\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Coronary sinus diverticulum: importance, function, and treatment}



\author[1]{Iman Razeghian-Jahromi}%
\author[1]{Mohammad Nikoo}%
\author[2]{Andrea Natale}%
\affil[1]{Shiraz University of Medical Sciences}%
\affil[2]{St. David's Medical Center}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
The importance of venous structure in the heart is usually overshadowed
by that of the arterial system. Coronary sinus is a part of cardiac
venous apparatus and connects left atria to the right atria. Other than
having role in physiological contractions of both atria, it contributes
substantially to cardiac electrical conduction system. Due to unique
placement and connections of the CS, it has become growing interest in
clinical cardiology. It is used in cardiac resynchronization therapy
with biventricular pacing, left-sided catheter ablation of arrhythmias
and administration of retrograde cardioplegia in cardiac surgery. In
some individuals, CS is presented with anatomical variants. CS
diverticulum is a congenital outpouching that provides muscular
connection between atria and ventricle. This connection provides a
suitable substrate for occurrence of arrhythmias, which even results in
life-threatening events such as sudden cardiac death. Early diagnosis
leads to treatment with ablation techniques which ultimately eliminates
origins of arrhythmias.%
\end{abstract}%



\sloppy


Coronary sinus diverticulum: importance, function, and treatment

Iman Razeghian-Jahromi\textsuperscript{1*}, PhD, Mohammad Hossein Nikoo,
MD\textsuperscript{1,2}, Andrea Natale\textsuperscript{3,4,5,6,7,8}

\textsuperscript{1} Cardiovascular research center, Shiraz University of
Medical Sciences, Shiraz, Iran

\textsuperscript{2} Non-Communicable Diseases Research Center, Shiraz
University of Medical Sciences, Shiraz, Iran

\textsuperscript{3}Texas Cardiac Arrhythmia Institute, St. David's
Medical Center, Austin, TX, USA;\textsuperscript{4}Dell Medical School,
University of Texas, Austin, TX, USA; \textsuperscript{5}Department of
Biomedical Engineering, University of Texas, Austin, TX,
USA;\textsuperscript{6}MetroHealth Medical Center, Case

Western Reserve University School of Medicine, Cleveland, OH,
USA;\textsuperscript{7}Division of Cardiology, Stanford University,
Stanford, CA, USA; and \textsuperscript{8}Electrophysiology and
Arrhythmia Services, California Pacific Medical Center, San Francisco,
CA, USA

*Corresponding author: Iman Razeghian-Jahromi

Postal address: Cardiovascular Research Center,
3\textsuperscript{rd}floor, Mohammad Rasoolallah Research Tower, Namazi
Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.

Postal code: 71936-35899

Tel: +98 713 628 1561

Fax: +98 713 612 2235

Email: \emph{razejahromi@yahoo.com}

Acknowledgements: N/A

Competing interests: The authors declare that they have no competing
interests.

Funding: This research was supported by Vice Chancellor of Research of
Shiraz University of Medical Sciences.

Abstract

The importance of venous structure in the heart is usually overshadowed
by that of the arterial system. Coronary sinus is a part of cardiac
venous apparatus and connects left atria to the right atria. Other than
having role in physiological contractions of both atria, it contributes
substantially to cardiac electrical conduction system. Due to unique
placement and connections of the CS, it has become growing interest in
clinical cardiology. It is used in cardiac resynchronization therapy
with biventricular pacing, left-sided catheter ablation of arrhythmias
and administration of retrograde cardioplegia in cardiac surgery. In
some individuals, CS is presented with anatomical variants. CS
diverticulum is a congenital outpouching that provides muscular
connection between atria and ventricle. This connection provides a
suitable substrate for occurrence of arrhythmias, which even results in
life-threatening events such as sudden cardiac death. Early diagnosis
leads to treatment with ablation techniques which ultimately eliminates
origins of arrhythmias.

Keywords: coronary sinus diverticulum; arrhythmia; ablation

Introduction

Coronary sinus (CS) anomalies such as diverticulum, persistent left
superior vena cava or CS ostium dilatation are predominantly found in
patients with accessory pathway-related tachycardias (1). Earlier
studies have reported diverticulum of proximal CS in 7-11\% of patients
with posteroseptal accessory pathways (2). In this review, a literature
appraisal was performed regarding importance, function, and ablation of
CS diverticulum.

CS

Several cardiac procedures like targeted drug delivery, stem cell
therapy as well as mapping and ablation of arrhythmias make use of CS
(3). By a multipurpose catheter and injection of contrast in LAO and RAO
views, CS anatomy was delineated. In the case of difficulty with
catheter to cannulate, a deflectable sheath is employed (4). The average
length ranges from 45 to 63mm. Different size of ostium ranges (4*5 to
9*16mm) have also been reported (5).

CS drains 60\% of cardiac venous blood into the right atrium. In
addition to the largest cardiac venous structure, it is an interatrial
connection (6). However, unlike the veins, it has myocardial tissue
which is the remnant of left atrial muscles (7). Although CS has been
regarded as a venous structure for a long time but recently it was
clarified its crucial role in the pathophysiology of atrial
tachyarrhythmia (8-10).

The most common atrial arrhythmia in humans is atrial fibrillation (AF).
Although pulmonary veins are closely associated to AF pathogenesis, it
seems that ablation of these veins is not enough for disappearance of
persistent AF. Additional reentry mechanism, probably by the involvement
of CS was proposed (6). Muscular sleeve, which is around the proximal
25-50mm of the CS length, connects the two atria (11). Arrhythmia most
likely emerges from these connections (12). Also, it was shown that CS
has the capability for spontaneous depolarization and slow conduction,
an indicator of intrinsic automaticity (13-15). Thereby, spontaneous
firing of the cells in the CS is in charge for triggering, maintenance,
and recurrence of AF (12, 16, 17). Accordingly, ablation of CS together
with pulmonary vein resulted in long term improvement through decreasing
the recurrences (18).

CS diverticulum

Variation in CS anatomy in terms of position, length, and diameter was
seen among individuals (19). CS anomalies are, but not limited to,
enlargement, absence, atresia of right ostium, and hypoplasia (6). These
anomalies may affect cardiac hemodynamics, which leads to clinical
manifestations and requiring prompt diagnosis and treatment. However,
some others are clinically occult without any obvious symptoms. They all
have the potential to increase morbidity and mortality after certain
surgical procedures. Moreover, electrophysiological characteristics of
the CS are influenced by the existence of these anomalies (20, 21).

CS diverticulum is a one of such anomalies. It is a CS congenital
outpouching with a distinct neck that extends behind the left ventricle
(22, 23). In most cases, diverticula were seen as a saccular dilatation
and sometimes it is a fusiform dilatation. In some patients, its sac was
bilobed. Contractility is its inherent characteristic (4). Diverticula
are commonly found at the inferior aspect of the CS at its junction with
the middle cardiac vein, 0 to 18mm away from the CS ostium. The neck of
the CS diverticulum is 5 to 10-mm wide, opens into the CS and is
proximal to the midcardiac vein (24). The orifice of the diverticula
ranges between 2.6 to 15mm. The smallest and largest surface area was
0.73cm\textsuperscript{2} and 6.45cm\textsuperscript{2}, respectively.
The mean diameter of the CS was 7.05mm \selectlanguage{ngerman}± 1.90. Thus, CS could be dilated
up to 11mm at measuring 3cm proximal to the CS ostium (25, 26). (Fig. 1)

Central parts of cardiac conduction system including atrioventricular
node and the His bundle are in the septal area. Approximately, one third
of accessory pathways (APs) are located at this complex anatomic region.
These pathways frequently have short refractory periods that predispose
to rapid ventricular response during atrial fibrillation, thus
increasing the risk of sudden death (24).

Therefore, precise localization of these pathways is critical during
ablation of APs. APs of this area are classified into anteroseptal,
midseptal, and posteroseptal (27). Diverticula with posteroseptal APs
were first reported in 1985 (28). This type of AP increases the
incidence of inducible AF (27). Myocardial fibers of CS diverticulum
establish a connection between CS coat and the ventricle, which
facilitates the incidence of AP (29, 30). Close proximity of the wall
and the neck of the diverticula with posteroseptal and left posterior
APs endangers patients to arrhythmias and even sudden cardiac death (22,
23).

Among 480 patients with posteroseptal or left posterior AP, CS
diverticula was found in only 36 (7.5\%) (30). It is a rare anomaly
which often diagnosed during venography and catheter ablation (31). The
existence of CS diverticula is expected in the case of previous failed
ablation, documented AF, when the best location for ablation is at the
proximal of CS, and in specific ECG findings like polarity of the delta
wave. A negative delta wave in lead II is an indicator of CS
diverticulum with highest specificity and sensitivity (29, 30, 32, 33).
(Fig 2.)

Treatment

Radiofrequency (RF) ablation is safe and treatment of choice for
resolving septal APs (28). Percutaneous access for ablation of
epicardial APs is feasible through CS cannulation. This was performed
even in patients with previously failed endocardial ablation (34).
Ablation of the CS eliminated focal tachyarrhythmia with CS origin (6).
As CS has anatomic and electropgysiological relationship with atria,
origin of multifocal tachyarrhythmia from either atria could be
determined. If myocardial part of the CS is the origin, high-frequency
higher-amplitude component indicates a near-field potential. Otherwise,
(low-frequency lower-amplitude) shows a far-field potential (35, 36).

Epicardial and endocardial ablation of the CS increase AF cycle length
and eventually leads to AF termination (8). One study reported
posteroseptal AP in a patient with a history of three previous failed
attempts of ablation. In such cases, open chest surgical ablation is
deemed as the only remaining choice. This difficult-to-ablate AP was
managed by epicardial mapping through pericardial catheter. Although,
existence of high impedance due to thick epicardial fat hampered the
ablation by this approach but a linear ablation within the CS targeting
the earliest activation area terminated the preexcitation (37).

CS ablation is performed in patients with AF without previous pulmonary
vein ablation (38). The anomalies of the CS sometimes becomes the
crucial sites for successful ablation of posteroseptal pathways (1).
Findings showed that CS diverticulum with APs were more prone to sudden
death during AF due to acceleration of atrioventricular conduction (33).
However, CS diverticulum is a well-known cause of unsuccessful AP
ablation in wolff-parkinson-white syndrome. This fact underscores the
necessity of identification and reporting of CS anomalies especially
that of diverticula (32).

Epicardial approach and the diverticula neck are the helpful points
toward a successful ablation in patients with CS diverticulum and
posteroseptal APs (29, 30, 32). The success rate of ablation in the neck
of the diverticulum reaches 90\% (2). After recording early retrograde
atrial signal at the neck by the ablation catheter which representing CS
activity, delivering controlled energy leads to elimination of APs
footprints (29). However, successful ablation was also reported within
the CS. In one patient with small diverticulum, ablation was done in the
adjacent CS. Overall, it seems that neck of the diverticula is the site
with highest rate of success for ablation (2, 4).

Posteroseptal APs are sometimes difficult to ablate due to complex
anatomic arrangements (29, 39). Other than anatomic complexity, the
inherent nature of diverticula with a pouch and a neck increase the
intricacy of the task (39). Not only is the matter the difficulty of
ablation of posteroseptal APs but also are the consequent
life-threatening complications because of close proximity to the
coronary arteries (39). It was reported that total occlusion of left
circumflex artery during ablation inside the CS augments the risk of
arrhythmias (40, 41). Even ventricular fibrillation following by sudden
cardiac death was reported (40). In order to prevent complications such
as perforation, formation of coagulation, excess heat, and right
coronary artery stenosis during ablation procedure in the CS, some
recommendations have been made like temperature control ablation,
irrigated RF ablation, and cryoablation (42, 43). Low temperature RF
ablation resulted in a safe and complication-free ablation (44).

Conclusion

CS diverticulum is a variant of CS. Importantly, it has been substrate
of APs near epicardium. CS diverticulum with AP is a rare disorder.
During an electrophysiologic study seeking for the underlying reasons of
left posterior and posteroseptal APs, CS diverticulum is detected in
coronary vein angiography. Treatment of choice for such patients is RF
catheter ablation. The target site for ablation is typically the narrow
neck of the CS diverticulum.

List of abbreviations

CS: coronary sinus; AP: accessory pathway; EPS: electrophysiologic
study; RF: radiofrequency

References:

1. Saad EB, Marrouche NF, Cole CR, Natale A. Simultaneous Epicardial and
Endocardial Mapping of a Left\selectlanguage{english}-Sided Posteroseptal Accessory Pathway
Associated with a Large Coronary Sinus Diverticulum: Successful Ablation
by Transection of the Diverticulum's Neck. Pacing and clinical
electrophysiology. 2002;25(10):1524-6.

2. Payami B, Shafiee A, Shahrzad M, Kazemisaeed A, Davoodi G,
Yaminisharif A. Posteroseptal accessory pathway in association with
coronary sinus diverticulum: electrocardiographic description and result
of catheter ablation. Journal of Interventional Cardiac
Electrophysiology. 2013;38(1):43-9.

3. Shah SS, Teague SD, Lu JC, Dorfman AL, Kazerooni EA, Agarwal PP.
Imaging of the coronary sinus: normal anatomy and congenital
abnormalities. Radiographics. 2012;32(4):991-1008.

4. Selvaraj RJ, Sarin K, Singh VR, Satheesh S, Pillai AA, Kumar M, et
al. Radiofrequency ablation of posteroseptal accessory pathways
associated with coronary sinus diverticula. Journal of Interventional
Cardiac Electrophysiology. 2016;47(2):253-9.

5. Ortale JR, Gabriel EA, Iost C, Marquez CQ. The anatomy of the
coronary sinus and its tributaries. Surgical and Radiologic Anatomy.
2001;23(1):15-21.

6. Ahmed N, Perveen S, Mehmood A, Rani GF, Molon G. Coronary Sinus
Ablation Is a Key Player Substrate in Recurrence of Persistent Atrial
Fibrillation. Cardiology. 2019;143(3-4):107-13.

7. Chauvin M, Shah DC, Haissaguerre M, Marcellin L, Brechenmacher C. The
anatomic basis of connections between the coronary sinus musculature and
the left atrium in humans. Circulation. 2000;101(6):647-52.

8. Haissaguerre M, Hocini M, Takahashi Y, O'Neill MD, Pernat A, Sanders
P, et al. Impact of catheter ablation of the coronary sinus on
paroxysmal or persistent atrial fibrillation. J Cardiovasc
Electrophysiol. 2007;18(4):378-86.

9. Haissaguerre M, Sanders P, Hocini M, Takahashi Y, Rotter M, Sacher F,
et al. Catheter ablation of long-lasting persistent atrial fibrillation:
critical structures for termination. J Cardiovasc Electrophysiol.
2005;16(11):1125-37.

10. Knecht S, O'Neill MD, Matsuo S, Lim KT, Arantes L, Derval N, et al.
Focal arrhythmia confined within the coronary sinus and maintaining
atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(11):1140-6.

11. Sanchez-Quintana D, Lopez-Minguez JR, Pizarro G, Murillo M, Cabrera
JA. Triggers and anatomical substrates in the genesis and perpetuation
of atrial fibrillation. Current cardiology reviews. 2012;8(4):310-26.

12. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland
JC, Jr., et al. 2014 AHA/ACC/HRS guideline for the management of
patients with atrial fibrillation: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
and the Heart Rhythm Society. Journal of the American College of
Cardiology. 2014;64(21):e1-76.

13. Ho SY, Sanchez-Quintana D, Becker AE. A review of the coronary
venous system: a road less travelled. Heart rhythm. 2004;1(1):107-12.

14. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B,
Vasavakul T, et al. A new approach for catheter ablation of atrial
fibrillation: mapping of the electrophysiologic substrate. Journal of
the American College of Cardiology. 2004;43(11):2044-53.

15. Oral H, Chugh A, Good E, Wimmer A, Dey S, Gadeela N, et al.
Radiofrequency catheter ablation of chronic atrial fibrillation guided
by complex electrograms. Circulation. 2007;115(20):2606-12.

16. Kugler S, Nagy N, Racz G, Tokes AM, Dorogi B, Nemeskeri A. Presence
of cardiomyocytes exhibiting Purkinje-type morphology and prominent
connexin45 immunoreactivity in the myocardial sleeves of cardiac veins.
Heart rhythm. 2018;15(2):258-64.

17. Romero J, Gianni C, Di Biase L, Natale A. Catheter Ablation for
Long-Standing Persistent Atrial Fibrillation. Methodist DeBakey
cardiovascular journal. 2015;11(2):87-93.

18. Di Biase L, Santangeli P, Natale A. How to ablate long-standing
persistent atrial fibrillation? Current opinion in cardiology.
2013;28(1):26-35.

19. Echeverri D, Cabrales J, Jimenez A. Myocardial venous drainage: from
anatomy to clinical use. The Journal of invasive cardiology.
2013;25(2):98-105.

20. Jha NK, Gogna A, Tan TH, Wong KY, Shankar S. Atresia of coronary
sinus ostium with retrograde drainage via persistent left superior vena
cava. The Annals of Thoracic Surgery. 2003;76(6):2091-2.

21. Yokota M, Kyoku I, Kitano M, Shimada I, Mizuhara H, Sakamoto K, et
al. Atresia of the coronary sinus orifice. Fatal outcome after
intraoperative division of the drainage left superior vena cava. J
Thorac Cardiovasc Surg. 1989;98(1):30-2.

22. Funabashi N, Asano M, Komuro I. Giant coronary sinus diverticulum
with persistent left superior vena cava demonstrated by multislice
computed tomography. International journal of cardiology.
2006;111(3):468-9.

23. Mandegar MH, Saidi B, Oraii S, Tehrai M, Roshanali F. Giant
diverticulum causing ventricular arrhythmia. Journal of cardiac surgery.
2011;26(1):117-8.

24. Guiraudon GM, Guiraudon CM, Klein GJ, Sharma AD, Yee R. The coronary
sinus diverticulum: a pathologic entity associated with the
Wolff-Parkinson-White syndrome. American Journal of Cardiology.
1988;62(10):733-5.

25. Isaacs D, Hazany S, Gamst A, Stark P, Mahmud E. Evaluation of the
coronary sinus on chest computed tomography in patients with and without
pulmonary artery hypertension. Journal of computer assisted tomography.
2009;33(4):513-6.

26. Saremi F, Krishnan S. Cardiac Conduction System: Anatomic Landmarks
Relevant to Interventional Electrophysiologic Techniques Demonstrated
with 64-Detector CT. RadioGraphics. 2007;27(6):1539-65.

27. Haghjoo M, Kharazi A, Fazelifar AF, Alizadeh A, Emkanjoo Z,
Sadr-Ameli MA. Electrocardiographic and electrophysiologic
characteristics of anteroseptal, midseptal, and posteroseptal accessory
pathways. Heart rhythm. 2007;4(11):1411-9.

28. Mulder HJGH, Schalij MJ, Kauer B, Visser RF, van Dijkman PRM, Jukema
JW, et al. Pravastatin and endothelium dependent vasomotion after
coronary angioplasty: the PREFACE trial. Heart. 2001;86(5):533.

29. Jang SW, Rho TH, Kim DB, Kwon BJ, Cho EJ, Shin WS, et al. Successful
radiofrequency catheter ablation for wolff-Parkinson-white syndrome
within the neck of a coronary sinus diverticulum. Korean circulation
journal. 2009;39(9):389-91.

30. Sun Y, Arruda M, Otomo K, Beckman K, Nakagawa H, Calame J, et al.
Coronary sinus-ventricular accessory connections producing posteroseptal
and left posterior accessory pathways: incidence and
electrophysiological identification. Circulation. 2002;106(11):1362-7.

31. Saremi F, Muresian H, Sanchez-Quintana D. Coronary Veins:
Comprehensive CT-Anatomic Classification and Review of Variants and
Clinical Implications. RadioGraphics. 2012;32(1):E1-E32.

32. ARRUDA MS, McCLELLAND JH, WANG X, BECKMAN KJ, WIDMAN LE, GONZALEZ
MD, et al. Development and Validation of an ECG Algorithm for
Identifying Accessory Pathway Ablation Site in Wolff-Parkinson-White
Syndrome. Journal of Cardiovascular Electrophysiology. 1998;9(1):2-12.

33. Blank R, Dieterle T, Osswald S, Sticherling C. Images in
cardiovascular medicine. Wolff-Parkinson-White syndrome and atrial
fibrillation in a patient with a coronary sinus diverticulum.
Circulation. 2007;115(20):e469-71.

34. Gaita F, Paperini L, Riccardi R, Ferraro A. Cryothermic ablation
within the coronary sinus of an epicardial posterolateral pathway. J
Cardiovasc Electrophysiol. 2002;13(11):1160-3.

35. Traykov VB. Mapping strategies in focal atrial tachycardias
demonstrating early septal activation: distinguishing left from right.
Current cardiology reviews. 2015;11(2):111-7.

36. Traykov VB, Pap R, Shalganov TN, Bencsik G, Makai A, Gallardo R, et
al. Electrogram analysis at the His bundle region and the proximal
coronary sinus as a tool to predict left atrial origin of focal atrial
tachycardias. Europace : European pacing, arrhythmias, and cardiac
electrophysiology : journal of the working groups on cardiac pacing,
arrhythmias, and cardiac cellular electrophysiology of the European
Society of Cardiology. 2011;13(7):1022-7.

37. Saad EB, Marrouche NF, Cole CR, Natale A. Simultaneous epicardial
and endocardial mapping of a left-sided posteroseptal accessory pathway
associated with a large coronary sinus diverticulum: successful ablation
by transection of the diverticulum's neck. Pacing and clinical
electrophysiology : PACE. 2002;25(10):1524-6.

38. Justaniah A, McKee B, Silver J, Wald C, Flacke S. Coronary sinus to
left atrium communication. Journal of radiology case reports.
2013;7(12):16-20.

39. Morin DP, Parker H, Khatib S, Dinshaw H. Computed tomography of a
coronary sinus diverticulum associated with Wolff-Parkinson-White
syndrome. Heart rhythm. 2012;9(8):1338-9.

40. Makimoto H, Zhang Q, Tilz RR, Wissner E, Cuneo A, Kuck KH, et al.
Aborted sudden cardiac death due to radiofrequency ablation within the
coronary sinus and subsequent total occlusion of the circumflex artery.
J Cardiovasc Electrophysiol. 2013;24(8):929-32.

41. Takahashi Y, Jais P, Hocini M, Sanders P, Rotter M, Rostock T, et
al. Acute occlusion of the left circumflex coronary artery during mitral
isthmus linear ablation. J Cardiovasc Electrophysiol.
2005;16(10):1104-7.

42. Hillegass WB, Patel MR, Klein LW, Gurm HS, Brennan JM, Anstrom KJ,
et al. Long-term outcomes of older diabetic patients after percutaneous
coronary stenting in the United States: a report from the National
Cardiovascular Data Registry, 2004 to 2008. Journal of the American
College of Cardiology. 2012;60(22):2280-9.

43. Veloor HP, Lokhandwala Y. A 2-year-old child with coronary sinus
diverticulum and Wolff-Parkinson-White syndrome. Cardiol Young.
2013;23(2):274-6.

44. Fujita S, Usuda K, Hatasaki K. Catheter ablation for
Wolff-Parkinson-White syndrome with coronary sinus diverticulum in a
15-year-old boy. Journal of cardiology cases. 2016;13(5):158-61.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/1/1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/2/2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

