Difficult cannulation of the coronary sinus due to a large Thebesian valve.


• Volume 116 • Number 3 www.anesthesia-analgesia.org 563 A 59-year-old man with a history of diabetes mellitus and renal dysfunction was scheduled for aortic valve replacement via a full median sternotomy, to treat moderate aortic stenosis due to a bicuspid aortic valve. After anesthetic induction and tracheal intubation, a transesophageal echocardiography (TEE) probe (X7-2t transducer, Philips Healthcare, Andover, MA) was inserted into the esophagus to intraoperatively assess cardiac function, guide the placement of cannulae, and assess the competency of the aortic valve prosthesis. The surgical plan was to administer the cardioplegic solution via a combination of anterograde and retrograde methods. TEE was used to guide cannulation of the coronary sinus (CS) for retrograde coronary perfusion. After scanning in the midesophageal 4-chamber view with the multiplane angle at 0°, the probe was turned slightly clockwise, while slowly advancing and slightly retroflexing it, and the CS was visualized at a sector depth of 7 cm. A large, dynamically moving Thebesian valve was noticed at the ostium of the CS (Fig. 1A, Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A509), with echogenecity similar to the surrounding walls. It was imaged to originate from the atrial wall, posterior (dorsal) to the site of the CS ostium. Its dynamic motion obstructed the ostium of the CS in diastole. With color Doppler, flow from the CS into the right atrium (RA) was seen in systole (Fig. 1B, Video 1, see Supplemental Digital Content 1, http://links. lww.com/AA/A509), but not in diastole (Fig. 1C, Video 1, see Supplemental Digital Content 1, http://links.lww. com/AA/A509). Orthogonal views scanned using the X-plane mode (Philips, Healthcare, Inc.), which scans and displays 2 independent 2-dimensional scanning planes, simultaneously demonstrated that the Thebesian valve was partly attached to the interatrial septum, superior (cranial) to the site of the CS ostium at the multiplane 90° angle (Fig. 2, Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A510). Although the surgeon attempted to place the CS cannula (Retro-Self Inflate for cardio-protection; Edwards Lifesciences, Inc., Irvine, CA) under direct echocardiographic guidance, the cannula Difficult Cannulation of the Coronary Sinus Due to a Large Thebesian Valve

DOI: 10.1213/ANE.0b013e31827bc77e

3 Figures and Tables

Cite this paper

@article{Kuroda2013DifficultCO, title={Difficult cannulation of the coronary sinus due to a large Thebesian valve.}, author={Masataka Kuroda and Toshikazu Takahashi and Norikatsu Mita and Shin Kagaya and Sohtaro Miyoshi and Shigeru Saito}, journal={Anesthesia and analgesia}, year={2013}, volume={116 3}, pages={563-6} }