Fluoroscopic viewsAnatomyLeftRightSuperiorInferiorLateralMedialAnteriorPosteriorAnatomy nervus phrenicus (= phrenic nerve)Anatomy of the right atriumAnatomy of the right atriumThebesianThebesian valve valveCS CS ososEustachian ridgeAnatomy of the CSAnatomy of the CSVenous system of the heartThe CS ends at the Vieussens valve that is frequently seen at the ostium of the primary posterolateral vein, but can also be at the start of the great cardiac veinAnatomy exterior of the heartAnatomy exterior of the heartAnatomy exterior of the heartAnatomy exterior of the heartArea of Vieussens ValveLateral VeinPosterior VeinCoronary SinusVein of MarshalBack flow (from CS os to great cardiac vein) preventing valve. Acces not gained by holding gentle pressure on the valve, since the valves open in the direction of the blood flow.Venous system of the heartCoronary Sinus (CS) Starts at the CS OS and ends at the great cardiac vein.Coronary Sinus Ostium (CS OS) Located in the posterior right atrium and is the opening to the coronary sinus.Middle Cardiac Vein (MCV) Travels from the apex along the posterior interventricular septum to the CS.Great Cardiac Vein (GCV) Starts at the end of the CS and travels around the mitral valve annulus anteriorly until it reaches the anterior vein.Posterior Vein (PV) Venous branch on the posterior side of the LV.Lateral Vein (LatV) Venous branch on the lateral side of the LV. This vein is usually used for LV lead placement.Anterior Vein (AntV) Travels from the apex along the anterior interventricular septum to the great cardiac vein. Inter-Patient VariationsTotal Venograms analyzedN = 861 Vein between AIV and MCVN = 44/86 (51%)2 Veins between AIV and MCVN = 40/86 (46%)More than 2 veins between AIV and MCVN = 2/86 (2%)Lateral(35%)Posterior(16%)2 Lateral(8%)2 Posterior(0%)Posterior and Lateral (38%)At least 1 Posterior0%At least 1 Lateral1%Narrow Veins1%Circulation 2001;104:442-447Oblique views of the heartRotation of the camera allows for better views of certain structures. Primary plane of rotation is across the chest. LAO view: left anterior oblique. RAO view: right anterior oblique. Cranial angulation: rotating camera toward the head. Caudal angulation: rotating camera toward the feet.Coronary Venous AnatomyFluoroscopic ImagingAnterior Posterior view (AP) AP (also sometimes called PA) is a straight-down view into the heart. The x-ray tube and intensifier line up directly over the spine and sternum. Spine is slightly left of the heart on the imageSternum is directly over the spineRibs angle downwardSilhouette of heart is right of center on image AP viewAPAPLateralAnterior LateralLAO viewIn the LAO view, you will see:The spine rightward of the heartThe sternum to the leftThe ribs angled downward to the leftThe short axis silhouette of the heartIn LAO, the left ventricle will have:The septal wall to the left of the imageThe lateral wall to the right of the imageLAO view In LAO view for lead placement: Determine anterior, lateral or posterior lead position LV lead should be on the right in the lateral vein LV lead should point out at the viewer Distance between LV and RV leads should be maximized LAOAnteriorPosteriorLateralLAOTarget LV lead in LAO3 oclock5 oclockLAOAlign to CS OS Middle VeinAnteriorLateralPosteriorRightVenogramFinal LV Lead PlacementRAO viewRight anterior oblique (RAO) view:Long axis view of the heart Spine to the left Sternum to the right Perpendicular to the intraventricular septumRAO view In RAO view for lead placement: Determine apical, mid or basal lead positionLV lead should appear to the rightLV lead appears elongated LV and RV leads should be parallelRAO viewbasalmedialapicalTarget LV lead in RAORAO venogramAnteriorRAOBasalMidApicalVenogramFinal LV Lead PlacementRAOAPLAORARAR RV VL LV VLAALAOAPRAOAlign to CS OS/ Middle VeinAnteriorLateralPosteriorRightBasalMidApicalCoronary Venous AnatomyTarget LV Lead APEnough distance between position LV and RV electrode Exercise RAO / AP / LAO?1 =2 =3 =213Exercise LAO1 = Antero-lateral?2 = Great CV3 = Lateral vein213Example 1 AHV Lead RVOTExample 1 AMid Cardiac VeinPosterior Cardiac VeinInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinHV Lead RVOTGreat Cardiac VeinExample 1BExample 1BMid Cardiac VeinPosterior Cardiac VeinInterventricular Anterior veinGreat Cardiac VeinExample 2AExample 2AInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinGreat Cardiac VeinExample 2BExample 2BPosterior Cardiac VeinInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinExample 3AExample 3AMid Cardiac VeinPosterior Cardiac VeinInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinGreat Cardiac VeinExample 3BExample 3BMid Cardiac VeinPosterior Cardiac VeinInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinGreat Cardiac VeinExample 4AExample 4AInterventricular Anterior veinLateral Cardiac VeinAnterior VeinExample 4BExample 4BMid Cardiac VeinPosterior Cardiac VeinInterventricular Anterior veinLateral Cariac VeinExample 5AExample 5AMid Cardiac VeinInterventricular Anterior veinPosterior Lateral VeinLateral Cariac VeinExample 5BExample 5BInterventricular Anterior veinLateral Cariac VeinPosterior Lateral VeinMid Cardiac VeinValve of VieussenDuring this venography, the balloon catheter could not be easily advanced beyond the coronary sinus proper into the great cardiac vein because of the presence of a prominent Valve of Vieussen, which is poorly visible. The site of the Valve of Vieussen is marked by the indentation at the venous wall (seen next to the balloon). DissectionsDissectionsDye extravasation during CS angiography: perforation: Dye will stay vessel: Dye is washed away