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Cardiovascular Anesthesiology: Echo Rounds

Difficult Cannulation of the Coronary Sinus Due to a Large Thebesian Valve

Kuroda, Masataka MD, PhD*; Takahashi, Toshikazu MD; Mita, Norikatsu MD; Kagaya, Shin MD, PhD; Miyoshi, Sohtaro MD, PhD; Saito, Shigeru MD, PhD*

Author Information
doi: 10.1213/ANE.0b013e31827bc77e

A 59-year-old man with a history of diabetes mellitus and renal dysfunction was scheduled for aortic valve replacement via a full median sternotomy, to treat moderate aortic stenosis due to a bicuspid aortic valve.

After anesthetic induction and tracheal intubation, a transesophageal echocardiography (TEE) probe (X7-2t transducer, Philips Healthcare, Andover, MA) was inserted into the esophagus to intraoperatively assess cardiac function, guide the placement of cannulae, and assess the competency of the aortic valve prosthesis. The surgical plan was to administer the cardioplegic solution via a combination of anterograde and retrograde methods. TEE was used to guide cannulation of the coronary sinus (CS) for retrograde coronary perfusion. After scanning in the midesophageal 4-chamber view with the multiplane angle at 0°, the probe was turned slightly clockwise, while slowly advancing and slightly retroflexing it, and the CS was visualized at a sector depth of 7 cm. A large, dynamically moving Thebesian valve was noticed at the ostium of the CS (Fig. 1A, Video 1, see Supplemental Digital Content 1,, with echogenecity similar to the surrounding walls. It was imaged to originate from the atrial wall, posterior (dorsal) to the site of the CS ostium. Its dynamic motion obstructed the ostium of the CS in diastole. With color Doppler, flow from the CS into the right atrium (RA) was seen in systole (Fig. 1B, Video 1, see Supplemental Digital Content 1,, but not in diastole (Fig. 1C, Video 1, see Supplemental Digital Content 1, Orthogonal views scanned using the X-plane mode (Philips, Healthcare, Inc.), which scans and displays 2 independent 2-dimensional scanning planes, simultaneously demonstrated that the Thebesian valve was partly attached to the interatrial septum, superior (cranial) to the site of the CS ostium at the multiplane 90° angle (Fig. 2, Video 2, see Supplemental Digital Content 2, Although the surgeon attempted to place the CS cannula (Retro-Self Inflate for cardio-protection; Edwards Lifesciences, Inc., Irvine, CA) under direct echocardiographic guidance, the cannula was observed to press the Thebesian valve into the CS and obstruct the orifice at the multiplane 34° angle (Video 3, see Supplemental Digital Content 3, Following the suggestion that the tip of the cannula should be directed to approach the CS ostium from the anterior-inferior direction, from the site without attachment of the valve (asterisk in Fig. 2), the cannula was successfully placed in the CS. Appropriate positioning of the CS cannula, with the cannula tip placed 2 cm from the ostium into the CS and the balloon inward from the ostium, was confirmed by TEE examination (Video 3, see Supplemental Digital Content 3, Retrograde perfusion via the CS was satisfactory and the subsequent operative course was uneventful. The patient recovered without any apparent complications postoperatively.

Figure 1
Figure 1:
Two-dimensional, color flow Doppler analysis of the Thebesian valve. A, A large Thebesian valve was scanned at the multiplane 0° angle of the modified midesophageal 4-chamber view. B, During ventricular systole. C, During ventricular diastole. CS = coronary sinus; RA = right atrium; PAC = pulmonary artery catheter; RV = right ventricle; TEE = transesophageal echocardiography.
Figure 2
Figure 2:
X-plane scanning of the axis of the Thebesian valve. The Thebesian valve was seen to originate not only from the posterior wall of the RA at the multiplane 0° angle (left panel), but also from the interatrial septum at the 90° angle (right panel). * indicates the leading site of the catheter tip (the catheter cannot be seen in this figure). # indicates the attachment site of the Thebesian valve. RA = right atrium; RV = right ventricle; CS = coronary sinus; LA = left atrium; IAS = interatrial septum; PAC = pulmonary artery catheter.


The Thebesian valve is a caudal remnant of embryonic sinoatrial valves that has been known to display significant variation. In a series of 75 autopsied human hearts,1 most of the valves were membranous in composition (46%), followed by fibrous (24%), fibromuscular (11%), and muscular compositions (18%). Fenestrations were noted in 26% of valves. More importantly, 27% of hearts had a valve that covered more than 75% of the coronary ostium. Fiberoptic endocardial study during cardiac resynchronization therapy2 demonstrated that most valves originated from either the inferior (61%) or posterior (33%) aspect of the ostium, with anterior insertion being found in 6% of cases.

Although the role of the Thebesian valve in normal physiology remains unclear, experience from clinical practice suggests that the valve may interfere with cannulation of the CS.1 When the valve is nonfenestrated, covers >75% of the ostium, and is fibrous, fibromuscular, or muscular in composition, it has the potential to prevent cannulation.1 Endoscopic study of isolated hearts has shown that cannulation can also be complicated by motion of the Thebesian valve during the cardiac cycle.3 The motion of the Thebesian valve is passive, reflecting the relative changes in pressures between the CS and RA, and does not always prevent cannulation. However, a large sized valve, as seen in our patient, can make its motion prominent enough to interfere with cannulation of the CS ostium. As indicated by the thickness, intensity and rigid motion of the valve in our case, its composition seemed to be fibrous or fibromuscular rather than membranous. Furthermore, the CS is usually cannulated using a superior-anterior approach. In our patient, however, the Thebesian valve was attached not only to the posterior aspect of the CS ostium, but also superiorly. This might be a rare origin of the Thebesian valve, which can potentially interfere with catheter insertion. Although 3-dimensional echocardiography may have been helpful for evaluating the spatial relationships between the Thebesian valve and the CS ostium, the quality of the 3-dimensional images obtained in this case was too low and could not be scanned.

Some previous reports have suggested that TEE is useful for guiding placement of the CS catheter in patients undergoing minimally invasive cardiac operations,4,5 and those in whom a Chiari network is likely to impede advancement of the catheter, due to the possibility of entanglement of the cannula in the fibers of the network.6 In cases with a large Thebesian valve such as ours, if TEE-guided change in direction of the catheter does not result in successful cannulation, catheter insertion with simultaneous valve opening during ventricular systole under TEE guidance might also be effective, provided the patient does not have tachycardia. Furthermore, CS cannulation in a nonbeating heart might be easier than in a beating heart, because of the absence of valve motion. However, care should be taken to avoid CS injury during the procedure, because in those situations, cannulation is performed without direct visualization. Cannulation under direct visualization minimizes the risk of trauma associated with repeated blind attempts, although it requires bicaval cannulation, right atriotomy, and RA emptying.

Thebesian valves need to be differentiated from other embryologic remnants that could possibly interfere with right-sided cannula insertion, such as the Eustachian valve7 and Chiari network,6 the characteristics of which are displayed in Table 1.

Table 1
Table 1:
Embryologic Remnants That Have the Potential to Interfere with Right-Sided Cannula Insertion

In conclusion, a large, fibrous, dynamic, and anomalously originating Thebesian valve can lead to difficulty in placement of the retrograde cardioplegia catheter into the coronary ostium. In such cases, TEE is a useful guide for the appropriate direction and timing of cannula insertion.

Video 1
Video 1:
Large, dynamic Thebesian valve. First part: Two-dimensional scanning of a large Thebesian valve demonstrating its motion in association with the cardiac cycle. Second part: Color flow Doppler analysis revealed venous inflow from the coronary sinus (CS) to the right atrium (RA).
Video 2
Video 2:
Orthogonal views scanned by the X-plane mode. The Thebesian valve was attached to the posterior wall of the right atrium (RA) at the 0° angle and the interatrial septum at the 90° angle.
Video 3
Video 3:
Cannulation of the coronary sinus (CS) ostium. First part: Obstruction of the CS ostium by the Thebesian valve after the surgeon attempted to insert the cannula. Second part: Successful insertion of the cannula into the CS. RA = right atrium; CS = coronary sinus; PAC = pulmonary artery catheter; LA = left atrium; IAS = interatrial septum.


Name: Masataka Kuroda, MD, PhD.

Contribution: This author helped design and conduct the study, collect and analyze data, and prepare the manuscript.

Attestation: Masataka Kuroda approved the final manuscript.

Name: Toshikazu Takahashi, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Toshikazu Takahashi approved the final manuscript.

Name: Norikatsu Mita, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Norikatsu Mita approved the final manuscript.

Name: Shin Kagaya, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Shin Kagaya approved the final manuscript.

Name: Sohtaro Miyoshi, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Sohtaro Miyoshi approved the final manuscript.

Name: Shigeru Saito.

Contribution: This author helped design and conduct the study and prepare the manuscript.

Attestation: Shigeru Saito approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.


1. Mak GS, Hill AJ, Moisiuc F, Krishnan SC. Variations in Thebesian valve anatomy and coronary sinus ostium: implications for invasive electrophysiology procedures. Europace. 2009;11:1188–92
2. Anh DJ, Eversull CS, Chen HA, Mofrad P, Mourlas NJ, Mead RH, Zei PC, Hsia HH, Wang PJ, Al-Ahmad A. Characterization of human coronary sinus valves by direct visualization during biventricular pacemaker implantation. Pacing Clin Electrophysiol. 2008;31:78–82
3. Hill AJ, Ahlberg SE, Wilkoff BL, Iaizzo PA. Dynamic obstruction to coronary sinus access: the Thebesian valve. Heart Rhythm. 2006;3:1240–1
4. Clements F, Wright SJ, de Bruijn N. Coronary sinus catheterization made easy for Port-Access miimally invasive cardiac surgery. J Cardiothorac Vasc Anesth. 1998;12:96–101
5. D’Alonzo RC, Rodriquez E, Ryan JW. Percutaneous coronary sinus catheter placement aided by 3-dimensional transesophageal echocardiography. Anesth Analg. 2010;110:722–4; discussion 724
6. Teo EY, Ittleman F, Hamlin MP. A Chiari network and difficult cannulation of the coronary sinus for retrograde perfusion. Anesth Analg. 2010;111:79–81
7. Schmid E, Scheule A, Locke A, Rosenberger P. Echocardiographic-guided placement of venous cannula due to inferior vena cava obstruction through a large eustachian valve. Anesth Analg. 2010;111:76–8

Clinician’s Key Teaching Points

By Kent H. Rehfeldt MD, Nikolaos J. Skubas MD, and Martin J. London MD

  • The Thebesian valve, also known as the valve of the coronary sinus (CS), is an embryologic remnant of the sinoatrial valves and in some individuals may cover up to 75% of the CS orifice.
  • The CS is imaged with intraoperative transesophageal echocardiography (TEE), most commonly in a modified midesophageal (ME) bicaval view or in a ME 4-chamber view with slight probe advancement and additional retroflexion. The Thebesian valve should be differentiated from other embryologic remnants, such as Chiari network or Eustachian valve, that may interfere with the passage of the CS catheter.
  • In this case, a prominent Thebesian valve was attached on the posterior and superior part of the CS ostium, instead of the more typical inferior and posterior aspects, and exhibited a dynamic motion during the cardiac cycle, sealing the CS ostium at diastole. The recognition of this variation with intraoperative TEE allowed the surgeon to successfully cannulate the CS using an anterior-inferior approach.
  • Cannulation of the CS is required to administer retrograde cardioplegia. Intraoperative TEE may be used to direct the insertion of a CS catheter, thus reducing trauma associated with multiple blind cannulation attempts.

Supplemental Digital Content

© 2013 International Anesthesia Research Society