Arrhythmogenicity of the Coronary Sinus

The coronary sinus (CS) is the cardiac venous system that begins at its ostium in the right atrium and ends at the origin of the great cardiac vein.1,2,3 The major tributaries of the CS include the great cardiac vein (anterior cardiac vein), the left obtuse marginal vein, the posterior (or inferior) left ventricular vein, the middle cardiac vein, and the right coronary vein. In addition, atrial veins and, notably, the vein of Marshall (or oblique left atrial vein) also enter the coronary sinus.1,2,3 From the perspective of electrophysiologists, the CS represents an anatomical structure of particular interest. First, it provides access to epicardial atrioventricular pathways.4,5 and arrhythmogenic foci of both atrial6 and ventricular arrhythmia.7,8 Second, it represents by itself a potential source of atrial arrhythmia.9,10,11,12,13,14 The arrhythmogenic potential of the thoracic veins in general has been recognised since the 1970s.15,16 Atrial arrhythmias can originate in the pulmonary veins,17 the superior vena cava,18 and the CS. Indeed, biatrial flutter,19,20 left atrial tachycardia,9,10 and atrial fibrillation12,14 involving the distal CS have been well described. There is now evidence that the CS apart from participating in arrhythmia circuits, such as in the slow-slow form of atrioventricular nodal reentrant tachycardia21 and atrioventricular reentrant tachycardia due to accessory pathways,22,23,24,25,26 may itself be a source of apparently atrial arrhythmia. In patients with paroxysmal atrial fibrillation apparently originating from the left superior or inferior pulmonary vein, detailed epicardial mapping through the distal coronary sinus might identify epicardial location of the arrhythmogenic focus.6 Therefore, the search for foci of abnormal automaticity within the CS should be part of the electrophysiologic evaluation of left atrial arrhythmias.13