1. Surgical Approach to Left Ventricular Inflow Obstruction Due to Dilated Coronary Sinus 
Florentino J. Vargas, MD, Jorge Rozenbaum, MD, Ricardo Lopez, MD, Miguel Granja, MD, Ana De Dios, MD, Beatriz Zarlenga, MD, Enrique Flores, MD, Enrique Fischman, MD, Eduardo Kreutzer, MD 
The Annals of Thoracic Surgery 
Volume 82, Issue 1, Pages (July 2006)
DOI: /j.athoracsur
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Preoperative echocardiogram. (A) Apical four-chamber view (systole). The interatrial septum bulges toward the right atrium in its superior portion, and toward the left atrium in the inferior part (arrows) adopting an S-shaped configuration. (B) Apical four-chamber view (diastole). The dilated coronary sinus is occupying a major part of the external border of the left atrium and protrudes, causing obstruction to the left atrial emptying at a supravalvular mitral level (arrow). Both the mitral valve and left ventricle are smaller than the tricuspid valve (mitral valve /tricuspid valve annulus ratio: 0.6 cm) and the right ventricular chamber. (CS = coronary sinus; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Preoperative angiogram performed in the inferior vena cava displays interruption of the inferior vena cava, with hemiazygous continuation to left superior vena cava and to a dilated coronary sinus. Washout from the left superior vena cava is observed at the hemiazygous-left superior vena cava junction level. (AZ = interrupted inferior vena cava-hemiazygous continuation; CS = coronary sinus; LSVC = left superior vena cava.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Surgical technique. (A) Interrupted inferior vena cava-hemiazygous continuation to left superior vena cava (dotted line) and to the dilated coronary sinus. The innominate vein is absent. The dilated coronary sinus causes left ventricular inflow obstruction. The mitral valve is hidden underneath the dilated coronary sinus. (B) Through a wide excision of the atrial septum, the wall of the coronary sinus was entirely removed (arrow) from inside the left atrium. (C) The previously enlarged atrial septal defect is closed with a pericardial patch. (D) The left superior vena cava together with a wide circular cuff of left atrial wall is separated from the left atrium. A large orifice was created in the roof of the left atrium. The left atrial appendage will be opened longitudinally following the dotted line (arrow) to create a flap. The pulmonary artery is retracted. (E) A wide flap was tailored with the opened left atrial appendage and used to close the large defect created in the roof of the left atrium. (F) The tip of the right atrial appendage is widely opened, its inner surface liberated from residual muscular trabeculae to create an unobstructed tubular structure, and a large anastomosis is performed with the wide circular cuff of left atrial tissue previously isolated together with the left superior vena cava, thereby establishing left superior vena cava-right atrium continuity. The right atriotomy was closed. (Ao = aorta; azg = hemiazygous [interrupted inferior vena cava-hemiazygous continuation to left superior vena cava]; cs = coronary sinus; laa = left atrial appendage; laf = left atrial flap; lsvc = left superior vena cava; m = mitral valve; p = atrial septal patch; pa = pulmonary artery; raa = right atrial appendage; rsvc = right superior vena cava.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Postoperative catheterization. (A) Anteroposterior. (B) Lateral. The cavogram performed in the interrupted inferior vena cava displayed the systemic venous return as it enters into the right atrium following its way from the interrupted inferior vena cava through the hemiazygous vein-left superior vena cava to right atrial appendage anastomosis. A widely patent left superior vena cava-right atrial appendage anastomosis was demonstrated. Washout from the upper left superior vena cava is present. (AZ = interrupted inferior vena cava-hemiazygous continuation; LSVC = left superior vena cava; RA = right atrium; RAA = right atrial appendage.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions