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A 41 year old male with Wolff-Parkinson-White syndrome and symptomatic atrioventricular re-entrant tachycardia was admitted for electrophysiological study. An exceptionally large coronary sinus diverticulum was identified (right) and found to contain the accessory atrioventricular pathway. Successful radiofrequency ablation to this posteroseptal accessory pathway was carried out.
Coronary sinus aneurysms or diverticulae are rare congenital anomalies with only a few published images. Diverticulae associated with a posteroseptal accessory atrioventricular connection were first described in 1985. They have been identified at necropsy in patients with Wolff-Parkinson-White syndrome or sudden death, during surgical ablation of posteroseptal pathways, and during angiographic and electrophysiological studies. They are venous pouches located within the epicardial layers of the posterior ventricular septum or posterosuperior process of the left ventricle, with necks opening into the proximal coronary sinus.
Surgical series suggest they may be present in 6–9% of patients with posteroseptal accessory pathways with symptoms severe enough to warrant surgery. In patients undergoing transoesophageal echocardiography following failed attempts at ablation of a posteroseptal accessory pathway, coronary sinus diverticulae were identified in 13% of cases.
Coronary sinus diverticulae may be associated with other congenital cardiac abnormalities. Aneurysms of the membranous ventricular septum and subaortic membranes have been described.
Radiofrequency catheter ablation appears to be safe and curative in this setting.