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Piotrowski M, Burysz M, Batko J, Litwinowicz R, Kowalewski M, Bartuś K, Wróbel K, Graczykowski Ł, Słomka A. The Right Coronary Anatomy and Operative Topography of the Tricuspid Valve Annulus. J Cardiovasc Dev Dis 2024; 11:159. [PMID: 38921659 PMCID: PMC11203864 DOI: 10.3390/jcdd11060159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND The region of the tricuspid valve is an important area for various cardiac interventions. In particular, the spatial relationships between the right coronary artery and the annulus of the tricuspid valve should be considered during surgical interventions. The aim of this study was to provide an accurate description of the clinical anatomy and topography of this region. METHODS We analyzed 107 computed tomography scans (44% female, age 62.1 ± 9.4 years) of the tricuspid valve region. The circumference of the free wall of the tricuspid valve annulus was divided into 13 annular points and measurements were taken at each point. The prevalence of danger zones (distance between artery and annulus less than 2 mm) was also investigated. RESULTS Danger zones were found in 20.56% of the cases studied. The highest prevalence of danger zones and the smallest distances were found at the annular points of the tricuspid valve located at the posterior insertion of the leaflets, without observed sex-specific differences. CONCLUSION The highest risk of iatrogenic damage to the right coronary artery is in the posterior part of the tricuspid valve annulus.
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Affiliation(s)
- Michał Piotrowski
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.P.)
| | - Marian Burysz
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.P.)
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland (A.S.)
| | - Jakub Batko
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.P.)
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland (A.S.)
| | - Radosław Litwinowicz
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.P.)
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland (A.S.)
| | - Mariusz Kowalewski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland (A.S.)
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), 6229 HX Maastricht, The Netherlands
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Krzysztof Wróbel
- Department of Cardiac Surgery, Warsaw Medicover Hospital, Lazarski University, 02-972 Warsaw, Poland
| | - Łukasz Graczykowski
- Department of Cardiology, Specialist Hospital in Wloclawek, 87-800 Wloclawek, Poland
| | - Artur Słomka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland (A.S.)
- Department of Pathophysiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
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Cottle B, Schriewer K, Tiwari S, Miller D, Kaza A, Hitchcock R, Sachse FB. 3D models of the cardiac conduction system in healthy neonatal human hearts. Cardiovasc Pathol 2024; 70:107626. [PMID: 38458505 PMCID: PMC11081815 DOI: 10.1016/j.carpath.2024.107626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024] Open
Abstract
Iatrogenic damage to the cardiac conduction system (CCS) remains a significant risk during congenital heart surgery. Current surgical best practice involves using superficial anatomical landmarks to locate and avoid damaging the CCS. Prior work indicates inherent variability in the anatomy of the CCS and supporting tissues. This study introduces high-resolution, 3D models of the CCS in normal pediatric human hearts to evaluate variability in the nodes and surrounding structures. Human pediatric hearts were obtained with an average donor age of 2.7 days. A pipeline was developed to excise, section, stain, and image atrioventricular (AVN) and sinus nodal (SN) tissue regions. A convolutional neural network was trained to enable precise multi-class segmentation of whole-slide images, which were subsequently used to generate high- resolution 3D tissue models. Nodal tissue region models were created. All models (10 AVN, 8 SN) contain tissue composition of neural tissue, vasculature, and nodal tissues at micrometer resolution. We describe novel nodal anatomical variations. We found that the depth of the His bundle in females was on average 304 μm shallower than those of male patients. These models provide surgeons with insight into the heterogeneity of the nodal regions and the intricate relationships between the CCS and surrounding structures.
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Affiliation(s)
- Brian Cottle
- Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, MBB 3100, Salt Lake City, UT 84112, USA
| | - Karl Schriewer
- Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, MBB 3100, Salt Lake City, UT 84112, USA
| | - Sarthak Tiwari
- Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, MBB 3100, Salt Lake City, UT 84112, USA
| | - Dylan Miller
- Intermountain Health, 5121 S Cottonwood St. Murray, UT 84107, USA
| | - Aditya Kaza
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert Hitchcock
- Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, MBB 3100, Salt Lake City, UT 84112, USA
| | - Frank B Sachse
- Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, MBB 3100, Salt Lake City, UT 84112, USA.
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Slow-Pathway Visualization by Using Panoramic View: A Novel Ablation Technique for Ablation of Atrioventricular Nodal Reentrant Tachycardia. J Cardiovasc Dev Dis 2022; 9:jcdd9040091. [PMID: 35448067 PMCID: PMC9026770 DOI: 10.3390/jcdd9040091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/17/2022] [Accepted: 03/20/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Background: The panoramic view of a novel wide-band dielectric mapping system could show the individual anatomy. We aimed to compare the feasibility, efficacy and safety of the panoramic view guided approach for ablation of AVNRT with the conventional approach. (2) Methods: Ablation distributions in eight patients were retrospectively analyzed using the panoramic view. The para-slow-pathway (para-SP) region was divided into three regions, and the region that most frequently appeared with the appropriate junctional rhythm or eliminated the slow-pathway was defined as the adaptive slow-pathway (aSP) region. Twenty patients with AVNRT were then ablated in the aSP region under the panoramic view and compared with 40 patients using the conventional approach. (3) Results: Thirty ablation points were analyzed. The majority of effective points (95.0%) were located in the inferior and anterior portions of the para-SP region and defined as the aSP region. Baseline characteristics, fluoroscopic duration, and mean number of ablations were similar among the two groups. The panoramic view group had a significantly higher percentage of appropriate junctional rhythm (81.9% ± 26.0% vs. 55.7% ± 30.5%, p = 0.002) than the conventional group. (4) Conclusions: The use of the panoramic view for AVNRT ablation achieved similar clinical endpoints with higher ablation efficiency than the conventional approach.
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Randomized trial of intracardiac echocardiography-guided slow pathway ablation. J Interv Card Electrophysiol 2022; 63:709-714. [PMID: 35044581 DOI: 10.1007/s10840-022-01126-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
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Tretter JT, Spicer DE, Sánchez-Quintana D, Back Sternick E, Farré J, Anderson RH. Miniseries 1-Part III: 'Behind the scenes' in the triangle of Koch. Europace 2022; 24:455-463. [PMID: 34999775 DOI: 10.1093/europace/euab285] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS To take full advantage of the knowledge of cardiac anatomy, structures should be considered in their correct attitudinal orientation. Our aim was to discuss the triangle of Koch in an attitudinally appropriate fashion. METHODS AND RESULTS We reviewed our material prepared by histological sectioning, along with computed tomographic datasets of human hearts. The triangle of Koch is the right atrial surface of the inferior pyramidal space, being bordered by the tendon of Todaro and the hinge of the septal leaflet of the tricuspid valve, with its base at the inferior cavotricuspid isthmus. The fibro-adipose tissues of the inferior pyramidal space separate the atrial wall from the crest of the muscular interventricular septum, thus producing an atrioventricular muscular sandwich. The overall area is better approached as a pyramid rather than a triangle. The apex of the inferior pyramidal space overlaps the infero-septal recess of the subaortic outflow tract, permitting the atrioventricular conduction axis to transition directly to the crest of the muscular ventricular septum. The compact atrioventricular node is formed at the apex of the pyramid by union of its inferior extensions, which represent the slow pathway, with the septal components formed in the buttress of the atrial septum, thus providing the fast pathway. CONCLUSIONS To understand its various implications in current cardiological catheter interventions, the triangle of Koch must be considered in conjunction with the inferior pyramidal space and the infero-septal recess. It is better to consider the overall region in terms of a pyramidal area of interest.
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Affiliation(s)
- Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Diane E Spicer
- Department of Pediatric Cardiology, University of Florida, Gainesville, FL, USA
| | | | | | - Jerónimo Farré
- Fundación Jiménez Díaz University Hospital and Institute of Biomedical Research, Madrid, Spain
| | - Robert H Anderson
- Institute of Biosciences, Newcastle University, Newcastle upon Tyne, UK
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Chaumont C, Mirolo A, Savouré A, Godin B, Auquier N, Viart G, Hatrel A, Gillibert A, Eltchaninoff H, Anselme F. Very long‐term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency? J Cardiovasc Electrophysiol 2020; 31:3215-3222. [DOI: 10.1111/jce.14784] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Corentin Chaumont
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Adrian Mirolo
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Arnaud Savouré
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Bénédicte Godin
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Nathanaël Auquier
- Department of Cardiology Groupe Hospitalier du Havre Le Havre France
| | - Guillaume Viart
- Department of Cardiology Rouen University Hospital Rouen France
| | - Amandine Hatrel
- Department of Cardiology Rouen University Hospital Rouen France
- Department of Cardiology Elbeuf Hospital Elbeuf France
| | - André Gillibert
- Department of Biostatistics Rouen University Hospital Rouen France
| | - Hélène Eltchaninoff
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Frédéric Anselme
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
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Wang Y, Liu L, Lakin R, Polidovitch N, Liu G, Yang H, Yu M, Yan M, Zhao D, Backx PH, Sun H, He Y, Yang P. Revisiting right anterior oblique projections for the triangle of Koch: implications from computed tomography. BMC Cardiovasc Disord 2020; 20:383. [PMID: 32838758 PMCID: PMC7446209 DOI: 10.1186/s12872-020-01632-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Variability in the anatomy and orientation of the triangle of Koch (TK) complicates ablation procedures involving the atrioventricular (AV) node. We used CT angiography (CTA) to assess the anatomical TK orientation, the CS ostium direction, and the relationship between the two, and we validated an individualized CS-guided projection during ablation procedures. Methods In 104 patients without structural heart disease undergoing computed tomography (CT) angiography, TK orientations were determined in relation to the coronary sinus ostium (CSo) as well as two standard right anterior oblique (RAO) projection angles (30o and 45o) commonly used in ablation procedures. Results A CS-guided RAO projection (RAOCS) was shown to best track the orientation of the TK compared to RAO30° and 45°, with TK orientation strongly correlating with the CSo direction (r = 0.86, P < 0.001). In addition, the mean relative difference between the angle of the CSo and TK orientation was 5.54 ± 0.48°, consistent with a reduction in the degree of image shortening compared to traditional RAOs. Moreover, in vivo validation following ablation revealed that using a CS-guided projection limited the degree of on-screen image shortening compared to both the RAO30° and 45° in 25 patients with catheter ablation procedures. Conclusion In hearts with a normal structure, the CSo direction offers a reliable predictor of the TK orientation which can be used to guide the projection of the TK during ablation procedures.
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Affiliation(s)
- Yanjing Wang
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Lin Liu
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Robert Lakin
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Nazari Polidovitch
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Guohui Liu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Hongliang Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Ming Yu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Mingzhou Yan
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Dong Zhao
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Peter H Backx
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Huan Sun
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Yuquan He
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Ping Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
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High-density mapping of Koch's triangle during sinus rhythm and typical AV nodal reentrant tachycardia: new insight. J Interv Card Electrophysiol 2020; 61:487-497. [PMID: 32766944 DOI: 10.1007/s10840-020-00841-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Atrial activation during typical atrioventricular nodal reentrant tachycardia (AVNRT) exhibits anatomic variability and spatially heterogeneous propagation inside the Koch's triangle (KT). The mechanism of the reentrant circuit has not been elucidated yet. Aim of this study is to describe the distribution of Jackman and Haïssaguerre potentials within the KT and to explore the activation mode of the KT, in sinus rhythm and during the slow-fast AVNRT. METHODS Forty-five consecutive cases of successful slow pathway (SP) ablation of typical slow-fast AVNRT from the CHARISMA registry were included. RESULTS The KT geometry was obtained on the basis of the electroanatomic information using the Rhythmia mapping system (Boston Scientific) (mean number of points acquired inside the KT = 277 ± 47, mean mapping time = 11.9 ± 4 min). The postero-septal regions bounded anteriorly by the tricuspid annulus and posteriorly by the lateral wall toward the crista terminalis showed a higher prevalence of Jackman potentials than mid-postero-septal regions along the tendon of Todaro and coronary sinus (CS) (98% vs. 16%, p < 0.0001). Haïssaguerre potentials seemed to have a converse distribution across the KT (0% vs. 84%, p < 0.0001). Fast pathway insertion, as located during AVNRT, was mostly recorded in an antero-septal position (n = 36, 80%), rather than in a mid-septal (n = 6, 13.3%) or even postero-septal (n = 3, 7%) location. During typical slow-fast AVNRT, two types of propagation around the CS were discernible: anterior and posterior, n = 31 (69%), or only anterior, n = 14 (31%). During the first procedure, the SP was eliminated, and acute procedural success was achieved (median of 4 [3-5] RF ablations). CONCLUSION High-density mapping of KT in AVNRT patients both during sinus rhythm and during tachycardia provides new electrophysiological insights. A better understanding and a more precise definition of the arrhythmogenic substrate in AVNRT patients may have prognostic value, especially in high-risk cases. TRIAL REGISTRATION Catheter Ablation of Arrhythmias With High Density Mapping System in the Real World Practice (CHARISMA) URL: http://clinicaltrials.gov/ Identifier: NCT03793998.
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Clinical and electrophysiological characteristics of idiopathic ventricular arrhythmias originating from the slow pathway region. Heart Rhythm 2019; 16:1421-1428. [DOI: 10.1016/j.hrthm.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 11/21/2022]
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10
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Garweg C, De Buck S, Vandenberk B, Willems R, Ector J. High-Detailed evaluation of the right atrial anatomy by three-dimensional rotational angiography during ablation procedures for atrioventricular nodal reentrant tachycardia and atrial flutter. SCAND CARDIOVASC J 2018; 52:268-274. [PMID: 30445881 DOI: 10.1080/14017431.2018.1546893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIM 3D Rotational angiography (3DRA) allows for detailed reconstruction of atrial anatomy and is often used to facilitate pulmonary vein isolation. This study aimed to reappraise the anatomy of the right atrium (RA) using 3DRA, specifically looking at Koch's triangle and the cavotricuspid isthmus (CTI) in atrio-ventricular reentrant tachycardia (AVNRT) and atrial flutter (AFl) ablation. METHODS AND RESULTS 3DRA was performed in 97 patients: AVNRT = 51 and AFl = 46. Dimensions of Koch's triangle and CTI were highly variable between individuals but were not different in both ablation groups. RA volume was significantly larger in AFl patients (p = .004) while indexed RA volume to the body surface area (RAVI) was lightly different (p = .024). In univariate Cox analysis, age (p = .003), RAVI (p < .001) and previous ablation of AFl (p = .003) were predictors of AF occurrence . In multivariate Cox analysis, RAVI was the only independent predictor of AF occurrence. RAVI >80 ml/m2 was a strong predictor for AF during follow-up. CONCLUSION 3DRA allows for detailed per-procedural evaluation of RA anatomy and revealed a great variability in Koch's triangle and CTI dimensions and morphology. RA enlargement as measured by RAVI was an independent predictor for AF occurrence during follow-up.
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Affiliation(s)
- Christophe Garweg
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Stijn De Buck
- b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Bert Vandenberk
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Rik Willems
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Joris Ector
- a Department of Cardiovascular Sciences , University of Leuven , Leuven , Belgium.,b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
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Fragakis N, Krexi L, Kyriakou P, Sotiriadou M, Lazaridis C, Karamanolis A, Dalampyras P, Tsakiroglou S, Skeberis V, Tsalikakis D, Vassilikos V. Electrophysiological markers predicting impeding AV-block during ablation of atrioventricular nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:7-13. [DOI: 10.1111/pace.13245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nikolaos Fragakis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Lydia Krexi
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiota Kyriakou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Melani Sotiriadou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Charalambos Lazaridis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Athanasios Karamanolis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiotis Dalampyras
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Stelios Tsakiroglou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Vassilios Skeberis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Dimitrios Tsalikakis
- Department of Informatics and Telecommunications; University of Western Macedonia; Macedonia Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
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Klimek-Piotrowska W, Holda MK, Koziej M, Salapa K, Piatek K, Holda J. Geometry of Koch's triangle. Europace 2017; 19:452-457. [PMID: 27247009 DOI: 10.1093/europace/euw022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/20/2016] [Indexed: 11/12/2022] Open
Abstract
Aims The first aim of this study was to determine the size of the Koch's triangle. The second one was to investigate relation between its dimensions and other individual-specific and heart-specific parameters as well as to create universal formula to estimate triangle dimensions based on these parameters. Methods and results This study is a prospective one, presenting 120 randomly selected autopsied hearts dissected from adult humans (Caucasian) of both sexes (31.7% females), with mean age of 49.3 ± 17.4 years. The length of triangle sides and angles were measured and the triangle area was calculated as well. Sixteen additional heart parameters were measured in order to analyse potential relationship between the dimensions of Koch's triangle and other dimensions of the heart, using linear regression analysis. The mean (±SD) length of the anterior edge was approximated to 18.0 ± 3.8 mm, the posterior edge to 20.3 ± 4.3 mm, and the basal edge to 18.5 ± 4.0 mm. The average values of the apex angle, the Eustachian angle, and the septal leaflet angle were 58.0 ± 14.4°, 53.8 ± 10.6°, and 67.6 ± 14.4°, respectively. The mean value of the Koch's triangle area was 151.5 ± 55.8 mm2. The 95th percentile of triangle's height (the distance from the apex to the coronary sinus) was 21.8 mm. Conclusion Mean values and proportions of triangle's sides and angles were presented. Koch's triangle showed considerable individual variations in size. The dimensions of the triangle were strongly independent from individual-specific and heart-specific morphometric parameters; however, the maximum triangle's height can be estimated as 22 mm.
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Affiliation(s)
| | - Mateusz K Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Kinga Salapa
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna Piatek
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Jakub Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
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Electroanatomically estimated length of slow pathway in atrioventricular nodal reentrant tachycardia. Heart Vessels 2015; 29:817-24. [PMID: 24121973 PMCID: PMC4226935 DOI: 10.1007/s00380-013-0424-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 09/27/2013] [Indexed: 11/02/2022]
Abstract
The length of the slow pathway (SP-L) in atrioventricular (AV) nodal reentrant tachycardia (NRT) has never been measured clinically. We studied the relationship among (a) SP-L, i.e., the distance between the most proximal His bundle (H) recording and the most posterior site of radiofrequency (RF) delivery associated with a junctional rhythm, (b) the length of Koch’s triangle (Koch-L), (c) the conduction time over the slow pathway (SP-T), measured by the AH interval during AVNRT at baseline, and (d) the distance between H and the site of successful ablation (SucABL-L) in 26 women and 20 men (mean age 64.6 ± 11.6 years), using a stepwise approach and an electroanatomic mapping system (EAMS). SP-L (15.0 ± 5.8 mm) was correlated with Koch-L (18.6 ± 5.6 mm; R 2 = 0.1665, P < 0.005), SP-T (415 ± 100 ms; R 2 = 0.3425, P = 0.036), and SucABL-L (11.6 ± 4.7 mm; R 2 = 0.5243, P < 0.0001). The site of successful ablation was located within 10 mm of the posterior end of the SP in 38 patients (82.6 %). EAMS-guided RF ablation, using a stepwise approach, revealed individual variations in SP-L related to the size of Koch’s triangle and AH interval during AVNRT. Since the site of successful ablation was also correlated with SP-L and was usually located near the posterior end of the SP, ablating anteriorly, away from the posterior end, is not a prerequisite for the success of ablation procedures.
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14
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Practical training on porcine hearts enhances students’ knowledge of human cardiac anatomy. Ann Anat 2014; 196:92-9. [DOI: 10.1016/j.aanat.2014.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 01/09/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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15
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Anatomical and electrophysiological variations of Koch's triangle and the impact on the slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia: a study using 3D mapping. J Interv Card Electrophysiol 2013; 37:111-20. [PMID: 23408048 DOI: 10.1007/s10840-012-9769-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to reveal individual variations in Koch's triangle using NavX and to evaluate the efficacy of the NavX-guided slow pathway ablation. METHODS A regional geometry around Koch's triangle was constructed in 42 consecutive patients with atrioventricular nodal reentrant tachycardia (AVNRT), and a bipolar electrogram map was created with 72 ± 30 sampling points during sinus rhythm to identify sites with Haissaguerre's slow potentials (SPs) and His bundle electrograms (HBEs) to examine the anatomical and electrical variations. Radiofrequency ablation was performed at the most prominent SP recording site. The acute results and long-term outcome were examined in comparison to another 42 consecutive patients who underwent a conventional fluoroscopy-guided slow pathway ablation in the previous months. RESULTS The size of Koch's triangle and the coronary sinus ostium varied over a wide range of 132 to 490 and 69 to 346 mm(2), respectively. HBEs were recorded linearly along the antero-septal right atrium (n = 29) or deviated downward toward the midseptum (n = 13, 31 %). The SPs were always distributed below the lowest HBE recording site. The NavX-guided ablation eliminated AVNRT with a median of 1 radiofrequency pulse, 9.1 ± 4.6 min of fluoroscopy, and 49 ± 14 min of procedure time, all of which were significantly smaller than those in fluoroscopy-guided ablation. No procedure-related complications or long-term recurrence was noted in either group. CONCLUSION Koch's triangle varies in terms of the size and electrogram distribution, and the NavX-guided slow pathway ablation overcomes the diversity and seems more effective than fluoroscopy-guided ablation.
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Pandozi C, Ficili S, Galeazzi M, Lavalle C, Russo M, Pandozi A, Venditti F, Pristipino C, Verbo B, Santini M. Propagation of the Sinus Impulse Into the Koch Triangle and Localization, Timing, and Origin of the Multicomponent Potentials Recorded in This Area. Circ Arrhythm Electrophysiol 2011; 4:225-34. [DOI: 10.1161/circep.110.957381] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The presence of a conduction block at the level of the Koch triangle (KT) and the origin of the multicomponent potentials inside this area are controversial issues. We investigated the propagation of the sinus impulse into the KT and the characteristics of multicomponent potentials recorded in that area in patients with and without atrioventricular nodal reentrant tachycardia (AVNRT).
Methods and Results—
Thirty-two patients (16 with AVNRT, 16 without AVNRT) underwent a sinus rhythm electroanatomic mapping of the right atrium (RA). Conduction velocities in the RA and in the KT were evaluated quantitatively on activation maps and qualitatively on isochronal and propagation maps. The presence, location, and timing of different types of multicomponent potentials were evaluated. A mean of 149±44 points were sampled in the RA, whereas a mean of 79±21 points were collected inside the KT. Propagation block at the level of crista terminalis was not found in any patient, whereas slow conduction inside the KT was found in all (median conduction velocity, 122 cm/s [110 to 135 cm/s] outside KT versus 60 cm/s [48 to 75 cm/s] inside KT;
P
<0.0001). Jackman potentials were identified inside KT in almost all the patients and were invariably found on the line of collision between the wavefronts activating the KT in opposite directions.
Conclusions—
No conduction block was detected inside the KT in patients with and without AVNRT. Conduction slowing was demonstrated during propagation of the sinus impulse inside the KT. The genesis of the Jackman potential may be related to the collision of the wavefronts activating KT in opposite directions.
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Affiliation(s)
- Claudio Pandozi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Sabina Ficili
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Marco Galeazzi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Carlo Lavalle
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Russo
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Angela Pandozi
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Franco Venditti
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Christian Pristipino
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Brunella Verbo
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
| | - Massimo Santini
- From the Department of Cardiology (C. Pandozi, S.F., M.G., C.L., M.R., A.P., F.V., B.V., M.S.) and Clinical Research Centre and Department of Cardiology (C. Pristipino), San Filippo Neri Hospital, Rome, Italy
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Matsuyama TA, Ishibashi-Ueda H, Ikeda Y, Yamada Y, Okamura H, Noda T, Satomi K, Suyama K, Shimizu W, Aihara N, Kamakura S, Inoue S. The positional relationship between the coronary sinus musculature and the atrioventricular septal junction. Europace 2010; 12:719-25. [PMID: 20228078 DOI: 10.1093/europace/euq067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The atrioventricular (AV) septal junction includes the coronary sinus (CS) and the compact part of the AV node and its posterior extensions. It has been recognized as the target site for ablation therapy of the AV nodal reentrant tachycardia and its variant forms. Despite the clinical significance of this region, the arrangement of the musculature in the AV septal junction, including the CS, has not fully been elucidated. We tried to explore the histological muscular diversity within the AV septal junction. METHODS AND RESULTS Sixteen autopsied human hearts (seven women), mean age 59.8 years, without structural anomalies, were studied. We removed the whole AV septum, including the CS opening after the macroscopic measurements, and prepared serial sections parallel to mitral and tricuspid annuli (short-axis style) to elucidate the positional relationships between the compact AV node and the CS musculature. Out of 16 hearts, the CS musculature extended deeply into the AV septal junction in eight hearts. In the other eight hearts, the CS musculature was located above the AV septal junction. In the former group, we found that the offset of both annuli was wide (mean 3.8 +/- 1.4 vs. 2.4 +/- 1.1 mm), the distance between CS opening and membranous septum was long (mean 14.8 +/- 1.6 vs. 12.3 +/- 2.2 mm), and the CS opening level was lower and closer to the His bundle level (mean 2.8 +/- 1.9 vs. 5.8 +/- 2.9 mm) (P < 0.05). CONCLUSION The deep extension of CS musculature into the AV septal junction seems to increase the tissue non-uniformity in this area.
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Affiliation(s)
- Taka-aki Matsuyama
- Department of Pathology, National Cardiovascular Center, 5-7-1 Fujishirodai Suita-City, 565-8565 Osaka, Japan.
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Tapanainen JM, Jurkko R, Holmqvist F, Husser D, Kongstad O, Mäkijärvi M, Toivonen L, Platonov PG. Interatrial right-to-left conduction in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2009; 25:117-22. [PMID: 19283459 DOI: 10.1007/s10840-008-9359-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 12/22/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE We wanted to illustrate the right-to-left impulse propagation routes during sinus in patients with paroxysmal atrial fibrillation (PAF), as alterations in conduction patterns have been linked to the pathogenesis of PAF, and as no large patient materials have been published. METHODS Patients underwent 3-D electroanatomical contact mapping prior to catheter ablation. The site of the earliest left atrial (LA) activation was determined. RESULTS Three different interatrial routes were identified, either as solitary pathways (36/50 patients, 72%) or in their combinations (14/50). Bachmann's bundle (BB) was involved in the majority of the cases with solitary routes (25/36). More seldom, impulse propagation occurred near the oval fossa (FO) (7/36) or the coronary sinus ostium (4/36). In patients with combined routes, both the BB (10/14) and FO routes (11/14) were included in most cases. CONCLUSIONS In PAF patients, LA can be activated during sinus rhythm through three distinct connections, either encompassing a single route or via any combination of these connections. In one third, the earliest LA activation occurs outside BB. The knowledge of the propagation patterns may give insight into the pathophysiology of PAF and into refining ablation therapy.
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Affiliation(s)
- Jari M Tapanainen
- Department of Cardiology, Helsinki University Central Hospital, Helsinki, Finland.
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Substrates for intra-atrial and interatrial conduction in the atrial septum: Anatomical study on 84 human hearts. Heart Rhythm 2008; 5:1189-95. [DOI: 10.1016/j.hrthm.2008.04.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 04/22/2008] [Indexed: 11/21/2022]
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Chang SL, Tai CT, Lin YJ, Ong MG, Wongcharoen W, Lo LW, Chang SH, Hsieh MH, Chen SA. The Electroanatomic Characteristics of the Cavotricuspid Isthmus: Implications for the Catheter Ablation of Atrial Flutter. J Cardiovasc Electrophysiol 2007; 18:18-22. [PMID: 17081213 DOI: 10.1111/j.1540-8167.2006.00647.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) of typical AFL is sometimes difficult because of the poor electroanatomic approach to the cavotricuspid isthmus (CTI). The aim of this study was to correlate the anatomy of the CTI between contact mapping (NavX) and right atrial angiography (RAG), and to investigate the impact of the electroanatomic characteristics of the CTI on the RFA of typical atrial flutter (AFL). METHODS One hundred patients with typical AFL undergoing RFA were studied. The image-guided group consisted of 50 consecutive patients with the guidance of NavX. NavX geometry and RAG were performed to investigate the morphology of the CTI. The bipolar voltages of the CTI were collected during sinus rhythm by a NavX. The control group consisted of 50 consecutive patients with the guidance of conventional fluoroscopy. RESULTS There was a good correlation between the angiography and NavX for the anatomy of the CTI. The pouch type had a longer length of CTI than the flat type (33.4 +/- 5.0 vs 22.6 +/- 8.4 mm, P < 0.0001) and deeper depth than the concave type (6.5 +/- 2.2 vs 3.7 +/- 0.8 mm, P < 0.0001) on the angiography. The pouch-type CTI had a longer ablation time and larger pulses of RFA than the other two types. The control group had a longer ablation time, fluoroscopy time, and larger pulses of RFA than image-guided group. CONCLUSIONS The 3-D mapping system provided a good reconstruction of CTI, which may help in the RFA in patients with a complex anatomy of the CTI.
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Affiliation(s)
- Shih-Lin Chang
- Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, and Taipei Veterans General Hospital, Taipei, Taiwan
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Batra R, Nair M, Kumar M, Mohan J, Shah P, Kaul U, Arora R. Intracardiac echocardiography guided radiofrequency catheter ablation of the slow pathway in atrioventricular nodal reentrant tachycardia. J Interv Card Electrophysiol 2002; 6:43-9. [PMID: 11839882 DOI: 10.1023/a:1014124206594] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND ICE has demonstrated its utility in imaging right atrial structures but its utility in slow pathway (SP) ablation has not been documented in a randomized trial. METHODS The feasibility of using ICE as a imaging modality to identify the effective site of SP ablation was done in part one of the study comprising 10 patients of typical AVNRT. Subsequently, a prospective randomized study was done comparing the conventional (group A) and ICE guided (group B) ablation of the SP. Each group had 20 patients of typical AVNRT. Ablation in the conventional arm was guided by intracardiac electrograms and fluoroscopy. Group B patients underwent SP ablation guided primarily by ICE imaging; fluoroscopy was used mainly for initial placement of catheters. RESULTS Reliable & stable ICE images were obtained in all patients. Part I of the study showed that RF pulses given when the ablation catheter was seen to cross the atrioventricular muscular septum (AVMS), always resulted in junctional rhythm. In Group B, RF pulse was delivered only when the ablation catheter was at the AVMS making an obtuse angle with the image of the His-bundle catheter. Consistent junctional rhythm and abolition of SP resulted at this site. Compared to group A, patients in group B required fewer pulses (mean 1.4 +/- 0.6 vs. 4.4 +/- 3.0; p < 0.05, median 1 vs. 5; p < 0.01), achieved a higher temperature (56 +/- 4 degrees C vs. 50 +/- 6 degrees C) and had more frequent junctional rhythm (100% vs. 70%) during RF pulse. CONCLUSIONS A critical portion of SP exists adjacent to Tricuspid valve overlying the AVMS. ICE imaging consistently and reliably localizes this site and RF applications here result in interruption of antegrade SP conduction.
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Affiliation(s)
- Ravinder Batra
- Department of Cardiology, GB Pant Hospital, JLN Marg, University of Delhi, New Delhi-10002, India
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Waki K, Kim JS, Becker AE. Morphology of the human atrioventricular node is age dependent: a feature of potential clinical significance. J Cardiovasc Electrophysiol 2000; 11:1144-51. [PMID: 11059979 DOI: 10.1111/j.1540-8167.2000.tb01761.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Advances in catheter ablation procedures have created the need to understand better the morphology of the AV node (AVN), particularly as it relates to age. METHODS AND RESULTS This study was based on 40 normally structured hearts obtained at autopsy from patients without a history of tachyarrhythmia in the following age ranges: < 1 year (n = 19); 1-12 years (n = 11); and 12-20 years (n = 10). In 38 hearts, the AV septal junctional area was removed en bloc and serially sectioned at 10-microm thickness at right angles to the AV annulus. The length of the compact node and the rightward and leftward inferior extensions were calculated. Computer-assisted three-dimensional reconstructions were made of six hearts. The ratio of right extension to compact AVN showed a statistically significant increase with age; the increase in ratio of left extension to compact AVN was not statistically significant. In addition, with increasing age the geometry of the AVN changed from a half-oval to a spindle shape, concomitant with development of a distinct so-called muscular AV septum. The three-dimensional reconstructions showed widening of the transitional cell zone with an increase in fibrofatty tissue related to age. CONCLUSION The AVN, inferior extensions, and transitional cell zone show distinct age-related changes that may be clinically relevant. The increase in length of the inferior extensions may set the scene for AVN reentry and could explain why this condition is more frequent in young adults than in infants.
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Affiliation(s)
- K Waki
- Department of Cardiovascular Pathology, University of Amsterdam, The Netherlands
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Heidbüchel H, Willems R, van Rensburg H, Adams J, Ector H, Van de Werf F. Right atrial angiographic evaluation of the posterior isthmus: relevance for ablation of typical atrial flutter. Circulation 2000; 101:2178-84. [PMID: 10801759 DOI: 10.1161/01.cir.101.18.2178] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gaining anatomic information about the posterior isthmus is not generally part of flutter ablation procedures. We postulated that right atrial (RA) angiography could rationalize the ablation approach by revealing the conformation of the isthmus. METHODS AND RESULTS In 100 consecutive patients, biplane RA angiography was performed before ablation to guide catheter contact with the isthmus along its length. Angiography showed a wide variation in the width of the isthmus (17 to 54 mm; 31.3+/-7.9), its angle with the inferior vena cava in the right anterior oblique projection (68 degrees to 114 degrees; 90.3+/-9.0 degrees ), and its lateral position relative to the inferior vena cava in the left anterior oblique projection. A deep sub-Eustachian recess was revealed in 47%, with a mean depth of 4.3+/-2.1 mm (1.5 to 9.4). A Eustachian valve was visualized in 24%. Ablation resulted in bidirectional conduction block (which could be transient) in all, with a median of 2 dragging radiofrequency (RF) applications (2.3+/-2.5 RF applications; 57 degrees C, < or =99 seconds each). Permanent block was achieved in 99%, with a median of 3 RF applications (3.4+/-3.0). The presence of a Eustachian valve or concave isthmus was associated with statistically more RF applications; the same trend was seen for patients with deep pouches. The number of RF applications decreased statistically throughout the study, indicating a learning curve. No patient had a recurrence after a follow-up of 13+/-11 months. CONCLUSIONS Right atrial angiography reveals a highly variable isthmus anatomy, often showing particular configurations that can make ablation more laborious. Rational adaptation of the ablation approach to these anatomic findings may contribute to successful ablation.
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Affiliation(s)
- H Heidbüchel
- Department of Cardiology, University Hospital Gasthuisberg, University of Leuven, Belgium.
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Yamane T, Iesaka Y, Goya M, Takahashi A, Fujiwara H, Hiraoka M. Optimal target site for slow AV nodal pathway ablation: possibility of predetermined focal mapping approach using anatomic reference in the Koch's triangle. J Cardiovasc Electrophysiol 1999; 10:529-37. [PMID: 10355694 DOI: 10.1111/j.1540-8167.1999.tb00709.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although a variety of ablation techniques have been developed in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT), there have been few reports discussing the location of the optimal target site. Based on our early experiences, we hypothesized that radiofrequency (RF) current applied around the upper margin of the coronary sinus ostium (UCSO) results in the most effective and safe treatment of AVNRT. METHODS AND RESULTS To confirm our hypothesis, the efficacy of RF currents applied around the UCSO guided by local electrograms in 59 patients (group B: predetermined focal mapping approach) were compared with the outcomes in 60 other patients previously treated with the standard electrogram-guided mapping method starting around the lower margin of the coronary sinus ostium (group A). The precise location of ablation catheters at successful sites (S) was also evaluated. All the patients were successfully treated without complications. Significantly fewer RF pulses and lower energies were needed in group B patients (mean RF applications: 4.3 vs 1.4 applications, mean total energy delivered: 4,699 vs 2,236 J in groups A and B, respectively, P < 0.01). Detailed analyses of the anatomical locations of S using CS venography in group B patients who received only a single RF application (46 patients) revealed that the distance between His and S varied according to the length of Koch's triangle, while that between S and UCSO was relatively constant. In 85 % of these 46 patients, S was located within 5 mm above and below the level of the UCSO. CONCLUSION RF applications around the UCSO guided by local electrograms yielded excellent outcomes in AVNRT patients with wide varieties in the size of Koch's triangle. The optimal target site was located within 5 mm above and below the level of UCSO along the tricuspid annulus.
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Affiliation(s)
- T Yamane
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
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