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Sánchez-Quintana D, Pizarro G, López-Mínguez JR, Ho SY, Cabrera JA. Standardized review of atrial anatomy for cardiac electrophysiologists. J Cardiovasc Transl Res 2013; 6:124-44. [PMID: 23389853 DOI: 10.1007/s12265-013-9447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
Catheter ablation of cardiac arrhythmias has rapidly evolved from a highly experimental procedure to a standard form of therapy for various tachyarrhythmias. The advances in this field have included, first, the development of techniques of catheter ablation that often requires the precise destruction of minute amounts of arrhythmogenic tissues and, second, techniques of resynchronization therapy that require pacing different parts of the ventricles. A detailed prepocedural knowledge of cardiac anatomy can improve the safety of the procedure and its rate success. It helps the electrophysiologist to choose the appropiate region for ablation, shortening the procedural time. The atrial anatomy structures are usually localized before ablation by different imaging techniques such as fluoroscopy, electroanatomic mapping, intracardiac echocardiography or multidetector computed tomography. In this review, we describe the normal anatomy of the atria, highlighting the landmarks of interest to intervencional cardiologist, stressing their relationship to other structures. This article is part of a JCTR special issue on Cardiac Anatomy.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Avenida de Elvas s/n, 06071 Badajoz, Spain.
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Siddiqui AU, Daimi SRH, Gandhi KR, Siddiqui AT, Trivedi S, Sinha MB, Rathore M. Crista terminalis, musculi pectinati, and taenia sagittalis: anatomical observations and applied significance. ISRN ANATOMY 2013; 2013:803853. [PMID: 25938104 PMCID: PMC4392954 DOI: 10.5402/2013/803853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/17/2013] [Indexed: 11/23/2022]
Abstract
Background. The complex architecture of the right atrium, crista terminalis (CT), and the musculi pectinati (MP) poses enormous challenges in electrophysiology and cardiac conduction. Few studies have been undertaken to substantiate the gross features of MP, in relation to the CT, but there is still scarcity of data regarding this. We tried to reinvestigate the gross arrangement of muscle bundles in the right atrium. Methods. Utilizing 151 human hearts and orientation of MP and its variations and relationship to the CT were investigated along with taenia sagittalis (TS). Patterns of MP were grouped in 6 categories and TS under three groups. Result. A plethora of variations were observed. Analysis of all the specimen revealed that 68 samples (45%) were of type 1 category and 27 (18%) fell into type 2 category. Prominent muscular columns were reported in 12 samples (8%). 83 samples (55%) presented with a single trunk of TS. Multiple trunks of TS were reported in 38 samples (25%). Conclusion. Samples with type 6 MP and type B/type C TS, which have a more complex arrangement of fibers, have a tendency to be damaged during cardiac catheterization. Nonetheless, the area as a whole is extremely significant considering the pragmatic application during various cardiac interventions.
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Affiliation(s)
- Abu Ubaida Siddiqui
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Tatibandh, GE Road, Raipur, Chhattisgarh 492099, India
| | - Syed Rehan Hafiz Daimi
- Department of Anatomy, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra 413736, India
| | - Kusum Rajendra Gandhi
- Department of Anatomy, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra 413736, India
| | - Abu Talha Siddiqui
- Department of Cardiothoracic and Vascular Surgery, JJ Hospital of Grants' Medical College, Mumbai, Maharashtra 400008, India
| | - Soumitra Trivedi
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Tatibandh, GE Road, Raipur, Chhattisgarh 492099, India
| | - Manisha B Sinha
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Tatibandh, GE Road, Raipur, Chhattisgarh 492099, India
| | - Mrithunjay Rathore
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Tatibandh, GE Road, Raipur, Chhattisgarh 492099, India
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Bolognesi M, Bolognesi D. A prominent crista terminalis associated with atrial septal aneurysm that mimics right atrial mass leading to atrial arrhythmias: a case report. J Med Case Rep 2012. [PMID: 23181398 PMCID: PMC3520722 DOI: 10.1186/1752-1947-6-403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED INTRODUCTION The crista terminalis is a variant of normal anatomical structures within the right atrium that mimics an atrial mass on a transthoracic echocardiogram. Atrial septal aneurysm is a rare but well-recognized cardiac abnormality of uncertain clinical significance. The association between crista terminalis and atrial septal aneurysm is unusual but not completely casual. Both anatomical heart structures can lead to atrial arrhythmias. CASE PRESENTATION This case report describes the accidental discovery during an echocardiographic examination of a 64-year-old Caucasian woman who had a left bundle branch block and palpitations. CONCLUSION The clinical relevance of this anatomical evidence in unknown. This was an occasional finding of transthoracic echocardiography, but in this case it is possible to assume its relationship with the occurrence of atrial arrhythmias, and also that computed tomography scan and cardiovascular magnetic resonance is mandatory to define the structure and function of these incidental findings.
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Affiliation(s)
- Massimo Bolognesi
- Clinical Echocardiography, Internal General Medicine, Asl 112 District of Cesena (Cesena, Italy), Via Ungaretti 494, Cesena 47521, Italy.
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Ueda A, McCarthy KP, Sánchez-Quintana D, Yen Ho S. Right atrial appendage and vestibule: further anatomical insights with implications for invasive electrophysiology†. ACTA ACUST UNITED AC 2012. [DOI: 10.1093/europace/eus382] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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An image-based model of the whole human heart with detailed anatomical structure and fiber orientation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2012; 2012:891070. [PMID: 22952559 PMCID: PMC3431151 DOI: 10.1155/2012/891070] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 07/20/2012] [Indexed: 12/14/2022]
Abstract
Many heart anatomy models have been developed to study the electrophysiological properties of the human heart. However, none of them includes the geometry of the whole human heart. In this study, an anatomically detailed mathematical model of the human heart was firstly reconstructed from the computed tomography images. In the reconstructed model, the atria consisted of atrial muscles, sinoatrial node, crista terminalis, pectinate muscles, Bachmann's bundle, intercaval bundles, and limbus of the fossa ovalis. The atrioventricular junction included the atrioventricular node and atrioventricular ring, and the ventricles had ventricular muscles, His bundle, bundle branches, and Purkinje network. The epicardial and endocardial myofiber orientations of the ventricles and one layer of atrial myofiber orientation were then measured. They were calculated using linear interpolation technique and minimum distance algorithm, respectively. To the best of our knowledge, this is the first anatomically-detailed human heart model with corresponding experimentally measured fibers orientation. In addition, the whole heart excitation propagation was simulated using a monodomain model. The simulated normal activation sequence agreed well with the published experimental findings.
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Dössel O, Krueger MW, Weber FM, Wilhelms M, Seemann G. Computational modeling of the human atrial anatomy and electrophysiology. Med Biol Eng Comput 2012; 50:773-99. [PMID: 22718317 DOI: 10.1007/s11517-012-0924-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 05/21/2012] [Indexed: 01/08/2023]
Abstract
This review article gives a comprehensive survey of the progress made in computational modeling of the human atria during the last 10 years. Modeling the anatomy has emerged from simple "peanut"-like structures to very detailed models including atrial wall and fiber direction. Electrophysiological models started with just two cellular models in 1998. Today, five models exist considering e.g. details of intracellular compartments and atrial heterogeneity. On the pathological side, modeling atrial remodeling and fibrotic tissue are the other important aspects. The bridge to data that are measured in the catheter laboratory and on the body surface (ECG) is under construction. Every measurement can be used either for model personalization or for validation. Potential clinical applications are briefly outlined and future research perspectives are suggested.
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Affiliation(s)
- Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany.
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TAKAMI MITSURU, YOSHIDA AKIHIRO, FUKUZAWA KOJI, TAKEI ASUMI, KANDA GAKU, TAKAMI KAORU, KUMAGAI HIROYUKI, TANAKA SATOKO, ITOH MITSUAKI, IMAMURA KIMITAKE, FUJIWARA RYUDO, SUZUKI ATSUSHI, HIRATA KENICHI. Rate-Dependent and Site-Specific Conduction Block at the Posterior Right Atrium and Drug Effects Evaluated Using a Noncontact Mapping System in Patients with Typical Atrial Flutter. J Cardiovasc Electrophysiol 2012; 23:827-34. [DOI: 10.1111/j.1540-8167.2012.02313.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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García-Cosío F, Pastor Fuentes A, Núñez Angulo A. Arrhythmias (IV). Clinical approach to atrial tachycardia and atrial flutter from an understanding of the mechanisms. Electrophysiology based on anatomy. Rev Esp Cardiol 2012; 65:363-75. [PMID: 22364957 DOI: 10.1016/j.recesp.2011.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/19/2011] [Indexed: 11/17/2022]
Abstract
In 2009, 2343 catheter ablation procedures were performed in Spain for focal atrial tachycardia or atrial flutter (typical and atypical), with a yearly growth rate of 8%, indicating the clinical importance of these arrhythmias. The classic categorization of atrial tachycardia and atrial flutter based on rate and morphological criteria has become almost irrelevant at a time when clinical electrophysiology may lead to curative intervention based on a definition of the mechanism, making it necessary to bring laboratory experience closer to clinical practice. In this review we outline our present understanding of atrial tachycardia mechanisms, both focal and macroreentrant, and attempt to establish the conceptual links with classic concepts that may help the clinician to make a differential diagnosis and establish therapeutic indications, including that of an electrophysiologic study. Some of the concepts may seem complex, but we thought it important to provide an overview of the electrophysiological methods that may eventually lead to the description of the anatomic bases of the arrhythmias; currently, these are easier to understand thanks to the virtual anatomic casts built using computerized navigation systems.
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Utility of virtual unipolar electrogram morphologies to detect transverse conduction block and turnaround points of typical atrial flutter. J Interv Card Electrophysiol 2011; 32:111-9. [PMID: 21505798 PMCID: PMC3204041 DOI: 10.1007/s10840-011-9571-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 03/21/2011] [Indexed: 11/17/2022]
Abstract
Background Noncontact mapping is useful for the diagnosis of various arrhythmias. Virtual unipolar electrogram morphologies (VUEM) of the conduction block and the turnaround points, however, are not well defined. We compared the VUEM characteristics of a transverse conduction block in the posterior right atrium (RA) with those of contact bipolar electrograms obtained during typical atrial flutter (AFL). Methods Contact bipolar electrograms were used to map the posterior RA during typical AFL in 16 patients. Twenty points of the VUEM recorded along the block line were analyzed and compared with contact bipolar electrograms. Results Seventeen AFLs were analyzed. Fifteen AFLs showed an incomplete transverse conduction block in the posterior RA by contact bipolar mapping. A double potential on the block line corresponded to the two components of the VUEM, in which the second component showed an Rs, RS, or rS pattern. At the turnaround point, a fused double potential of the contact bipolar electrograms corresponded to a change of the second component of the VUEM from an rS to a QS morphology. Two AFLs showed a complete block line in the posterior RA. The contact bipolar electrogram showed double potentials from the inferior vena cava to the superior vena cava, whereas the second component of the VUEM remained in an unchanged Rs, RS, or rS pattern. Conclusion VUEM analysis was a reliable method for identifying the posterior block line during AFL. This method may also be applicable for detecting block lines and turnaround points of circuits in other unmappable arrhythmias.
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Focus on the Atrial Structure —Useful Anatomical Information for Catheter Ablation—. J Arrhythm 2011. [DOI: 10.1016/s1880-4276(11)80030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Krueger MW, Schmidt V, Tobón C, Weber FM, Lorenz C, Keller DUJ, Barschdorf H, Burdumy M, Neher P, Plank G, Rhode K, Seemann G, Sanchez-Quintana D, Saiz J, Razavi R, Dössel O. Modeling Atrial Fiber Orientation in Patient-Specific Geometries: A Semi-automatic Rule-Based Approach. FUNCTIONAL IMAGING AND MODELING OF THE HEART 2011. [DOI: 10.1007/978-3-642-21028-0_28] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Upper turnaround point of the reentry circuit of common atrial flutter—three-dimensional mapping and entrainment study. J Interv Card Electrophysiol 2010; 29:147-56. [DOI: 10.1007/s10840-010-9526-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
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CORRADI DOMENICO, MAESTRI ROBERTA, MACCHI EMILIO, CALLEGARI SERGIO. Clinical Reviews: The Atria: From Morphology to Function. J Cardiovasc Electrophysiol 2010; 22:223-35. [DOI: 10.1111/j.1540-8167.2010.01887.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Seifert M, Schau T, Moeller V, Neuss M, Meyhoefer J, Butter C. Influence of pacing configurations, body mass index, and position of coronary sinus lead on frequency of phrenic nerve stimulation and pacing thresholds under cardiac resynchronization therapy. Europace 2010; 12:961-7. [PMID: 20444725 DOI: 10.1093/europace/euq119] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Martin Seifert
- Department of Cardiology, Heart Center Brandenburg, Ladeburger Strasse 17, 16321 Bernau/Berlin, Germany.
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65
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Saremi F, Torrone M, Yashar N. Cardiac conduction system: delineation of anatomic landmarks with multidetector CT. Indian Pacing Electrophysiol J 2009; 9:318-33. [PMID: 19898655 PMCID: PMC2766580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Major components of the cardiac conduction system including the sinoatrial node (SAN), atrioventricular node (AVN), the His Bundle, and the right and left bundle branches are too small to be directly visualized by multidetector CT (MDCT) given the limited spatial resolution of current scanners. However, the related anatomic landmarks and variants of this system a well as the areas with special interest to electrophysiologists can be reliably demonstrated by MDCT. Some of these structures and landmarks include the right SAN artery, right atrial cavotricuspid isthmus, Koch triangle, AVN artery, interatrial muscle bundles, and pulmonary veins. In addition, MDCT has an imperative role in demarcating potential arrhythmogenic structures. The aim of this review will be to assess the extent at which MDCT can outline the described anatomic landmarks and therefore provide crucial information used in clinical practice.
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66
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Morita N, Kobayashi Y, Horie T, Iwasaki YK, Hayashi M, Miyauchi Y, Atarashi H, Katoh T, Mizuno K. The undetermined geometrical factors contributing to the transverse conduction block of the crista terminalis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:868-78. [PMID: 19572862 DOI: 10.1111/j.1540-8159.2009.02402.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The crista terminalis (CT) is known to be a functional barrier during typical atrial flutter (AFL). The relationship between the CT structural characteristics and its transverse conduction block, however, has not been understood well. METHODS This study consisted of AFL (group 1, N = 15) and non-AFL patients (group 2, N = 13). The CT structural characteristics were determined with intracardiac echocardiography. A 20-pole electrode catheter was located along the CT and pacing at progressively faster rates from either low anterolateral right atrium (LRA) or coronary sinus (CS) was applied. RESULTS The CT height, width, and area were significantly greater in group 1 than in group 2 (P < 0.001). In both groups, at the longest pacing cycle length during CS pacing resulting in CT transverse conduction block at some levels, the width and area were significantly greater at the levels with block than at those without block. During LRA pacing, the area was also significantly larger at the levels with block than at those without in group 1, but not in group 2. The slope angle of CT ridge was significantly steeper at the levels with block than at those without in both groups (P < 0.01), but that was not the case with CS pacing. CT arborization in its inferior portion was more frequently documented in group 1 than group 2 (P < 0.05). CONCLUSIONS The CT structural characteristics that may influence its transverse conduction differ between LRA and CS pacing. Steep slope and arborization of the CT are implicated as a geometric factor in its transverse conduction block.
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Affiliation(s)
- Norishige Morita
- Division of Cardiology, Department of Medicine, Nippon Medical School, Tokyo, Japan.
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67
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Ender J, Erdoes G, Krohmer E, Olthoff D, Mukherjee C. Transesophageal Echocardiography for Verification of the Position of the Electrocardiographically-Placed Central Venous Catheter. J Cardiothorac Vasc Anesth 2009; 23:457-61. [DOI: 10.1053/j.jvca.2008.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Indexed: 11/11/2022]
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68
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Saoudi N, Ercyies D, Anselme F. Why Do Patients Develop Atrial Flutter? Is This Crista Terminalis Geometry? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:866-7. [PMID: 19572861 DOI: 10.1111/j.1540-8159.2009.02401.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Havmöller R, Carlson J, Holmqvist F, Olsson B, Platonov P. Evolution of P-wave morphology in healthy individuals: a 3-year follow-up study. Ann Noninvasive Electrocardiol 2009; 14:226-33. [PMID: 19614633 PMCID: PMC6931929 DOI: 10.1111/j.1542-474x.2009.00301.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Orthogonal P-wave morphology in healthy men and women has been described using unfiltered signal-averaged technique and holds information on interatrial conduction. The stability of P-wave morphology in healthy subjects over time is not fully known. METHODS Sixty-seven healthy volunteers were investigated (29 males, aged 63 +/- 14 years, 48 females, 60 +/- 13 years). Orthogonal lead data (X, Y, and Z) were derived from standard 12-lead ECGs (recording length 6 minutes, sampling rate 1kHz, resolution 0.625 muV) recorded at baseline (BL), and 3 years later at follow-up (FU). P waves were then signal-averaged and analyzed regarding P-wave morphology, locations of maxima, minima, zero-crossings, and P-wave duration (PWD). RESULTS No differences of P-wave variables were observed at FU compared to BL, including PWD (127 +/- 12 vs 125 +/- 14 ms at BL and FU, respectively, n.s.). In 59 of the 67 subjects (88%), the P-wave morphology was unaltered at FU. However, in the remaining eight cases a distinctively different morphology was observed. The most common change (P=0.030) was from negative polarity to biphasic (-/+) in Lead Z (n=5). In one case the opposite change was observed and in two cases transition into advanced interatrial block morphology was evident at FU. CONCLUSIONS In the majority of healthy subjects, P-wave morphology is stable at 3-year FU. Subtle morphological changes, observed principally in Lead Z, suggest variation of interatrial conduction. These changes could not be detected by measuring conventional PWD that remained unchanged in the total population.
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70
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Saremi F, Tafti M. The role of computed tomography and magnetic resonance imaging in ablation procedures for treatment of atrial fibrillation. Semin Ultrasound CT MR 2009; 30:125-56. [PMID: 19358443 DOI: 10.1053/j.sult.2008.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac ablation procedures have become the standard of therapy for various arrhythmias including atrial fibrillation. Understanding the morphological characteristics of the left atrium (LA) and pulmonary veins (PV) in detail and identification of its anatomic variants is crucial to perform a successful ablation procedure and minimize complications. The current techniques for radiofrequency ablation of atrial fibrillation include targeting the PVs or the tissue in the antrum of the LA. Localization of the anatomic structures within the LA is performed by using fluoroscopy, electroanatomic mapping, and intracardiac echocardiography. Multidimentional computed tomography and magnetic resonance angiography are invaluable techniques for better visualization of the anatomic landmarks that are essential for cardiac ablation procedures as well as prompt diagnosis and, in selected cases, prevention of procedure-related complications. Some of the complications of ablation procedures may include cardiac tamponade, PV stenosis, as well as esophageal and phrenic nerve injuries.
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Affiliation(s)
- Farhood Saremi
- Department of Radiological Sciences, University of California, Irvine, CA, USA.
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71
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Lin YJ, Higa S, Tai CT, Chang SL, Lee KT, Lo LW, Ishigaki S, Tuan TC, Wongcharoen W, Hu YF, Hsieh MH, Tsao HM, Chen SA. Role of the right atrial substrate in different types of atrial arrhythmias. Heart Rhythm 2009; 6:592-8. [DOI: 10.1016/j.hrthm.2009.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 02/10/2009] [Indexed: 10/21/2022]
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Abstract
Atrial structures are important in the current era of cardiac interventions using percutaneous transcatheter procedures. Understanding their locations and component parts helps to reduce risks of procedural-related damage. The general arrangement of the myofibers that make up the atrial walls is reviewed to provide a morphologic basis for atrial conduction and potential substrates of arrhythmias. The right atrium, dominated by its appendage, is characterized by having an extensive array of pectinate muscles. These extend almost perpendicularly from the terminal crest. The left atrium has relatively smooth walls and a small tubular-shaped appendage. The myofibers show changes in orientations when traced through the thickness of the walls. Extensions of atrial myocardium onto the pulmonary veins and the superior caval vein are common. Apart from Bachmann's bundle, there are other muscular bridges of variable numbers and sizes that provide interatrial connections, connections between the left atrium and the coronary sinus, and connections between the muscular sleeves of the right pulmonary veins and the right atrium. The purpose of this review is to summarize the three-dimensional arrangement of gross atrial structures, the myoarchitecture and variations in muscular interatrial connections. These are important features in intra- and interatrial conduction.
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Affiliation(s)
- S Y Ho
- Cardiac Morphology Unit, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Dovehouse Street, London, United Kingdom.
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Prassl AJ, Kickinger F, Ahammer H, Grau V, Schneider JE, Hofer E, Vigmond EJ, Trayanova NA, Plank G. Automatically generated, anatomically accurate meshes for cardiac electrophysiology problems. IEEE Trans Biomed Eng 2009; 56:1318-30. [PMID: 19203877 DOI: 10.1109/tbme.2009.2014243] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Significant advancements in imaging technology and the dramatic increase in computer power over the last few years broke the ground for the construction of anatomically realistic models of the heart at an unprecedented level of detail. To effectively make use of high-resolution imaging datasets for modeling purposes, the imaged objects have to be discretized. This procedure is trivial for structured grids. However, to develop generally applicable heart models, unstructured grids are much preferable. In this study, a novel image-based unstructured mesh generation technique is proposed. It uses the dual mesh of an octree applied directly to segmented 3-D image stacks. The method produces conformal, boundary-fitted, and hexahedra-dominant meshes. The algorithm operates fully automatically with no requirements for interactivity and generates accurate volume-preserving representations of arbitrarily complex geometries with smooth surfaces. The method is very well suited for cardiac electrophysiological simulations. In the myocardium, the algorithm minimizes variations in element size, whereas in the surrounding medium, the element size is grown larger with the distance to the myocardial surfaces to reduce the computational burden. The numerical feasibility of the approach is demonstrated by discretizing and solving the monodomain and bidomain equations on the generated grids for two preparations of high experimental relevance, a left ventricular wedge preparation, and a papillary muscle.
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Affiliation(s)
- Anton J Prassl
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD 21218 USA.
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Sakamoto SI, Voeller RK, Melby SJ, Lall SC, Chang NL, Schuessler RB, Damiano RJ. Surgical ablation for atrial fibrillation: the efficacy of a novel bipolar pen device in the cardioplegically arrested and beating heart. J Thorac Cardiovasc Surg 2008; 136:1295-301. [PMID: 19026819 DOI: 10.1016/j.jtcvs.2008.04.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 03/18/2008] [Accepted: 04/03/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The introduction of ablation technology has simplified surgical intervention for atrial fibrillation. However, most ablation devices cannot create focal transmural lesions on the beating heart and have difficulty ablating specific regions of the atria, such as the atrioventricular isthmus, coronary sinus, and ganglionated plexus. The purpose of this study was to examine the efficacy of a pen-type bipolar radiofrequency ablation device on both arrested and beating hearts. METHODS Endocardial and epicardial atrial tissues in the free wall, left atrial roof, atrioventricular annuli, and coronary sinus were ablated for varying time intervals (2.5-15 seconds) in porcine cardioplegically arrested (n = 6) and beating (n = 9) hearts. The hearts were stained with 1% 2,3,5-triphenyl-tetrazolium chloride solution and sectioned to determine lesion depth and width. In 5 animals epicardial fat pads containing ganglionated plexus were stimulated and ablated. RESULTS Lesion depth increased with ablation time similarly in both arrested and beating hearts. Transmurality was fully achieved in the thin atrial tissue (<4 mm) at 10 seconds in the beating and arrested hearts. The device had a maximal penetration depth of 6.1 mm. Epicardial ablation of the coronary sinus showed complete penetration through the left posterior atrium only in the arrested heart. Seven of 17 fat pads demonstrated a vagal response. All vagal responses were eliminated after ablation. CONCLUSION The bipolar pen effectively ablated atrial tissue in both arrested and beating hearts. This device might allow the surgeon to ablate tissue in regions not accessible to other devices during atrial fibrillation surgery.
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Affiliation(s)
- Shun-ichiro Sakamoto
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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Liuba I, Walfridsson H. Focal atrial tachycardia: increased electrogram fractionation in the vicinity of the earliest activation site. Europace 2008; 10:1195-204. [DOI: 10.1093/europace/eun192] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Saremi F, Channual S, Krishnan S, Gurudevan SV, Narula J, Abolhoda A. Bachmann Bundle and Its Arterial Supply: Imaging with Multidetector CT—Implications for Interatrial Conduction Abnormalities and Arrhythmias. Radiology 2008; 248:447-57. [DOI: 10.1148/radiol.2482071908] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Loukas M, Tubbs RS, Tongson JM, Polepalli S, Curry B, Jordan R, Wagner T. The clinical anatomy of the crista terminalis, pectinate muscles and the teniae sagittalis. Ann Anat 2008; 190:81-7. [DOI: 10.1016/j.aanat.2007.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Accepted: 05/31/2007] [Indexed: 10/22/2022]
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TAI CHINGTAI, GERTRUDE ONG MARY, CHEN SHIHANN. Electrophysiologic Characteristics of the Sinus Venosa in Patients with Typical Atrial Flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 31:99-102. [DOI: 10.1111/j.1540-8159.2007.00932.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saremi F, Krishnan S. Cardiac Conduction System: Anatomic Landmarks Relevant to Interventional Electrophysiologic Techniques Demonstrated with 64-Detector CT. Radiographics 2007; 27:1539-65; discussion 1566-7. [DOI: 10.1148/rg.276075003] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Havmoller R, Carlson J, Holmqvist F, Herreros A, Meurling CJ, Olsson B, Platonov P. Age-related changes in P wave morphology in healthy subjects. BMC Cardiovasc Disord 2007; 7:22. [PMID: 17662128 PMCID: PMC1949837 DOI: 10.1186/1471-2261-7-22] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 07/27/2007] [Indexed: 11/24/2022] Open
Abstract
Background We have previously documented significant differences in orthogonal P wave morphology between patients with and without paroxysmal atrial fibrillation (PAF). However, there exists little data concerning normal P wave morphology. This study was aimed at exploring orthogonal P wave morphology and its variations in healthy subjects. Methods 120 healthy volunteers were included, evenly distributed in decades from 20–80 years of age; 60 men (age 50+/-17) and 60 women (50+/-16). Six-minute long 12-lead ECG registrations were acquired and transformed into orthogonal leads. Using a previously described P wave triggered P wave signal averaging method we were able to compare similarities and differences in P wave morphologies. Results Orthogonal P wave morphology in healthy individuals was predominately positive in Leads X and Y. In Lead Z, one third had negative morphology and two-thirds a biphasic one with a transition from negative to positive. The latter P wave morphology type was significantly more common after the age of 50 (P < 0.01). P wave duration (PWD) increased with age being slightly longer in subjects older than 50 (121+/-13 ms vs. 128+/-12 ms, P < 0.005). Minimal intraindividual variation of P wave morphology was observed. Conclusion Changes of signal averaged orthogonal P wave morphology (biphasic signal in Lead Z), earlier reported in PAF patients, are common in healthy subjects and appear predominantly after the age of 50. Subtle age-related prolongation of PWD is unlikely to be sufficient as a sole explanation of this finding that is thought to represent interatrial conduction disturbances. To serve as future reference, P wave morphology parameters of the healthy subjects are provided.
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Affiliation(s)
- Rasmus Havmoller
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Jonas Carlson
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | | | - Alberto Herreros
- Department of Automatic Control, Valladolid University, Valladolid, Spain
| | - Carl J Meurling
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Bertil Olsson
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Pyotr Platonov
- Department of Cardiology, Lund University Hospital, Lund, Sweden
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Okumura Y, Watanabe I, Ashino S, Kofune M, Ohkubo K, Takagi Y, Kawauchi K, Yamada T, Hashimoto K, Shindo A, Sugimura H, Nakai T, Saito S. Electrophysiologic and Anatomical Characteristics of the Right Atrial Posterior Wall in Patients With and Without Atrial Flutter Analysis by Intracardiac Echocardiography. Circ J 2007; 71:636-42. [PMID: 17456984 DOI: 10.1253/circj.71.636] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The posterior right atrial transverse conduction capability during typical atrial flutter (AFL) is well known, but its relationship to the anatomical characteristics remains controversial. METHODS AND RESULTS Thirty-four AFL and 16 controls underwent intracardiac echocardiography after placement of a 20-polar catheter at the posterior block site during AFL or pacing. In 31 patients, the effective refractory period (ERP) at the block site was determined as the longest coupling interval that resulted in double potentials during extrastimuli from the mid-septal (SW) and free (FW) walls. The block site was located 3.0-29.0 mm posterior to the crista terminalis (CT) in each AFL and control patient. The CT area indexed to the body surface area was larger in AFL patients than in control patients (16.4+/-6.5 mm(2)/m(2) vs 11.3+/-6.4 mm(2)/m(2), p=0.01), and was positively correlated to age (r=0.34, p=0.02). The ERP was longer in the AFL patients than in controls (SW: median value 600 [270-725] ms vs 220 [200-253] ms; FW: 280 [230-675] ms vs 215 [188-260] ms, p<0.05 for each). CONCLUSIONS A functional block line was located on the septal side of the CT in all patients. A limited conduction capability and age-related CT enlargement might have important implications for the pathogenesis in AFL.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiovascular Disease, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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García Cosío F, Pastor A, Núñez A, Magalhaes AP, Awamleh P. Flúter auricular: perspectiva clínica actual. Rev Esp Cardiol 2006. [DOI: 10.1157/13091886] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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84
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Duytschaever M, Ho SY, Devos D, Tavernier R. The left hand as a model for the right atrium: a simple teaching tool. ACTA ACUST UNITED AC 2006; 8:245-50. [PMID: 16627449 DOI: 10.1093/europace/euj039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS Knowledge of the complex three-dimensional anatomy of the right atrium is mandatory for the electrophysiologist and interventional cardiologist, but its understanding remains difficult. We hypothesized that the left hand, loosely clenched, is a good three-dimensional model to understand the position of the different anatomical and electrical regions in the right atrium. For validation, we compared the hand with an endocast that had been prepared from an adult human right atrium and with a three-dimensional electro-anatomical CT image of the right atrium. METHODS AND RESULTS Views of the left hand were photographed from various angles to replicate as closely as possible the standard fluoroscopic views. Using the nomenclature of the bones of the hand, we assigned the different regions of the hand to represent regions and structures of the right atrium. An endocast was prepared from an adult human right atrium. A three-dimensional electro-anatomical right atrial map with CT integration (CartoMerge) was used as the gold standard for the exact localization of electrical regions such as the sinus node (SN), bundle of His, and slow pathway region. Using the left hand, it is possible to mark the free wall, terminal crest, appendage, septal surface, oval fossa and orifices of the caval veins, tricuspid valve, and coronary sinus. We also marked the anticipated locations of the SN, His bundle, triangle of Koch, slow pathway region, inferior isthmus, and right atrial insertion of Bachmann's bundle. When compared with an endocast and a three-dimensional electro-anatomical CT image, the position and orientation of the marked regions were deemed to be anatomically correct. CONCLUSION Compared with an endocast and a CT-guided electro-anatomical reconstruction of the right atrium, the left hand is a reliable model to understand the position and orientation of the different anatomical and electrical regions in the right atrium. Although an oversimplification of the complex right atrial anatomy, this model is 'handy' to understand, guide, and teach electrophysiological and interventional procedures.
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Affiliation(s)
- Mattias Duytschaever
- Department of Cardiology, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium.
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85
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Boyett MR, Li J, Inada S, Dobrzynski H, Schneider JE, Holden AV, Zhang H. Imaging the heart: computer 3-dimensional anatomic models of the heart. J Electrocardiol 2005; 38:113-20. [PMID: 16226085 DOI: 10.1016/j.jelectrocard.2005.06.102] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/24/2022]
Abstract
Since the 1960s, models of the action potential in various cardiac cell types have been developed, and since the 1990s, 3-dimensional anatomic (or geometric) models of various cardiac structures have been developed. We are approaching the time when, for one species, we should have a complete set of action potential and anatomic models for the various cardiac tissues and then we will have realized the aim of constructing a "virtual heart" with accurate anatomy and electrophysiology. However, already the two types of model are beginning to be used in tandem to reconstruct the activation sequence of the heart both during sinus rhythm and arrhythmias.
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Affiliation(s)
- Mark R Boyett
- Division of Cardiovascular and Endocrine Sciences, University of Manchester, M13 9XX Manchester, UK.
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Sakamoto SI, Nitta T, Ishii Y, Miyagi Y, Ohmori H, Shimizu K. Interatrial Electrical Connections: The Precise Location and Preferential Conduction. J Cardiovasc Electrophysiol 2005; 16:1077-86. [PMID: 16191118 DOI: 10.1111/j.1540-8167.2005.40659.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The atria are assumed to be connected electrically to each other at the level of the Bachmann's bundle, coronary sinus (CS) musculature, and interatrial septum, and these connections may have an important role in the interatrial conduction and perpetuation of various types of atrial tachyarrhythmias. However, the number, location, and preferential connections of the interatrial conduction related to the site of activation have not been examined yet. METHODS The endocardium of both atria and the CS were mapped during continuous pacing from the left superior and inferior pulmonary veins, right pulmonary veins, upper and lower right atrium, or right atrial septum at various paced cycle lengths in 14 canines. The electrograms were recorded by custom-made form-fitted electrodes mounted on a specially designed device that allowed the septal aspects of the electrode forms to be spatially fixed to each other accurately. RESULTS Four distinct interatrial electrical connections were identified at the Bachmann's bundle, CS, and antero-superior and postero-inferior septa. Decremental conduction was not seen in any of the connections. Bachmann's bundle was the most preferential connection during pacing from any epicardial site. The transseptal connections were evident only during pacing from the interatrial septum. The preference among the four connections was determined by the site of stimulation and the propagation of the activation related to the myocardial architecture. CONCLUSION These unique preferential connections may play a significant role in the interatrial conduction and perpetuation of atrial tachyarrhythmias.
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Zanchetta M, Rigatelli G, Ho SY. A mystery featuring right-to-left shunting despite normal intracardiac pressure. Chest 2005; 128:998-1002. [PMID: 16100198 DOI: 10.1378/chest.128.2.998] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The cause of right-to-left atrial shunting despite normal intracardiac pressures and normal or near-normal pulmonary function through a patent foramen ovale has still not been completely clarified. It is probably responsible for several linked diseases, such as paradoxical embolism, platypnea-orthodeoxia syndrome, migraine with aura, transient global amnesia, and decompression sickness in sport divers. Despite modern diagnostic methods, the underlying anatomophysiologic and pathogenic mechanisms of right-to-left atrial shunting without abnormal intracardiac pressures remain a matter of debate and controversy. Holistically speaking, a return to a direct study of embryology, gross anatomy, and physiology may help us elucidate the real mechanism of this paradoxical shunting.
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Affiliation(s)
- Mario Zanchetta
- Department of Cardiovascular Disease, Cittadella General Hospital, Padua, Italy.
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Dobrzynski H, Li J, Tellez J, Greener ID, Nikolski VP, Wright SE, Parson SH, Jones SA, Lancaster MK, Yamamoto M, Honjo H, Takagishi Y, Kodama I, Efimov IR, Billeter R, Boyett MR. Computer three-dimensional reconstruction of the sinoatrial node. Circulation 2005; 111:846-54. [PMID: 15699261 DOI: 10.1161/01.cir.0000152100.04087.db] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an effort to build an anatomically and biophysically detailed virtual heart, and, although there are models for the atria and ventricles, there is no model for the sinoatrial node (SAN). For the SAN to show pacemaking and drive atrial muscle, theoretically, there should be a gradient in electrical coupling from the center to the periphery of the SAN and an interdigitation of SAN and atrial cells at the periphery. Any model should include such features. METHODS AND RESULTS Staining of rabbit SAN preparations for histology, middle neurofilament, atrial natriuretic peptide, and connexin (Cx) 43 revealed multiple cell types within and around the SAN (SAN and atrial cells, fibroblasts, and adipocytes). In contrast to atrial cells, all SAN cells expressed middle neurofilament (but not atrial natriuretic peptide) mRNA and protein. However, 2 distinct SAN cell types were observed: cells in the center (leading pacemaker site) were small, were organized in a mesh, and did not express Cx43. In contrast, cells in the periphery (exit pathway from the SAN) were large, were arranged predominantly in parallel, often expressed Cx43, and were mixed with atrial cells. An approximately 2.5-million-element array model of the SAN and surrounding atrium, incorporating all cell types, was constructed. CONCLUSIONS For the first time, a 3D anatomically detailed mathematical model of the SAN has been constructed, and this shows the presence of a specialized interface between the SAN and atrial muscle.
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Gonzalez MD, Erga KS, Rivera J, Contreras LJ, Mladinich CR, Schultz JD, Afonso VX. Rate-Dependent Block in the Sinus Venosa of the Swine Heart during Transverse Right Atrial Activation: Correlation Between Electrophysiologic and Anatomic Findings. J Cardiovasc Electrophysiol 2005; 16:193-200. [PMID: 15720459 DOI: 10.1046/j.1540-8167.2004.40483.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Rate-dependent block in the sinus venosa. INTRODUCTION Whether the crista terminalis or the sinus venosa result in rate-dependent block during transverse activation of the right atrial activation remains unknown. In the present study, right atrial activation at different cycle lengths was studied in the swine heart using high-resolution noncontact mapping (Endocardial Solutions). The location of the block was tagged and correlated with postmortem anatomical findings. METHODS AND RESULTS Eight pigs were studied using noncontact mapping to obtain right atrial geometry and detailed sequence of activation using noncontact endocardial mapping. During sinus rhythm, activation proceeded uninterrupted craniocaudally along the sinus venosa and crista terminalis with similar conduction velocities (1.08+/-0.17 and 1.17+/-0.14 m/sec, respectively). Proximal coronary sinus stimulation was used to create transverse activation of the posterior right atrial wall. A rate-dependent decrease in conduction velocity occurred in the sinus venosa region (0.93+/-0.21, 0.82+/-0.14, and 0.52+/-0.09 m/sec at 500, 400, and 300 ms, respectively; P<0.05). The line of block verified by isopotential mapping and double potentials was obtained at cycle lengths of 240+/-30 ms. This line of the block was tagged with radiofrequency current lesions. Postmortem, all lesions were located in the sinus venosa region, 9.8+/-4.1 mm from the posteromedial edge of the crista terminalis. This region showed abrupt changes in muscle fiber thickness and orientation as well as in collagen content. CONCLUSIONS The sinus venosa and not the crista terminalis results in a rate-dependent line of block during transverse right atrial activation. The morphologic characteristics of the sinus venosa appear to facilitate block in this region.
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Affiliation(s)
- Mario D Gonzalez
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida 32610-0277, USA.
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90
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Okumura Y, Watanabe I, Yamada T, Ohkubo K, Sugimura H, Hashimoto K, Kofune T, Takagi Y, Wakita R, Oshikawa N, Kawauchi K, Saito S, Ozawa Y, Kanmatsuse K, Yoshikawa Y, Asakawa Y. Relationship Between Anatomic Location of the Crista Terminalis and Double Potentials Recorded During Atrial Flutter:. J Cardiovasc Electrophysiol 2004; 15:1426-32. [PMID: 15610291 DOI: 10.1046/j.1540-8167.2004.04379.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The activation sequence in typical atrial flutter (AFL) around the tricuspid annulus is well described. However, activation of the remainder of the right atrium (RA) is not well defined. Previous studies have shown a linear block at the crista terminalis (CT) during AFL. The aim of this study was to evaluate the relationship between the location of the CT and the line of block by intracardiac echocardiography (ICE). METHODS AND RESULTS Twenty-one patients with typical AFL were included in the study. The ICE imaging catheter (9-French with 9-MHz ultrasound transducer) was advanced to the RA. Under ICE guidance, a 20-pole roving catheter was used to map double potentials (DPs) during AFL, and three-dimensional images of the RA were reconstructed. During counterclockwise (CCW), clockwise (CW) AFL, or both, a line of conduction block manifested by DPs was identified at a septal site adjacent to the CT in 12 patients and in the posteroseptal RA in 9 patients. CONCLUSION The functional line of block in CCW and CW AFL is localized not at the CT but at the septal edge of the CT or in the posteroseptal RA.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiovascular Disease, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Chu PH, Yeh HI, Jung SM, Chien LY, Cheng NF, Wu HH, Chu JJ, Hsueh C, Lee YS. Irregular connexin43 expressed in a rare cardiac hamartoma containing adipose tissue in the crista terminalis. Virchows Arch 2004; 444:383-6. [PMID: 15067542 DOI: 10.1007/s00428-003-0960-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Accepted: 12/04/2003] [Indexed: 11/25/2022]
Abstract
Cardiac hamartomas are very rare and are demarcated masses of enlarged, hypertrophied, mature myocytes and collagen tissue. Cardiac hamartomas are generally circumscribed in the right ventricle or atrium, but not reported in the crista terminalis (CRT). The CRT is crucial in electrophysiology, is related to arrhythmogenesis, and is targeted by radiofrequency catheter procedures. Previous works only described the benign natures of prominent CRT using non-invasive methods. This study describes an unusual cardiac hamartoma originating from the CRT and extending toward the tricuspid valve. Microscopically, this hamartoma comprised dense collagen and adipose tissue, mixed with hypertrophy, but with disarrayed cardiomyocytes. An irregular gap junction, connexin43, was demonstrated in this cardiac hamartoma.
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Affiliation(s)
- Pao-Hsien Chu
- The First Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University, 199 Tun-Hwa North Road, 105 Taipei, Taiwan.
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Chen J, Hoff PI, Erga KS, Rossvoll O, Ohm OJ. Global Right Atrial Mapping Delineates Double Posterior Lines of Block in Patients with Typical Atrial Flutter:. J Cardiovasc Electrophysiol 2003; 14:1041-8. [PMID: 14521656 DOI: 10.1046/j.1540-8167.2003.03068.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Double Posterior Lines of Block in Typical Atrial Flutter. INTRODUCTION The crista terminalis (CT) has been shown to be a barrier to transverse conduction during typical atrial flutter (AFL). However, some studies have demonstrated the presence of functional block in the sinus venosa region but not at the CT. The aim of this study was to define these regions of block in the right atrium using a three-dimensional noncontact mapping system. METHODS AND RESULTS In 39 AFL patients (33 men and six women, mean age 56 +/- 13 years), a noncontact multielectrode array was used to reconstruct electrograms in the right atrium. Isochronal and isopotential propagation mapping was performed during AFL and during pacing from the coronary sinus ostium and the low lateral wall (cycle length from 600 to 240 msec) in sinus rhythm after creation of isthmus block. A single line of block along the CT area was found in 18 patients (46%). Two lines of block were found in 21 patients (54%), with the first line located along the CT area. The second was located in the sinus venosa region in 20 patients (51%) and in the lateral wall in 1 patient (3%). In all patients, the block in the lower part of the CT was observed during AFL (60%) and during pacing at all cycle lengths (48%-62%). The length and proportion of block were inversely proportional to pacing cycle length. CONCLUSION Double lines of block were frequently observed in patients with AFL, and both lines may form the posterior boundaries of the AFL circuit. Block was fixed in the lower part of the CT and was functional in the upper part of the CT.
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Affiliation(s)
- Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
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