Transcript click here to - Queens Hospital Center

EXTREME CLINICAL PRESENTATIONS OF VENOUS
STASIS: CORONARY SINUS THROMBOSIS
Amit Kachalia, MD. Mian Javaid, MD. Sethu Muralidharan, MD. Pilar
Stevens-Cohen, MD.
Mount Sinai School of Medicine at Queens Hospital Center, Jamaica, New York. USA
Introduction
Coronary sinus thrombosis is a rare clinical entity with a very high
fatality rate. Invasive procedures of right heart including central
venous line placements, pacemaker wire insertion, coronary sinus
catheterization for ventricular lead placement in resynchronization
therapy, heart surgeries can lead to damage of coronary sinus
endothelium and subsequent thrombosis. Coronary sinus
thrombosis has also been observed in patients with hypercoagulable states. Primary thrombosis of coronary sinus without
any preceding cardiac interventions and in absence of hypercoagulable state has been very rarely reported in medical
literature. We report the occurrence of primary coronary
thrombosis which was noted incidentally on an echocardiogram. Figure
1 showing a Trans thoracic echocardiography
image of a coronary sinus thrombus.
Case
We present a case of Coronary sinus
thrombosis diagnosed incidentally on an
echocardiogram (Fig. 1) in a patient with no
history indicative of damage to coronary sinus
endothelium or hyper-coagulability. Venous
stasis is long known to cause thrombosis in
deep venous system of legs; however this
factor has never been reported as a sole
etiological factor in formation of coronary sinus
thrombus. The venous system of heart consists
of three separate systems. The large bore
coronary sinus and the anterior cardiac veins
both empty in the Right atrium and drain 60%
and 40% respectively of the total cardiac
venous return.
There are many anastomotic connections between tributaries of these two
venous systems. Finally, the heart is also drained by minor Thebesian veins into
66 y/o man with history of HTN, stroke, and systolic heart failure since all four chambers of heart. This explains how coronary sinus thrombosis can
8 years prior to admission was admitted with complaints of epigastric
present as a benign entity due to efficient collateral circulation.
pain, dysphagia, dyspnea Grade C, decreased exercise tolerance and Typically acute thrombosis of coronary sinus usually results in mortality and
weight loss. Cardiac catheterization done eight years prior to
presents with chest pain, dynamic electrocardiogram changes and signs of
admission did not show evidence of coronary artery disease. No
acute cardiac decompensation1. This probably results secondary to acute onset
history of any invasive cardiac procedures or history of central venous venous infarction of myocardium. However chronic development of thrombus
line placement.
does not present with ischemic signs due to formation of efficient collateral
Vitals recorded were Blood Pressure 116/86; Pulse 68/min, Breathing circulation between coronary sinus, anterior cardiac and Thebesian veins. Thus
18/min, maintaining 97% saturation on two liters oxygen by nasal
chronic development may go unnoticed until it develops complications such as
canula. Examination revealed a well built individual lying comfortable
acute plaque rupture causing myocardial infarction4, myocardial dysfunction
in bed. Chest examination revealed bibasilar crackles. Cardiac
without infarction potentially reversible with thrombectomy5, cardiac
examination revealed tachycardia, irregular rate, systolic murmur
tamponade2. These cases are usually fatal2,5 and diagnosis is often made at
grade III loudest in the mitral area and all peripheral pulses were well autopsy; thus limiting the evidence reported in such instances.
felt. There was pitting pedal edema bilaterally extending till knee. Rest Congestive heart failure is the leading cause of mortality amongst geriatric
of the examination was unremarkable.
population and it is very important to focus on its potentially fatal complications.
EKG showed sinus rhythm with frequent premature atrial and
It is important for physicians to be alert and look for coronary sinus thrombosis
ventricular contractions, incomplete LBBB and left axis deviation. TTE in long standing surviving cases of heart failure who have chronic venous stasis
revealed severely reduced biventricular ventricular systolic function
in coronary circulation, as missing diagnosis can lead to sudden death.
with EF 10%; PASP 75-80mmHg, moderate TR, moderate to severe
Conclusion
MR and moderate AR. Parasternal long views revealed a markedly
dilated coronary sinus with a visible, mobile 2 cm thrombus. CT neck
Considering the fact that coronary sinus thrombosis is a potential, though rare
done for evaluation of dysphagia indicated thickening of the
complication of invasive cardiac procedures; it is important to look for such an
esophageal wall suggesting an infiltrative process. Upper endoscopy
event in cases of chronic coronary venous stasis also. The evidence for the role
and barium studies followed which confirmed the diagnosis of
of long term anticoagulation and diagnostic standards is unclear and further
achalasia and ruled out any infiltrative process. Coagulation profile
guidelines are warranted.
was normal and all prothrombotic factors were negative.
During the admission patient was treated for acute on chronic
References
decompensated systolic heart failure, coronary sinus thrombosis and
1. K K Yeo, J Davenport, G Raff and JR. Laird. Life-threatening coronary sinus
achalasia. Patient responded to furosemide and improved
thrombosis following catheter ablation: case report and review of literature.
symptomatically. Patient was recommended Coumadin with
Cardiovascular Revascularization Medicine Volume 11, Issue 4, OctoberEnoxaparin bridging for his coronary sinus thrombosis but he declined
December 2010, Pages 262.e1-262.e5
Coumadin, hence was anti-coagulated with Enoxaparin alone during
2. Figuerola M, Tomas MT, Armengol J, Bejar A, Adrados M, Bonet A. Pericardial
inhospital stay. Patient was recommended defibrillator placement but
tamponade and coronary sinus thrombosis associated with central venous
he refused the same. Patient was continued and discharged on
catheterization. Chest. 1992;101(4):1154-1155.
Aspirin, clopidogrel, lisinopril, carvedilol and furosemide with follow up
in GI and cardiology clinic. At discharge patient was symptomatically 3. Parmar RC, Kulkarni S, Nayar S, Shivaraman A: Coronary sinus thrombosis. J
Postgrad Med 2002, 48:312-313.
stable with Grade C dyspnea and able to tolerate medium consistency
4. Salim Dabbah MD, Shimon A. Reisner MD, Zvi Adler MD, Simcha Milo MD,
oral feeds.
Yoram Agmon MD: Intermittent Coronary Sinus Occlusion Complicating
Discussion
Coronary Sinus Cannulation During Coronary Artery Bypass Operation; Journal
of
the
American
Society
of
Echocardiography
Volume
18,
Issue
8,
August
2005,
The most common mechanism to initiate thrombus formation in
Pages
882
coronary sinus is endothelial damage, usually occurring as a
5.
Neri
E,
Tripodi
A,
Tucci
E,
Capannini
G,
Sassi
C.
Dramatic
improvement
of
LV
secondary complication of procedures such as central venous line
function
after
coronary
sinus
thromboembolectomy.
Ann
Thorac
Surg.
2
3
placement , pacemaker wire placement, cardiac surgery , heart
2000;70(3):961-963.
4
transplantation, coronary artery bypass grafting , radiofrequency
6.
Kitazawa,
S.,
Kitazawa,
R.,
Kondo,
T.,
Mori,
K.,
Matsui,
T.,
Watanabe,
H.,
1
ablation around AV node . Apart from endothelial damage, hyperWatanabe,
M.:
Fatal
cardiac
tamponade
due
to
coronary
sinus
thrombosis
in
coagulability (secondary to malignancy) and venous stasis also play a
acute
lymphoblastic
leukemia;
Cases
Journal.
2009;
2:9095
role in development of coronary sinus thrombosis although very few
incidents have been reported6.