Europace (2009) 11, v15v21

doi:10.1093/europace/eup270

The anatomy of the coronary sinus venous system

for the cardiac electrophysiologist
Ammar Habib 1, Nirusha Lachman 2,3, Kevin N. Christensen 2,
and Samuel J. Asirvatham 3,4*
1
Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA; 2Department of Anatomy, Mayo Clinic College of Medicine, Rochester, MN, USA;
3
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA; and 4Department
of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA

Cardiac electrophysiologists use of the coronary sinus (CS) to map and ablate accessory pathways and implant left ventricular leads has
emphasized the need for understanding CS anatomy. In this review, we briefly examine the developmental and radiological anatomy of
the CS and discuss in detail the gross anatomy of this cardiac vein. We highlight the correlations of the acquired anatomical knowledge rel-
evant to clinical electrophysiology practice.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Coronary sinus Cardiac veins

anterior interventricular vein is similar to the adjacent left anterior

Introduction
The coronary sinus (CS) has become a clinically important struc-
ture especially through its role in providing access for different
cardiac procedures. Historically, cardiac vascular studies have
focused mainly on the coronary artery circulation. Although not
studied to the extent of the coronary arteries, the coronary
venous system is important in many electrophysiological pro-
cedures, including arrhythmia ablation, biventricular pacing, and
for deployment of an array of cardiac devices.1 3 The advent of
advanced invasive and interventional cardiac treatment and man-
agement tools for common disorders like heart failure has made
understanding of CS anatomy necessary.4 6 There is also an
increased interest in the CS as an access point for interventionalists
for ablation procedures of an arrhythmia source and for
mapping.7 9 The CS is the main cardiac vein. This review will
describe the basic gross and developmental anatomy of the CS
and venous supply with focus on specific anatomical aspects that
are encountered in invasive and interventional settings.
Coronary sinus anatomy
The myocardium drains mainly by two groups of veins: the tribu-
taries of the greater and smaller cardiac veins, or the Thebesian
veins. The main vein of the greater venous system is the CS that
runs in the posterior aspect of the coronary groove. The anterior
wall of the left ventricle and the interventricular septum are
drained by branches of the anterior interventricular vein, known
as the great cardiac vein on the annulus.3,10,11 The course of the
descending artery in the interventricular groove. In a study using
electron beam computed tomography (CT), the anterior interven-
tricular vein was visualized in up to 100% of subjects scanned.12 In
addition, the diameter of the anterior interventricular vein was
seen to be similar to the neighbouring artery for the length of
its course. The great cardiac vein in turn joins the main posterior
lateral vein to form the CS. Other major tributaries entering the
CS include inferior left ventricular vein and the middle cardiac
vein (MCV) that drain the posterior aspect of the left ventricle.
The atrial myocardium also drains into the CS via the various
atrial veins and the vein of Marshall. The vein of Marshall is a
remnant of the left superior vena cava; it runs along the posterior
aspect of left atrium and is formed by the junction of the great
cardiac vein and the posterolateral vein.13 The right atrium and
the posterior and posterolateral portions of the right ventricle
are drained by the small cardiac vein into the CS at the ostium
of the right atrium.
The smaller cardiac venous system is the Thebesian venous
network. This system is responsible for draining the inner layers
of the myocardium of the right ventricular venous system and por-
tions of the interventricular septum directly into the right ventricle
via orifices that are often ,0.5 mm in diameter.
Embryology
Development of the CS occurs through differentiation of the sinus
venosus (Figure 1). During foetal development, a single heart tube
separates around the third week giving rise to the primordial

* Corresponding author. Tel: 1 507 255 2440, Fax: 1 507 255 2550, Email: asirvatham.samuel@mayo.edu
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
v16
Figure 1 Developmental anatomy of the coronary sinus (CS)
(26 weeks)the right horn of the sinus venosus remains as the
venous portion of the right atrium between the vena cava (light
blue). The left horn of the sinus venosus remains in adult life as
the CS and portion of the great cardiac vein (dark blue).
atrium and sinus venosus. Initially, the sinus venosus opens into the
posterior wall of the right atrium. Around the fourth week, the
sinus venosus differentiates into right horn and left horns which
through a process of degeneration and absorption, give rise to
the venous channels entering the right atrium. The right horn is
absorbed by the right atrium and persists as the smooth portion
of the superior vena cava as well as the area between the vena
cava extending into the CS ostium, whereas the left horn under-
goes progressive degeneration until the 10th week, giving rise to
the CS.14,15
Detailed anatomy
Coronary sinus
The length of the CS varies from 3 to 5.5 cm and is dependent on
the site of the drainage of the posterolateral vein.16 The diameter
of the CS is also variable and is dependent on the loading con-
ditions, presence and extent of atrial myocardium with the coron-
ary vein, and the presence of underlying cardiac disease or prior
cardiac surgery. The CS lies in the sulcus between the left
atrium and ventricle and is a continuation of the great cardiac
vein from the valve of the great cardiac vein to the ostium of
the CS as it terminates in the right atrium. The CS begins proxi-
mally at the right atrial orifice and ends distally at the valve of
Vieussens. The CS receives blood from the ventricular veins
during ventricular systole and empties into the right atrium
during atrial systole.
The wall of the CS is made up of striated myocardium that is
continuous with the atria, forming a myocardial sleeve around
the venous system17 (Figure 2). This sleeve does not usually
extend into the ventricle myocardium. In variations, where a con-
tinuation into the ventricle is formed, however, an atrioventricular
bypass tract referred to as an epicardial pathway is formed.18
The CS, like the rest of the cardiac venous system, contains
various valves.19,20 The most common valve is the Thebesian
valve at the ostium of the CS. The Thebesian valve is a crescent
A. Habib et al.
Figure 2 The CS has been dissected open along its long axis,
CS musculature is seen in the proximal portion of the CS up
to the orifice of the vein of Marshall. In this patient multiple pos-
terior and posterolateral veins are also seen draining into the CS.
shaped structure often found guarding the mouth of the CS as it
opens to the right atrium. The Thebesian valve is highly variable
and occasionally may present an obstruction during cannulation
of the CS.21 The CS also contains the valve of Vieussens that
often marks the end of the vein. These venous valves are also fre-
quently found at the entrance of the ventricular veins into the great
cardiac vein. The right ventricular venous system drains directly
into the right ventricle through the Thebesian venous network.
The CS ostium is 515 mm in diameter and is located on the
posterior interatrial septum anterior to the Eustachian ridge and
valve and posterior to the tricuspid annulus.11,17 The ostium is
often covered, to a variable extent, by the Thebesian valve. The
valve usually covers the superior and posterior surfaces of the
ostium, but may be covered completely with formation of fenestra-
tions. In rare instances, the valve may cover the inferior
hemi-circumference.
Clinical application
The CS has increasingly been recognized as a vital structure for an
array of clinical interventions. The CS is of interest to the electro-
physiologist because it provides a useful route for mapping and
ablation of left-sided accessory pathways. Nevertheless, pathways
that are located close to the mitral valve may be difficult to
ablate given their significant distance from the CS. In addition,
the CS is an electrophysiologically active structure. Previous
studies have demonstrated the capability of spontaneous depolar-
ization and slow conduction in the smooth muscle of the CS, pro-
viding inherent automaticity.9,22 24 Also, the atrial myocardial
sleeve that covers the proximal CS provides the ability for conduc-
tion and automaticity, forming an electrical connection between
the two atria. Studies have shown that this connection is of clinical
importance as it may be a source of arrhythmias such as atrial
fibrillation.18,23 25 Active myocardium within the CS may serve
either as a source for abnormal automaticity generating a focal
tachycardia or as a part of a reentrant circuit. In patients with
Cardiac venous system v17

Figure 4 Valves can be found in the CS at various locations.

Most common are at the ostium of the CS (Thebesian valve)
and at the ostium of the postural lateral vein at the junction of
Figure 3 The CS has been dissected open along its long axis.
the Great Cardiac vein and CS (Vieussens valve). These valves
Note the multiple ostia of various ventricular veins (hatched
cover various extents of the area of the orifice.
arrows). A remnant of the Thebesian valve that partly covers
the ostium of the middle cardiac vein (MCV) is seen (arrow).

atrial fibrillation, although myocardial sleeves within the pulmonary

veins are a more common source, CS myocardium may also initiate
recurrent atrial fibrillation. Since the CS is one of the connections
between the right and left atria, with Bachmanns bundle forming
the other important connection, reentrant tachycardia involving
the CS muscle and both atria are sometimes seen in patients
with marked atrial enlargement, especially after a surgical maze
procedure.
The vein of Marshall may give rise to atrial fibrillation either by
virtue of myocardial extensions into the structure or as a result of
node like remnants within the vein or by virtue of the rich auto-
nomic innervation that typically encapsulates the structure.18,23 25
With regard to left ventricular pacing, atrial electrograms may be
sensed by the ventricular lead if it is placed too proximal (basal)
within a ventricular branch of the CS.
Cannulation of the CS during interventional procedures may be
complicated by obstruction due to Thebesian valves (Figures 3 5).
A three-dimensional, functional anatomy study showed that The-
besian valve morphology varied greatly, and included instances of Figure 5 Coronary venous angiogram in the left anterior
dynamic obstruction.26 Cannulation would be likely to be more oblique (LAO) projection showing a near occlusive valve
complicated in the living heart during the cardiac cycle. Studies (arrow) in the region of the posterolateral vein (Vieussens valve).
have demonstrated that valves that obstruct a significant portion
of the CS ostium may be successfully transversed by use of
modern cannulation techniques (i.e. softer-tipped sheath, pre- cava. Thus, when it is completely patent, it is known as a persistent
shaped sheath, and anterior approach).27 left superior vena cava. The branch is known as the vein of Marshall
In addition, cannulation of the CS for percutaneous mitral valve when it is patent in its atrial course. Occasionally, it may be par-
annuloplasty has been described.28 tially or completely occluded; in which case it is known as the
oblique vein of Marshall.13,29,30

Atrial venous drainage Clinical application

The atrial myocardium drains into the CS via the various atrial
veins and the vein of Marshall. The largest atrial vein branch
usually occurs opposite to the posterolateral vein coursing
between the anterior surface of the left-sided pulmonary veins
and the posterior surface of the route of the left atrial appendage.
This branch is an embryological remnant of the left superior vena
The left atrial veins can be used for atrial pacing. When thresholds
are poor in the right atrium or precise left atrial-left ventricular
synchrony is needed. Specific cannulation of the CS and then
placing the lead into an atrial branch can be done. Bi-atrial
pacing with both a right and left atrial lead has been attempted
for pacing related therapy of atrial fibrillation.13,29
v18
Figure 6 A lateral view of the left ventricle showing venous
anastomoses on the lateral wall. Note, veins interdigitate
between the anterior and lateral venous system (see text for
details).
Ventricular veins
Anterior interventricular vein
The anterior interventricular vein, the largest and most consistent
of the cardiac veins, courses in the interventricular groove adjacent
to the left anterior descending artery as it runs towards the base of
the heart. It is the most anterior vein seen in the right anterior
oblique (RAO) projection. Although the anterior interventricular
vein is the venous parallel of the left anterior descending artery,
its proximal tributary courses along the first diagonal branch. As
it approaches the base of the heart, the anterior interventricular
vein courses laterally towards the atrioventricular groove to
form the great vein. A large tributary that arises proximally
drains a significant portion of the anterolateral wall of the left ven-
tricle. This apical branch is thought to be continuous with branches
of the posterior and MCVs in 30% of hearts.8,11,16,31 The phrenic
nerve forms an anterior relation to the anterolateral branch of the
anterior interventricular vein in a fraction of patients.
Lateral cardiac veins
The lateral wall of the left ventricle is typically drained by three dis-
tinct veins (Figure 6), largest and most consistent of which is the
posterolateral vein.11,16,31 Other veins, specifically the straight
lateral vein and the anterior lateral veins are also found in this
region. The posterolateral vein occurs directly opposite the vein
of Marshall.
In addition to receiving tributaries from the anterior interventri-
cular vein, the great cardiac vein also receives tributaries from left
posterior vein and the left marginal vein. The phrenic nerve typi-
cally crosses superficial to the great cardiac vein and forms variable
relations with the lateral vein, posterior branches of the anterolat-
eral vein, and anterior branches of posterolateral cardiac vein.
Because of the thickness of the ventricular myocardium at this
site, secondary tributaries of these lateral veins often run an intra-
myocardial course.
A. Habib et al.
Figure 7 The MCV is a very consistent tributary of the CS
present in nearly all hearts. In our study of 219 hearts the
MCV was found in its usual location in the posterior interventri-
cular sulcus draining to the ostium of the CS in 98% of these
cases. Rarely, in 2.8%, the MCV has a separate ostium into the
right atrium and in 18% of the cases the vein receives an immedi-
ate tributary from a posterior or posterolateral vein.
Middle cardiac vein
The largest proximal tributary of the CS is the MCV (Figure 7), also
known as the posterior interventricular vein. The MCV receives
communications from the anterior veins as well as from branches
from the septal wall and inferior walls of both ventricles. The MCV
courses with the posterior descending artery in the posterior
interventricular groove and enters the CS close to the right
atrial orifice or, rarely, enters directly into the right atrium apical
to the septal attachment of the tricuspid valve. Cardiac autonomic
fibres are often found in the posterior crux near the junction of the
MCV with the CS. The MCV also has a varied number of branches,
the most relevant being the left marginal and inferior veins.32
Posterior ventricular vein
The origin of the posterior ventricular vein is highly variable, but in
25% of patients, the posterior ventricular vein shares a common
cloacal ostium with the MCV.11,17,31 In some cases it has been
shown to arise as a tributary from the MCV. This vein courses
along the lateral wall together with the posterolateral branches
of the right coronary artery and drain the lateral and diaphragmatic
walls of the left ventricle. Because of its course, it may be confused
with a branch of the MCV. Its distal branches often interdigitate
with branches of the lateral venous system and may be closely
related to the phrenic nerve.
Clinical application
The MCV can be specifically targeted for placing a left ventricular
lead (Table 1). Although the MCV lies in the posterior interventri-
cular septum various branches/tributaries drain the lateral wall
Cardiac venous system v19

Table 1 Clinical correlates of specific coronary venous anatomic characteristics

Coronary vein anatomy Clinical application

...............................................................................................................................................................................
Coronary sinus Cannulation may be hindered by a large Thebesian valve
Myocardial extensions may constitute an accessory pathway
The vein is one of the primary electrical connections between the right and left atrium
The vein of Marshall and other atrial veins The vein of Marshall may require ablation for atrial fibrillation
autonomic nerves
myocardial extensions
nodal remnants
Atrial veins can be used for pacing the left atrium
The anterior interventricular vein Lateral tributaries can be used to pace the left ventricular free wall
Ablation within this vein sometimes required for outflow tract ventricular tachycardia
The phrenic nerve may lie close to lateral branches of this vein
Posterolateral vein Ideal vein to attempt cannulation as it drains the free wall of the left ventricle
The valve of Vieussen typically found at the ostium of this vein and can hinder cannulation
Posterior ventricular vein Sometimes mistaken for the middle cardiac vein
Lateral tributaries can be used for effective left ventricular pacing
Cannulation of this vein at times not immediately recognized during a procedure
Middle cardiac vein An option to consider for placing left ventricular pacing leads, particularly into one of the its lateral tributaries
Well established site for posterior epicardial pathways
Diverticula or aneurismal dilation of this vein may occur with or without associated arrhythmias

toward this vein. Because of the unique anatomy of this vein (being
perpendicular to the main access of the CS) cannulation is not
straightforward. The operator typically uses counterclockwise
torque to cannulate the CS. Once the CS has been cannulated,
clockwise torque needs to be applied to turn the sheath or
guiding catheter towards a ventricular vein. Often the posterior
vein will be cannulated in this rotation and can be used. If,
however, because of phrenic nerve stimulation or absence of
good pacing thresholds within the vein, the guiding sheath or cath-
eter can be withdrawn from this vein whereas continuing to apply
clockwise torque. The MCV can then be cannulated just before the
sheath or catheter slips out of the CS. Once entered the pacing
lead can then be placed in this vein and carefully manoeuvred to
the left ventricular free wall.12,14,16 Figure 8 Epicardial fat is seen close to the ostium of the CS,
The venous drainage of the lateral wall of the ventricle is variable particularly in the right anterior oblique (RAO) view (left
and typically gives multiple options for the implanter.33,34 panel). A lead or catheter placed in the CS will be seen proceed-
ing towards the left in the LAO view (right panel). In the RAO
Because of the posterior and posterior lateral veins can form
view the ventricular veins are seen anteriorly and the atrial
various angles with the main body of the CS inexperienced oper-
veins posteriorly. Note the position of the bundle of His
ators may not realize that this vein has been cannulated and
(coloured in green).
unnecessarily withdraw the catheter or guiding sheath. When
doubt exists as a result of prior knowledge of the anatomy of
this region venography or ultrasound imaging is required. Some- on the right. In addition, this venous system provides drainage to
times a common ostium for the posterior and MCV occurs and the right appendage as well as a significant portion of the muscular
may need specific cannulation either for placement of pacing ventricular septum.
leads or ablation of posterior epicardial accessory pathways.

Thebesian venous system Radiology

The smaller cardiac venous system that is composed of small
venous branches and drains the subendocardium is known as the
Thebesian venous system. The Thebesian veins are vessels com-
posed primarily of endothelial cells, which are continuous with
the lining of the cardiac chambers.35 These vessels are found
throughout all four chambers of the heart, but are more prominent
With standard fluoroscopy the CS cannot be directly visualized.
However, the epicardial fat found in the posteroseptal space just
posterior to the CS ostium can be detected on cine fluoroscopy
(Figure 8). A characteristic radiolucency best seen in the RAO pro-
jection can be noted, where the cardiac and any diaphragmatic sil-
houettes meet.
v20
Figure 9 Reconstructed computed tomography image showing
the coronary veins. Note the complex origin of the MCV close to
the ostium of the CS. In this patient there is a paucity of venous
drainage of the posterolateral wall.
Perhaps more importantly accurate radiographic anatomy is
needed with standardized fluoroscopic views [right and left
anterior oblique (LAO) projections] to guide placement of leads
and sheath of catheter cannulation of the main body of this vein.
In the LAO projection, when cannulating the CS, the lead catheter
will be seen to move leftward after entry.14,33,34 In the RAO pro-
jection, catheter or lead movement towards the sternum
(anterior) signifies cannulation of ventricular vein where as pos-
terior deflection or orientation suggests that an atrial vein has
been entered.
Multi-slice CT is used increasingly as a non-invasive alternative
for preoperative evaluation of the coronary arteries and cardiac
veins (Figure 9). On CT scans, the CS appears to average 30 mm
in length (2140 mm) with an average diameter of 9 mm
(4 14 mm).12 The CS is clearly visible with contrast material and
is identified by its characteristic vertical segment superiorly that
then forms a bend or a turn to join a horizontal segment
inferiorly. The horizontal segment corresponds with the right
atrial termination of the CS whereas the vertical segment, due to
its perpendicular orientation to the CT cross-sectional slice, may
be observed as a round density on some scans. The bend or
turn of the sinus, due to its oblique orientation, is seen as an
oval density.36
Summary
Accurate knowledge of the coronary venous anatomy is essential
for electrophysiologists performing left ventricular pacing pro-
cedures or radiofrequency ablation. Although many variations
occur constant features include a large anterior interventricular
vein that continues in the left atrial ventricular groove as the
A. Habib et al.
Great Cardiac vein and then joined by one or more posterolateral
ventricular veins the CS forms the continuation until it drains
into the right atrium. The middle cardiac and posterior veins, as
well as various atrial veins including the vein of Marshall are
other consistent tributaries. In this review, we discuss the gross,
developmental radiographic anatomy of the important cardiac
venous system to improve understanding amongst interventional
electrophysiologists.
Conflict of interest: none declared.
References
1. Alonso C, Leclercq C, dAllonnes FR, Pavin D, Victor F, Mabo P et al. Six year
experience of transvenous left ventricular lead implantation for permanent biven-
tricular pacing in patients with advanced heart failure: technical aspects. Heart
2001;86:405 10.
2. Gerber TC, Kantor B, Keelan PC, Hayes DL, Schwartz RS, Holmes DR. The coron-
ary venous System: an alternate portal to the myocardium for diagnostic and thera-
peutic procedures in invasive cardiology. Curr Interv Cardiol Rep 2000;2:27 37.
3. Grzybiak M. Morphology of the CS and contemporary cardiac electrophysiology.
Folia Morphol (Warsz) 1996;55:272 3.
4. Abraham W, Leon A, Hannon C, Prather W, Fieberg A. Results of the InSync III
Marquis clinical trial. Heart Rhythm 2005;2:S65 (Abstract).
5. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E et al. Cardiac
resynchronization in chronic heart failure. N Engl J Med 2002;346:1845 53.
6. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.
The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): ration-
ale, design and end-points. Eur J Heart Fail 2001;3:481 9.
7. Asirvatham S, Packer DL Evidence of electrical conduction within the CS muscu-
lature by non-contact mapping. Circulation 1999;100 (Abstract).
8. Gilard M, Mansourati J, Etienne Y, Larlet JM, Truong B, Boschat J et al. Angio-
graphic anatomy of the CS and its tributaries. Pacing Clin Electrophysiol 1998;21:
2280 4.
9. Giudici M, Winston S, Kappler J, Shinn T, Singer I, Scheiner A et al. Mapping the
CS and great cardiac vein. Pacing Clin Electrophysiol 2002;25:414 9.
10. DCruz IA, Shala MB, Johns C. Echocardiography of the CS in adults. Clin Cardiol
2000;23:149 54.
11. Ortale JR, Gabriel EA, Iost C, Marquez CQ. The anatomy of the CS and its tribu-
taries. Surg Radiol Anat 2001;23:1521.
12. Schaffler GJ, Groell R, Peichel KH, Rienmuller R. Imaging the coronary venous
drainage system using electron-beam CT. Surg Radiol Anat 2000;22:359.
13. Cendrowska-Pinkosz M, Urbanowicz Z. Analysis of the course and the ostium of
the oblique vein of the left atrium. Folia Morphol (Warsz) 2000;59:163 6.
14. Asirvatham S. Anatomy of the CS. In: Cheuk-Man Y (ed). Cardiac Resynchronization
Therapy. Oxford: Blackwell Publishing; 2006. p. 211 38.
15. Moore K, Persaud T. Before We are Born: Essentials of Embryology and Birth Defects.
7th ed. Philadelphia: Saunders Elsevier; 2003.
16. von Ludinghausen M. Clinical anatomy of cardiac veins, Vv. cardiacae. Surg Radiol
Anat 1987;9:159 68.
17. Ludinghausen M, Ohmachi N, Boot C. Myocardial coverage of the CS and related
veins. Clin Anat 1992;5:1 15.
18. Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J et al.
CS-ventricular accessory connections producing posteroseptal and left posterior
accessory pathways: incidence and electrophysiological identification. Circulation
2002;106:1362 7.
19. Dobosz PM, Kolesnik A, Aleksandrowicz R, Ciszek B. Anatomy of the valve of the
coronary (Thebesian valve). Clin Anat 1995;8:438 9.
20. Duda B, Grzybiak M. Variability of valve configuration in the lumen of the CS in
the adult human hearts. Folia Morphol (Warsz) 2000;59:207 9.
21. Gami A, Edwards W, Lachman N, Friedman P, Talreja D, Munger T et al. Electro-
physiological anatomy of typical atrial flutter: the posterior boundary and causes
for difficulty with ablation. J Cardiac Electrophysiol 2009; Epub ahead of print.
22. Aronson RS, Cranefield PF, Wit AL. The effects of caffeine and ryanodine on the
electrical activity of the canine CS. J Physiol 1985;368:593 610.
23. Olgin JE, Jayachandran JV, Engesstein E, Groh W, Zipes DP. Atrial macroreentry
involving the myocardium of the CS: a unique mechanism for atypical flutter.
J Cardiovasc Electrophysiol 1998;9:1094 9.
24. Takatsuki S, Mitamura H, Ieda M, Ogawa S. Accessory pathway associated with an
anomalous coronary vein in a patient with Wolff ParkinsonWhite syndrome.
J Cardiovasc Electrophysiol 2001;12:1080 2.
25. Volkmer M, Antz M, Hebe J, Kuck KH. Focal atrial tachycardia originating from the
musculature of the CS. J Cardiovasc Electrophysiol 2002;13:68 71.
Cardiac venous system
26. Hill AJ, Ahlberg SE, Wilkoff BL, Iaizzo PA. Dynamic obstruction to CS access: the
Thebesian valve. Heart Rhythm 2006;3:1240 1.
27. Anh DJ, Eversull CS, Chen HA, Mofrad P, Mourlas NJ, Mead RH et al. Character-
ization of human CS valves by direct visualization during biventricular pacemaker
implantation. Pacing Clin Electrophysiol 2008;31:7882.
28. Webb JG, Harnek J, Munt BI, Kimblad PO, Chandavimol M, Thompson CR et al.
Percutaneous transvenous mitral annuloplasty: initial human experience with
device implantation in the CS. Circulation 2006;113:851 5.
29. Hwang C, Wu TJ, Doshi RN, Peter CT, Chen PS. Vein of Marshall cannulation for
the analysis of electrical activity in patients with focal atrial fibrillation. Circulation
2000;101:1503 5.
30. Kim DT, Lai AC, Hwang C, Fan LT, Karagueuzian HS, Chen PS et al. The ligament
of Marshall: a structural analysis in human hearts with implications for atrial
arrhythmias. J Am Coll Cardiol 2000;36:1324 7.
v21
31. Duda B, Grzybiak M. Main tributaries of the CS in the adult human heart. Folia
Morphol (Warsz) 1998;57:363 9.
32. Jongbloed MR, Lamb HJ, Bax JJ, Schuijf JD, de Roos A, van der Wall EE et al. Non-
invasive visualization of the cardiac venous system using multislice computed tom-
ography. J Am Coll Cardiol 2005;45:749 53.
33. Ruengsakulrach P, Buxton BF. Anatomic and hemodynamic considerations influ-
encing the efficiency of retrograde cardioplegia. Ann Thorac Surg 2001;71:
1389 95.
34. Sethna DH, Moffitt EA. An appreciation of the coronary circulation. Anesth Analg
1986;65:294 305.
35. von Ludinghausen M, Ohmachi N, Besch S, Mettenleiter A. Atrial veins of the
human heart. Clin Anat 1995;8:16989.
36. Micklos TJ, Proto AV. CT demonstration of the CS. J Comput Assist Tomogr 1985;9:
60 4.