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Cardiovascular Anesthesiology: Echo Rounds

Identification of Coronary Sinus Injury by Transesophageal Echocardiography During Placement of a Retrograde Cardioplegia Catheter for Minimally Invasive Cardiac Surgery

Krishnan, Sundar MBBS*; Papworth, David P. MBBS*; Farivar, Robert S. MD, PhD; Ueda, Kenichi MD*

Author Information
doi: 10.1213/ANE.0b013e31827bc352

A 70-year-old man presented with chest pain and progressive shortness of breath. Written consent for publication of this case has been obtained from the patient. His medical history was significant for coronary artery bypass grafting through a full sternotomy 16 years previously. Transthoracic echocardiography showed a severely calcified aortic valve (AV) with moderate to severe aortic stenosis, mild aortic regurgitation, mild concentric left ventricular hypertrophy, and left ventricular ejection fraction of 55% to 60%. He was scheduled for AV replacement via a reoperative upper hemisternotomy.

After induction of anesthesia, transesophageal echocardiography (TEE) confirmed severe aortic stenosis. We then attempted to place a coronary sinus (CS) catheter (EndoplegeTM sinus catheter, Edwards Lifesciences LLC, Irvine, CA) through the right internal jugular vein via an 11 Fr introducer sheath. The CS was visualized in the modified midesophageal 4-chamber view and the modified midesophageal bicaval view. After multiple attempts, the catheter was successfully engaged just beyond the ostium of the CS with the aid of echocardiography. There was some difficulty in advancing the catheter further into the CS. Venous angiogram under fluoroscopy, using manual injection of 6 to 8 mL of contrast diluted 1:1 with saline, was performed to determine vascular anatomy. Fluoroscopy confirmed catheter tip engagement in the CS ostium; however, it also suggested extravasation of contrast (Fig. 1 and Video 1, see Supplemental Digital Content 1, On TEE, air and fluid were noticed in the pericardial space in the posterior left atrioventricular groove (Fig. 2 and Video 2, see Supplemental Digital Content 2,, along with a small generalized pericardial effusion (Video 3, see Supplemental Digital Content 3, without signs of tamponade. Close to the CS ostium a bifurcation was noticed in the CS, which was possibly the junction of the middle cardiac vein into the CS (Video 3, This combination of radiographic and echocardiographic signs suggested possible injury to the CS. The CS catheter was consequently removed. Since the patient was hemodynamically stable at this point, the surgical procedure was abandoned to allow the CS time to heal. The patient was admitted to the intensive care unit for overnight observation. Continuous invasive hemodynamic monitoring and serial transthoracic echocardiograms were performed to monitor the pericardial effusion. He remained stable and was discharged home on postoperative day 3. An AV replacement was subsequently performed without complication 3 weeks later, through a full sternotomy and with conventional CS catheter placement via the right atrium.

Figure 1
Figure 1:
Antero-posterior fluoroscopic image of the chest during coronary sinus catheter placement demonstrating coronary sinus catheter (thick arrow) and extravasated contrast (thin arrow).
Figure 2
Figure 2:
Midesophageal 4-chamber view demonstrating air (black arrow) in the left posterior atrioventricular groove. TEE = transesophageal echocardiography.


We report a case of CS injury during retrograde cardioplegia catheter placement through the right internal jugular vein, identified by TEE. The TEE images showed air and fluid in the left posterior atrioventricular groove and a small pericardial effusion.

CS catheter placement via the right internal jugular vein is increasingly performed1 for retrograde administration of cardioplegia in patients undergoing minimally invasive cardiac surgery. Possible complications include CS injury and right ventricle perforation. Fluoroscopy allows visual confirmation of CS cannulation and detects extravasation. Hence, contrast injection is recommended before advancement and balloon inflation during CS catheter placement by the manufacturer (Coronary Sinus Catheter Placement, 2nd ed., Gregory S. Miller available at, accessed June 20, 2012).

In this case, TEE was helpful in confirming the diagnosis of CS injury and in excluding pericardial tamponade in the presence of a new pericardial effusion. TEE also provided a baseline for monitoring of pericardial effusion over the next 24 hours. Air in the left posterior atrioventricular groove could be caused by localized injury in this region to the CS or by a generalized pneumopericardium due to trauma, purulent pericarditis, or a fistulous connection between the pulmonary tree or gastrointestinal tract and the pericardium.2 Disruption of the atrioventricular groove during mitral valve surgery can cause a fluid collection in this region.

The CS is imaged in long axis by slightly advancing or retroflexing the probe from the midesophageal 4-chamber view. It is seen in short axis in the midesophageal 2-chamber view just superior to the atrioventricular groove. The modified bicaval view with the probe in the midesophagus at 110–120 degrees shows the orifice of the CS and is useful for placing percutaneous CS catheters during minimally invasive procedures.3 Previous Echo Rounds have discussed deliberate closure3 and thrombosis4 of the CS.

CS injury has been reported during retrograde pacemaker lead implantation for biventricular simulation5 and during conventional retrograde cardioplegia catheter placement through the right atrium.6 CS injury during percutaneous cannulation is usually well tolerated, with long-term angiographic follow-up demonstrating no significant vessel damage or vessel remodeling.5 While rare (incidence, 0.6%), CS injury during cardiac surgery can lead to disastrous consequences,6 likely because of heparinization for cardiopulmonary bypass and retrograde administration of cardioplegia solution.

Poirier et al.7 reported a case of CS injury due to retrograde cardioplegia catheter placement through a right atrial stab during cardiac surgery, in which TEE performed after separation from cardiopulmonary bypass revealed a 20-mm thick hematoma posterior to the left atrium. We believe that early recognition of injury to the CS on fluoroscopy and echocardiography is important in preventing further complications.

Video 1
Video 1:
Fluoroscopic image taken during coronary sinus catheter placement, showing engagement of the catheter tip in the coronary sinus, along with extravasation of contrast. White arrow = coronary sinus catheter tip engaged in the coronary sinus; blue arrow = coronary sinus; red arrow = extravasated contrast.
Video 2
Video 2:
Transesophageal echocardiography image taken in a horizontal plane inferior to the midesophageal 4-chamber view, showing air and fluid in the pericardial space around the posterior left atrioventricular groove (white arrow and label). Includes zoomed-in images of the coronary sinus.
Video 3
Video 3:
Transesophageal echocardiography (TEE) image taken in the midesophageal 4-chamber view, with the TEE probe turned further to the left. The clip shows a small pericardial effusion (white arrow and label) and bifurcation of the coronary sinus and middle cardiac vein at the apex of the image (white arrow and label).


Name: Sundar Krishnan, MBBS.

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

Attestation: Sundar Krishnan approved the final manuscript.

Name: David P. Papworth, MBBS.

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

Attestation: David P. Papworth approved the final manuscript.

Name: Robert S. Farivar, MD, PhD.

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

Attestation: Robert S. Farivar approved the final manuscript.

Name: Kenichi Ueda, MD.

Contribution: This author helped design the study, analyze the data, and write the manuscript.

Attestation: Kenichi Ueda approved the final manuscript.

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


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2. Katabathina VS, Restrepo CS, Martinez-Jimenez S, Riascos RF. Nonvascular, nontraumatic mediastinal emergencies in adults: a comprehensive review of imaging findings. Radiographics. 2011;31:1141–60
3. Mauermann WJ, Rehfeldt KH, Lynch JJ, Click RL, Dearani JA. Functional right-to-left shunt caused by deliberate closure of the coronary sinus orifice. Anesth Analg. 2008;107:1828–9
4. Frogel JK, Weiss SJ, Kohl BA. Transesophageal echocardiography diagnosis of coronary sinus thrombosis. Anesth Analg. 2009;108:441–2
5. de Cock CC, van Campen CM, Visser CA. Major dissection of the coronary sinus and its tributaries during lead implantation for biventricular stimulation: angiographic follow-up. Europace. 2004;6:43–7
6. Economopoulos GC, Michalis A, Palatianos GM, Sarris GE. Management of catheter-related injuries to the coronary sinus. Ann Thorac Surg. 2003;76:112–6
7. Poirier NC, Ugolini P, Pellerin M, Petitclerc R, Tardif JC. Transesophageal echocardiographic evaluation of perioperative coronary sinus trauma. Ann Thorac Surg. 1998;66:573–5

Clinician’s Key Teaching Points

By Roman M. Sniecinski MD, Martin M. Stechert, MD, and Martin J. London MD

  • Coronary sinus (CS) catheters are routinely used in cardiac surgery to deliver retrograde cardioplegia. During minimally invasive cardiac surgery, these catheters are usually placed percutaneously via the internal jugular vein. Proper placement is facilitated by transesophageal echocardiography (TEE) and may be confirmed by fluoroscopy. CS perforation is a potential adverse effect of this procedure that should be actively screened for as minimally invasive cardiac surgery precludes direct surgical inspection.
  • Using 2-dimensional (D) TEE, the left atrioventricular groove containing the CS and contributing cardiac veins can be visualized using modified bicaval, 4-chamber, and 2-chamber views. Three-D TEE can be helpful in visualizing the anatomy of the CS orifice, and the actual placement process can be monitored using real-time 3-D modes in some instances. After placement, the same views can be used to identify CS injury.
  • In this case, TEE helped identify a CS perforation when an air-fluid level was noted in the left atrioventricular groove along with a new pericardial effusion. Fluoroscopy demonstrated extravasation of contrast from the CS, confirming the diagnosis.
  • TEE can reliably image the posterior aspect of the atrioventricular groove, where the CS lies before entering the middle cardiac vein. Thrombus or air in this area should immediately alert the echocardiographer to a venous injury, or a catastrophic injury such as an atrioventricular groove separation.

Supplemental Digital Content

© 2013 International Anesthesia Research Society