BACKGROUND: Sinus of Valsalva aneurysm (SOVA), a rare cardiac malformation, is usually congenital and rarely acquired and most commonly occurring in the right coronary sinus. The clinical presentation of patients with SOVA varies. It is usually asymptomatic when it has not ruptured, and when it compresses neighboring structures or ruptures, it can lead to heart failure or shock, at which point urgent surgical intervention is usually required. Rupture of the sinus of Valsalva aneurysm (RSOVA) during pregnancy is really hard to come by, especially if the clinical presentations resemble that of an acute myocardial infarction. This report describes a pregnant woman with severe chest pain and hypotension with aVR and V1 ST-segment elevation due to RSOVA.
METHODS: Effects of RSOVA on the fetus, disease survival, and prognosis.
METHODS: RSOVA.
METHODS: Open SOVA repair.
RESULTS: The patient\'s blood pressure returned to normal range and clinical symptoms disappeared after the surgery. After 3 months of follow-up, the patient was hemodynamically stable without chest discomfort, and an echocardiogram showed a normal aortic sinus.
CONCLUSIONS: Progressive aneurysm dilatation or rupture has a poor prognosis. A thorough history and physical examination are fundamental, with echocardiography being the initial diagnostic tool of choice, and other ancillary tests (e.g., computed tomography) being used to complement and confirm the diagnosis. Surgery remains the current treatment of choice for patients with RSOVA, while the continuation of pregnancy in pregnant patients with RSOVA remains a case-by-case measure.

BACKGROUND: Low voltage areas (LVA) are pivotal in atrial fibrillation (AF) pathogenesis, influencing local left atrial LA excitation and perpetuating AF occurrences. While pulmonary vein isolation (PVI) with cryo-balloon (CB) ablation is effective for AF, it doesn\'t provide insights into the LA substrate or detect LVA, which affects ablation success rates. This study examines whether LA voltage and LVAs can be anticipated by analyzing the voltage signal amplitude at the coronary sinus (CS) catheter, which is standard in CB and radiofrequency ablation procedures.
METHODS: A retrospective analysis of 284 patients with recurrent AF undergoing RF catheter ablation was conducted at a high-volume EP center in Germany. The correlation between LA voltage and LVA with the CS signal was explored.
RESULTS: The signal amplitude in the CS significantly correlated with voltage in LA walls, particularly in the proximal CS (correlation coefficient ρ = 0.81, p < 0.001). A CS signal cut-off of 1.155 mV effectively predicted severe atrial LVAs (>40%) with a sensitivity of 90.7% and a specificity of 100%. While a threshold of 1.945 mV identified patients with no significant atrial LVAs (<5%) with a sensitivity of 88% and a specificity of 50% (AUC: 0.81, 95% CI: 0.71-0.89, p < 0.001).
CONCLUSIONS: The CS signal amplitude is associated with the LA voltage. Due to its potential as a diagnostic tool for atrial LVAs, the signal amplitude in the CS could provide valuable information about the LA substrate, especially when 3D mapping is not feasible.

UNASSIGNED: Atrial tachycardias (AT) originating from the Marshall bundle (MB) are rare and present significant challenges in diagnosis and management. The authors present the case of a 29-year-old male with recurrent AT successfully treated with a combined ethanol and radiofrequency ablation approach. This case highlights the effectiveness of this dual ablation strategy in resolving AT originating from the MB, contributing valuable insights into managing complex AT cases.
UNASSIGNED: A 29-year-old male with recurrent, symptomatic palpitations was initially suspected of orthodromic atrioventricular reentrant tachycardia, but an initial electrophysiological study (EPS) failed to induce arrhythmia. Subsequent spontaneous episodes led to a detailed EPS, revealing automatic AT originating presumably from an epicardial focus on the posterior wall of the left atrium (LA). Detailed mapping identified the earliest activation at the vein of Marshall (VoM) ostium within the coronary sinus (CS). Suspecting the involvement of MB structures, VoM ethanol ablation was performed. Complete arrhythmia elimination was achieved with radiofrequency ablation (RFA) at the VoM ostium within the CS, with no recurrence.
UNASSIGNED: Most cases in the literature are associated with atrial fibrillation (AF) or AT within AF, typically involving re-entry mechanisms. The given case is unique as it presents a highly probable VoM origin of automatic AT with no concomitant AF. The VoM\'s anatomical and electrophysiological properties make it a potential source of refractory AT. In this case, ethanol ablation supplemented by targeted, limited RFA emerged as an effective strategy, highlighting the importance of comprehensive mapping and tailored ablation approaches in managing complex atrial arrhythmias.
UNASSIGNED: The potential implications for clinical practice include recognizing the VoM as a critical target in refractory AT cases and adopting a combined ablation strategy to improve patient outcomes in similarly challenging scenarios.

A 15-year-old male patient presented with a 3-year history of recurrent dizziness and headaches and was initially diagnosed with patent foramen ovale. A transcatheter closure procedure was planned and conducted under general anesthesia, utilizing ultrasound guidance through the femoral vein. Preadmission echocardiography confirmed the presence of a patent foramen ovale. However, further investigation with transesophageal echocardiography (TEE) performed under general anesthesia, revealed that the observed atrial septal anomaly was not a patent foramen ovale. Instead, real-time TEE identified it as the left atrial opening of the coronary vein. Subsequent detailed TEE tracking confirmed a rare case of coronary sinus ostium atresia with left atrial reflux of the coronary vein, leading to a significant revision of the initial diagnosis and planned treatment.

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Coronary sinus reducer implantation is a percutaneous technique creating a narrowing in the coronary sinus through the implantation of an hourglass-shaped endoprosthesis. It is proposed to reduce symptoms in patients suffering from refractory angina pectoris. This innovative treatment is experiencing a major craze among interventional cardiologists. It is associated with very high procedural success rates. Complications are rare and include coronary sinus dissection or perforation and migration of the device. This review exposes the device implantation technique, the potential anatomical difficulties, the tips and tricks to overcome challenging situations. It also focuses on the prevention and management of potential complications.

UNASSIGNED: Insertion of electrode catheters into the coronary sinus (CS) through the right internal jugular vein (RIJV) carries risks of pneumothorax and severe hematoma formation. This study was performed to compare the safety and feasibility of catheterization through the left cubital superficial vein versus the RIJV.
UNASSIGNED: This prospective nonrandomized study involved consecutive patients who underwent catheter ablation from September 2021 to February 2023. Blind puncture techniques were used in the left cubital vein group; ultrasound-guided insertion was performed in the RIJV group. The success rates of sheath insertion and CS catheterization, the procedure and fluoroscopy times of CS cannulation, and complications were compared between groups.
UNASSIGNED: The left cubital vein group comprised 152 patients, and the RIJV group comprised 58 patients. The sheath insertion success rate was significantly lower in the cubital vein group than in the RIJV group (84.9% vs 100%, respectively; p = .0008). In the cubital vein group, blind puncture attempts failed in 20 patients; three patients developed guidewire-induced venous injury. One arterial puncture occurred in the RIJV group. After successful sheath insertion, no significant differences were observed in the CS cannulation success rate (97% vs 100%, p = .55), procedure time (median [range], 93 [51-174] vs 74 [44-129] s; p = .19), or fluoroscopy time (median [range], 66 [36-134] vs 48 [30-92] s; p = .17). No serious complications requiring procedural discontinuation occurred.
UNASSIGNED: The left cubital vein approach is practical, offering a viable alternative to the RIJV approach.

OBJECTIVE: To assess the coronary sinus (CS) presence, size, and CS to atrial ratio (CS/A) in the first trimester (FT) compared with the second trimester (ST).
METHODS: In this IRB-approved retrospective study, fetuses with adequate FT cardiac sweeps and normal ST hearts were included. Maternal and fetal characteristics were obtained. CS and atrial diameters were measured by a single sonologist. The CS/A ratio was compared between FT and ST. Linear regression assessed the relationship between biparietal diameter (BPD) and CS and atrial diameters. Statistical significance was set at P < .05.
RESULTS: Among 99 fetuses, the CS was seen in 42/53 (79.2%) in the FT and 14/32 (43.8%) in the ST. No significant associations were found between CS visualization and the factors analyzed. The CS/A ratio was significantly higher in the FT versus ST (0.43 vs 0.25; P < .0001). Combined FT and ST data revealed positive correlations between BPD and both CS (slope = 0.018, P < .0001) and atrial diameters (slope = 0.135, P < .0001), suggesting differential growth rates, with the atrium exhibiting a faster growth rate as BPD increased.
CONCLUSIONS: The CS appears prominent in the FT compared with the ST, likely due to differential growth rates between the CS and atrium. Remnants of embryonic structures, differences in myocardial drainage, and hemodynamics may also be contributing factors. Larger prospective studies are needed to confirm these findings and assess the value of the FT CS/A ratio.

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