Transesophageal Echocardiography Diagnosis of Coronary Sinus Thrombosis

Abstract

A36-yr-old man with a medical history significant for anabolic steroid abuse initially presented to the operating room with aortic valve endocarditis with a focal perforation of the anterior leaflet of the mitral valve secondary to a prolapsing aortic valve vegetation. The patient underwent uneventful aortic valve replacement with a 25 mm On-X (MCRI, Austin, TX) mechanical valve and repair of the mitral valve perforation with a bovine pericardial patch. Throughout the procedure, he received intermittent retrograde cardioplegia via a coronary sinus catheter that was placed without difficulty under transesophageal echocardiography (TEE) guidance in the prebypass period.The patient's postoperative course was complicated by persistent high grade fevers and respiratory failure. A repeat TEE examination on postoperative day 10 revealed an ejection fraction (EF) of 45% and multiple echodense masses adherent to both the atrial and ventricular aspects of the patient's mitral valve. In addition, an elliptical sessile mass was discovered adhering to the lateral wall of the right atrium and impinging on the anterior leaflet of the tricuspid valve. There was moderate tricuspid regurgitation secondary to leaflet restriction. The mechanical aortic valve appeared to be functioning normally. No abnormalities of the coronary sinus were noted at the time.The patient returned to the operating room for reexploration and debridement of presumed recurrent endocarditis. Intraoperative TEE once again revealed a low normal EF and echogenic masses adherent to the mitral valve (Fig. 1A) and to the lateral wall of the right atrium (Fig. 1B). In addition, a dilated coronary sinus was noted in the midesophageal views (Fig. 1A). Further inspection of the coronary sinus in a modified four-chamber view demonstrated the presence of thrombus with near complete occlusion of the coronary sinus which measured nearly 2 cm in diameter (Figs. 2A and B, Video Clip 1; please see video clips available at www.anesthesia-analgesia.org).Surgical exploration confirmed the presence of multiple thrombi that did not seem infectious in origin. Examination of the coronary sinus verified complete occlusion of the sinus with thrombus. The patient underwent thrombectomy of the tricuspid valve, mitral valve, and coronary sinus without complication. Postcardiopulmonary bypass TEE demonstrated normal mitral and tricuspid valve function. The postprocedure left ventricular function was markedly improved, with an EF of 65%, compared to 45% before operation (Video Clip 2; please see video clips available at www.anesthesia-analgesia.org). Pathologic examination confirmed noninfectious organized thrombus recovered from the mitral valve, tricuspid valve, and coronary sinus.The coronary sinus is responsible for the venous drainage of the heart under normal conditions. It receives contributions from the small, middle, oblique and great cardiac veins, courses through the coronary sulcus and empties into the right atrium between the inferior vena cava inlet and the septal leaflet of...

Coronary sinus endocarditis in a hemodialysis patient: A case report and review of literature

“…Similar to CS vegetation, spontaneous CS thrombosis without iatrogenic injury has been reported in less than 15 cases. CS thrombosis mostly occurred in conditions leading to a static status of the right atrium, including atrial fibrillation[ 18 - 21 ], right heart failure with severe pulmonary hypertension[ 18 , 19 , 22 , 23 ], or hypercoagulable conditions such as severe inflammation/infection[ 20 , 24 - 26 ] and malignancy[ 27 ]; this presentation is similar to that of thrombosis at other sites. Patients with CS thrombosis primarily have symptoms and signs associated with partial or complete obstruction of the CS, but no symptoms and signs of infection.…”

Pylephlebitis presenting as spontaneous coronary sinus thrombosis: a case report

“…Thrombosis of the CS is an exceedingly rare event, with the majority of cases reported in the literature occurring in the setting of invasive procedures or infection. Development of CST in the absence of instrumentation is even less common, and believed to be secondary to underlying prothrombotic states [ 1 – 3 ]. Despite this, the potential complications of CST can be catastrophic and include myocardial infarction, cardiac tamponade, sudden cardiac arrest, and death [ 1 , 4 – 6 ].…”

Venous Thrombosis in Rare or Unusual Sites: A Diagnostic Challenge

“…Diagnosis is achieved by sonography, particularly by transesophageal sonography. 26,27 Differential diagnosis has to take into account myxoma of atrium which may also give pulmonary arteria occlusion, when undergoing spontaneous fragmentation.…”

“…Coronary sinus thrombosis is sometimes associated with right atrium thrombosis. [26][27][28][29] Patients present a precipitous clinical aggravation of preexisting cardiac condition (severe dyspnea, chest pain, and pericardial tamponade). Coronary sinus thrombosis is sometimes the cause of sudden death.…”