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Kalyanasundaram A, Li N, Augostini RS, Weiss R, Hummel JD, Fedorov VV. Three-dimensional functional anatomy of the human sinoatrial node for epicardial and endocardial mapping and ablation. Heart Rhythm 2023; 20:122-133. [PMID: 36113768 PMCID: PMC9897959 DOI: 10.1016/j.hrthm.2022.08.039] [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: 05/10/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/05/2023]
Abstract
The sinoatrial node (SAN) is the primary pacemaker of the human heart. It is a single, elongated, 3-dimensional (3D) intramural fibrotic structure located at the junction of the superior vena cava intercaval region bordering the crista terminalis (CT). SAN activation originates in the intranodal pacemakers and is conducted to the atria through 1 or more discrete sinoatrial conduction pathways. The complexity of the 3D SAN pacemaker structure and intramural conduction are underappreciated during clinical multielectrode mapping and ablation procedures of SAN and atrial arrhythmias. In fact, defining and targeting SAN is extremely challenging because, even during sinus rhythm, surface-only multielectrode mapping may not define the leading pacemaker sites in intramural SAN but instead misinterpret them as epicardial or endocardial exit sites through sinoatrial conduction pathways. These SAN exit sites may be distributed up to 50 mm along the CT beyond the ∼20-mm-long anatomic SAN structure. Moreover, because SAN reentrant tachycardia beats may exit through the same sinoatrial conduction pathway as during sinus rhythm, many SAN arrhythmias are underdiagnosed. Misinterpretation of arrhythmia sources and/or mechanisms (eg, enhanced automaticity, intranodal vs CT reentry) limits diagnosis and success of catheter ablation treatments for poorly understood SAN arrhythmias. The aim of this review is to provide a state-of-the-art overview of the 3D structure and function of the human SAN complex, mechanisms of SAN arrhythmias and available approaches for electrophysiological mapping, 3D structural imaging, pharmacologic interventions, and ablation to improve diagnosis and mechanistic treatment of SAN and atrial arrhythmias.
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Affiliation(s)
- Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ning Li
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ralph S Augostini
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raul Weiss
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John D Hummel
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Valeri Y, Bagliani G, Compagnucci P, Volpato G, Cipolletta L, Parisi Q, Misiani A, Fogante M, Molini S, Dello Russo A, Casella M. Pathophysiology of Typical Atrial Flutter. Card Electrophysiol Clin 2022; 14:401-409. [PMID: 36153122 DOI: 10.1016/j.ccep.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nowadays, the pathophysiology mechanism of initiation and maintenance of reentrant arrhythmias, including atrial flutter, is well characterized. However, the anatomic and functional elements of the macro reentrant arrhythmias are not always well defined. In this article, we illustrate the anatomic structures that delineate the typical atrial flutter circuit, both clockwise and counterclockwise, paying attention to the inferior vena cava-tricuspid isthmus (CTI) and crista terminalis crucial role. Finally, we describe the left atrial role during typical atrial flutter, electrophysiologically a by-stander but essential in the phenotypic electrocardiogram (ECG).
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Affiliation(s)
- Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy.
| | - Giuseppe Bagliani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Agostino Misiani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Marco Fogante
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Silvano Molini
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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Shah SR, Luu SW, Calestino M, David J, Christopher B. Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence. J Community Hosp Intern Med Perspect 2018; 8:269-275. [PMID: 30357020 PMCID: PMC6197036 DOI: 10.1080/20009666.2018.1514932] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/14/2018] [Indexed: 02/08/2023] Open
Abstract
The term 'flutter' and 'fibrillation' were first coined to differentiate the differences between fast, regular contractions in Atrial Flutter (AFLUT) with irregular, vermiform contractions of Atrial Fibrillation (AFIB). Management of these two diseases has been a challenge for physicians. Rate control (along with rhythm control) is the first line of management for symptomatic AFIB/AFLUT with Rapid Ventricular Rate (RVR). In some situations, atrial rhythms may not be well controlled by these anti-arrhythmic drugs, making cardioversion to sinus rhythm necessary. Anti-coagulation therapy in both the disease population is essential. Catheter ablation is an effective treatment option in certain patients that have AFIB/AFLUT refractory to medical management. Newer techniques like left atrial appendage (LAA) has been developed and is a highly attractive concept for the future in the management of AFIB/AFLUT. Newer novel drugs targeting specific ion channels are approaching the stages of clinical investigation. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain. This literature review serves as one of the guideline papers for current up-to-date management on both AFIB and AFLUT.
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Affiliation(s)
- Syed Raza Shah
- North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Sue-Wei Luu
- Graduate Medical Education, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Matthew Calestino
- Graduate Medical Education, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - John David
- Graduate Medical Education, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Bray Christopher
- Graduate Medical Education, University of Central Florida College of Medicine, Gainesville, FL, USA
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Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jaïs P, Josephson ME, Keegan R, Kim YH, Knight BP, Kuck KH, Lane DA, Lip GYH, Malmborg H, Oral H, Pappone C, Themistoclakis S, Wood KA, Blomström-Lundqvist C, Gorenek B, Dagres N, Dan GA, Vos MA, Kudaiberdieva G, Crijns H, Roberts-Thomson K, Lin YJ, Vanegas D, Caorsi WR, Cronin E, Rickard J. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace 2018; 19:465-511. [PMID: 27856540 DOI: 10.1093/europace/euw301] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Demosthenes G Katritsis
- Athens Euroclinic, Athens, Greece; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Pierre Jaïs
- University of Bordeaux, CHU Bordeaux, LIRYC, France
| | | | - Roberto Keegan
- Hospital Privado del Sur y Hospital Español, Bahia Blanca, Argentina
| | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea
| | | | | | - Deirdre A Lane
- Asklepios Hospital St Georg, Hamburg, Germany.,University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helena Malmborg
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Hakan Oral
- University of Michigan, Ann Arbor, MI, USA
| | - Carlo Pappone
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bulent Gorenek
- Cardiology Department, Eskisehir Osmangazi University, Eskisehir, Turkey
| | | | - Gheorge-Andrei Dan
- Colentina University Hospital, 'Carol Davila' University of Medicine, Bucharest, Romania
| | - Marc A Vos
- Department of Medical Physiology, Division Heart and Lungs, Umc Utrecht, The Netherlands
| | | | - Harry Crijns
- Mastricht University Medical Centre, Cardiology & CARIM, The Netherlands
| | | | | | - Diego Vanegas
- Hospital Militar Central - Unidad de Electrofisiologìa - FUNDARRITMIA, Bogotà, Colombia
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5
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Typical Flutter Rewritten. JACC Clin Electrophysiol 2017; 3:987-990. [DOI: 10.1016/j.jacep.2017.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/16/2017] [Indexed: 11/22/2022]
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Abstract
Clinical electrophysiology has made the traditional classification of rapid atrial rhythms into flutter and tachycardia of little clinical use. Electrophysiological studies have defined multiple mechanisms of tachycardia, both re-entrant and focal, with varying ECG morphologies and rates, authenticated by the results of catheter ablation of the focal triggers or critical isthmuses of re-entry circuits. In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Secondary prevention, based on the treatment of associated atrial fibrillation risk factors, is emerging as a therapeutic option. In patients subjected to cardiac surgery or catheter ablation for the treatment of atrial fibrillation or showing atypical ECG patterns, macro-re-entrant and focal tachycardia mechanisms can be very complex and electrophysiological studies are necessary to guide ablation treatment in poorly tolerated cases.
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Affiliation(s)
- Francisco G Cosío
- Getafe University Hospital, European University of Madrid, Madrid, Spain
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Rissi R, Marques MJ, Santo Neto H. Correlation of crista terminalis thickness and right atrial appendage lobation: Implications on arrhythmias and atrial thrombosis. Int J Cardiol 2016; 223:152-153. [PMID: 27537746 DOI: 10.1016/j.ijcard.2016.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Renato Rissi
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), 13083-865 Campinas, São Paulo, Brazil
| | - Maria Julia Marques
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), 13083-865 Campinas, São Paulo, Brazil
| | - Humberto Santo Neto
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), 13083-865 Campinas, São Paulo, Brazil.
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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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