Real time three-dimensional transesophageal echocardiography guided coronary sinus cannulation during CARILLON mitral annuloplasty device therapy for a patient with chronic severe mitral regurgitation

Abstract

The coronary sinus (CS) has become a clinically important structure especially through its role in providing access for different cardiac procedures such as arrhythmia ablation, biventricular pacing and recently, percutaneous valvular interventions. Fluoroscopy with or without two-dimensional transesophageal echocardiography is the widely used method for guidance. A 78-year-old female patient undergoing percutaneous CARILLON mitral annuloplasty device therapy for chronic severe symptomatic mitral regurgitation. After insertion of the CS catheter through the right internal jugular vein, multiple trials for CS cannulation guided by fluoroscopy and two-dimensional transesophageal echocardiography were unsuccessful. So, real time three-dimensional zoom mode was used. Then, the volume was rotated to have the anatomically oriented enface view of the interatrial septum from the right atrial perspective. The CS ostium was identified adjacent to the eustachian valve. Then the catheter was reintroduced through the superior vena cava into the right atrium then easily navigated to cannulate the CS ostium. The position was confirmed by the fluoroscopically known course of the CS plus the pattern of the invasive pressure wave form. CS cannulation is not always feasible using fluoroscopy and/or two-dimensional Echocardiography guidance. Real time three-dimensional transesophageal echocardiography can be used to guide CS cannulation as it provides an anatomically oriented and informative enface view of the CS ostium. It can help reducing fluoroscopic radiation time. Mini-Abstract The coronary sinus (CS) has become a clinically important structure especially through its role in providing access for different cardiac procedures. Fluoroscopy with or without two dimensional transesophageal echocardiography (2DTEE) is the widely used method for guidance. A 78-year-old female patient was undergoing percutaneous CARILLON mitral annuloplasty device therapy for chronic severe symptomatic mitral regurgitation. After insertion of the coronary sinus catheter through the right internal jugular vein, multiple trials for coronary sinus cannulation guided by fluoroscopy and 2DTEE were unsuccessful. So, real time three-dimensional zoom mode was used to get the anatomically oriented en face view of the interatrial septum from the right atrial perspective. The CS ostium was identified then the catheter was reintroduced through the SVC into the right atrium then easily navigated to cannulate the coronary sinus ostium.