and sampling from the coro-nary sinus which is convenient for both the patientand the operator. To prevent clotting, the catheteris filled with normal saline containing 500 IUheparin/ml, some 30 min prior to the procedure.The whole period of radiographic screening leadingup to positioning of the catheter in the coronary sinususually occupies less than 4 min.Once in the superior vena cava (Fig. la) the cath-
eter is advanced into the right atrium and thenrotated along the posterior atrial wall (Fig. Ib) to asite just above the septal leaflet of the tricuspid valve(Fig. Ic) as indicated by a slight resistance to theforward direction of the catheter. The ostium of thecoronary sinus is located when atrial premature beatswith inverted P-waves occur on the electrocardio-gram. At this stage, gentle advancement of the cathe-ter allows it to enter the coronary sinus where it isplaced in a non-obstructing mid-position (Fig. ld).
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FIG. 1. From the superior vena cava (a) the catheter is advanced into the right atriumand rotated along the posterior atrial wall (b) to a site just above the septal leaflet of thetricuspid valve (c). The catheter is placed in a non-obstructing mid-position in thecoronary sinus (d) and its position confirmed by retrograde venogram (e) with freewash-out of dye into the atrium (f). The alternative initial procedure for catheterizationof the sinus begins with a 'hockey-stick' position of the catheter against the lateral atrialwall (g) and then the distal portion becomes horizontal (h) prior to antero-medialrotation of the catheter tip into the ostium of the coronary sinus.
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Coronary sinus catheterization in man 601
This position can be confirmed by a retrogradevenogram, injecting a few millilitres of 65% Hypaquesolution by hand pressure, which outlines the sinus(Fig. le) and its tributaries, and then the radio-opaque dye shows free washout into the atrium(Fig. If).The position of the catheter can be checked during
a sampling and pacing procedure using an underly-ing rib shadow as a reference point. At the end ofthe procedure a repeat venogram acts as a final checkon the position of the catheter immediately prior toits withdrawal.
If, in the initial stages of the procedure, the cath-eter is advanced in an anterior-inferior direction theanterior cardiac veins can be entered in error. Thisis shown by a ventricular position of the catheter inthe absence of ventricular premature beats on theelectrocardiogram and can be confirmed by retro-grade venogram.The sinus could not be entered in the direct manner
described above in only four of the first thirtypatients. In these patients the procedure was modi-fied as follows: a 'hockey-stick' position was ob-tained with the catheter tip against the lateral atrialwall (Fig. 1g). The catheter was then advanced untilthe distal portion became horizontal (Fig. lh). Thepatient's head was then turned fully away from theoperator to stabilize the catheter in the superiormediastinum. The catheter was then slowly rotated
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FIG. 2. Electrogram patterns obtained from a bipolarcatheter in the right innominate vein (a), superior venacava (b), inferior cava (c), at the sino-atrial node (d), inthe atrial cavity (e), in the coronary sinus (f), across thetricuspid valve (g), in contact with the ventricular wall(h)- lodaed in the ventricular wall (iM.
antero-medially until the ostium of the coronarysinus was located as before and the catheter was thenentered into the sinus. In more than sixty subse-quent patients the direct approach has always beensuccessful. Any occasional initial difficulty could beovercome by using the smaller 6F catheter.
DiscussionThe complications of catheterization of the coro-
nary sinus are those of a simple proximal right heartcatheterization study. Indeed, the hazards of theprocedure are much less than the intubation of theright ventricle and pulmonary artery necessitated byright heart catheterization, because the sinus issituated in the subepicardial layers ofthe right atriumfar removed from the sensitive ventricular areas ofthe endocardium. The pacing-sampling procedure iscarried out on out-patients who are allowed to gohome after resting for 1 hr.As the catheter is advanced along the vein in the
arm, some patients experience a transient un-pleasant sensation which lasts until the innominatevein is entered.When the catheter tip touches the atrial wall,
atrial premature beats occur especially when the tipis near the orifice of the coronary sinus. In this seriesonly one patient developed a prolonged bout ofatrial fibrillation which subsequently spontaneouslyreverted to sinus rhythm and which did not preventcatheterization of the sinus.On the occasions when the catheter passes across
the tricuspid valve, irritation of the right ventricleproduces a ventricular ectopic rhythm which settlesas soon as the catheter is withdrawn to the superiorvena cava. This phenomenon is usual during rightheart catheterization.Using the simple technique described above there
have been no other complications.
AcknowledgmentsThe author wishes to acknowledge with gratitude the en-
couragement which Dr Samuel Oram has given to this work.This catheterization technique was developed using a
Sierex Cinefluographic Unit which had previously beendonated by The Wates Foundation. The illustrations havebeen provided by the Department of Medical Photography,King's College Hospital.
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