Echocardiographic imaging of a bifurcated double barrel coronary sinus

BACKGROUND: The coronary sinus (CS) is the terminal collecting vessel of the myocardial venous network, which returns deoxygenated blood used by the heart to the right atrium. The advent of high-fidelity imaging via CT and transesophageal echocardiography (TEE) has further defined the anatomy of the CS and its multiple tributaries. Understanding this anatomy is crucial for cardiac surgical cases that require the cannulation of the coronary sinus to deliver retrograde cardioplegia. However, anatomical variants of the CS may frustrate surgical retrograde catheter placement, in turn increasing the risk of CS injury or leading to inadequate cardioplegia delivery. Here, we present an especially unique CS presentation, a bifurcated, double-barrel CS, which was discovered via intraoperative TEE imaging that revealed a CS with two smaller lumens instead of the singular large os. CASE PRESENTATION: A 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant. CONCLUSIONS: Discovery of this patient’s double-barrel CS during the pre-bypass TEE was incidental, showing that such anatomical variants may be completely asymptomatic and benign in the non-operative setting. However, the delivery of cardioplegia proved challenging for this patient, highlighting some degree of risk with certain cardiac interventions. This case demonstrates the utility of intraoperative TEE to quickly ascertain unforeseen anatomical variants of the CS which could compromise the safety of cardiac surgery cases.