Cardiac Anatomy_20120909_中區

Cardiac AnatomyCardiac Anatomy From view of From view of Interventiona

lElectrophysiologists

Taiwan Heart Rhythm Society~ Allied Professional Education Program

林圀宏林圀宏心臟內科心臟內科

中國醫藥大學附設醫院中國醫藥大學附設醫院

Anderson R H et al. Heart 2001;85:716-720

Cardiac StructureCardiac Structure

H.

A cross-section of the ventricular mass is shown as viewed in left anterior oblique orientation.

Anderson R H et al. Heart 2001;85:716-720

Normal Heart ConductionNormal Heart Conduction

Electrical activation always Electrical activation always precedes mechanical precedes mechanical activation, just by milliseconds.activation, just by milliseconds.

Heartbeats occur as electrical Heartbeats occur as electrical impulses move through the impulses move through the heart. heart.

The electrical side of the heart The electrical side of the heart and its contractions are at the and its contractions are at the core of how the heart operates. core of how the heart operates. This is what constitutes a This is what constitutes a heartbeat. heartbeat.

Coronary sinusCoronary sinus

Position of EP catheterPosition of EP catheter

AP viewAP view LAO viewLAO view

HRHRAA His

RVA

CS

Left AtriumLeft Atrium

Supraventricular Supraventricular tachycardiatachycardia

N Engl J Med 2006;354:1039-51

Spontaneous Initiation of Atrial Fibrillation by Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary VeinsEctopic Beats Originating in the Pulmonary Veins

HAISSAGUERRE; N Engl J Med 1998; 339:659-666HAISSAGUERRE; N Engl J Med 1998; 339:659-666

Circumferential Pulmonary-Vein Isolation

PericardiumPericardium

PericardiumPericardiumThin membranous, fibroserThin membranous, fibroserous sac Surrounds and proteous sac Surrounds and protects heart Confines and stabilcts heart Confines and stabilizes position of heartizes position of heart

Pericardial CavityPericardial CavityLocated between pericardiLocated between pericardium and epicardiumum and epicardiumContains pericardial fluid tContains pericardial fluid that acts as lubricanthat acts as lubricant

Pericardial sacPericardial sac

Part of the ascending aorta, the pulmonary trunk, the superior caval vein, and portions of the pulmonary veins are intrapericardial.

Phrenic NervePhrenic NerveMade up of motor nerve fibers that produce contractions of the diaphragm, and sensory innervation for the mediastinum, pericardium, pleura, diaphragm, upper abdo

men, liver, and gallbladder.

Left Phrenic Nervedescends on theleft side close to the aortic arch and onto the pericardiumover the left atrial appendage and the LV

Right Phrenic NervRight Phrenic Nerveedescends vertically alodescends vertically along the right lateral surfng the right lateral surface of the superior cavace of the superior caval vein to be related to al vein to be related to the right posteriorthe right posterioraspect of the RA wall, aaspect of the RA wall, and in close proximity to nd in close proximity to the anterior wall of the the anterior wall of the right superior pulmonaright superior pulmonary veinry vein

arterial ligamentarterial ligament(dactus arteriosus)(dactus arteriosus)

Relationship to Neighboring Structures of the Left Atrium

The right phrenic nerve running along the fibrous pericardium is close to the atrial insertion of the right superior pulmonary vein.

The left phrenic nerve passes over the left atrial appendage.

Posteriorly, the esophagus descends adjacent to the fibrous pericardium covering the posterior and postero-inferior walls of the left atrium.

Interatrial muscular connections exist at the septum, along Bachmann’s bundle and also at the muscular sleeves of the coronary sinus and pulmonary veins.

Thoracic organs viewed from the back after removal of the descending thoracic aorta to show the course of the esophagus (Es)

Sánchez-Quintana D et al. Circulation 2005;112:1400-1405

A, B, Sagittal sections through the heart and esophagus (Es) showing a middle section between the left and right PVs and a section close to the left

PVs (LS and LI), respectively.


RIPVRIPVLIPVLIPV

Close relationship of the left atrium to the esophagus

Sagittal section close to the left VA junction showing the nonuniform thickness of the atrial wall and 3 levels (red lines) at which

measurements were made.


Thickness of LA wallThickness of LA wall

Bachmann’s bundlepatent foramen ovalepatent foramen ovale(PFO)(PFO)

Vein of MarshellVein of Marshell Persistent left superior vena cava Persistent left superior vena cava

Left atrial appendageLeft atrial appendage

Ho S Y et al. Cardiovasc Res 2002;54:325-336

Orientation of Pulmonary veins

Anatomic landmark of atrial transseptal Anatomic landmark of atrial transseptal puncturepuncture

Atrial Structure and PulmonaAtrial Structure and Pulmonary Veinsry Veins

Transseptal Procedure in Ordinary AF Patients

RAO 30 LAO 60

Transeptal procedure from IVC

Catheter in the Left PV

esophagus

anteriorposterior

inside

outside

RAO for anterior and posterior LAO for inside and outside PV

Catheter in the Right PV

insideoutside

RS

RI

Anterior line, more away from spine border

RS anterior RS posterior

RI anterior

RI posteriorIn chronic cases

Catheter in RS anterior roof

RAO for inside and outside LAO for anterior and posterior of PV

Transeptal ProcedureTranseptal Procedure

Right AtriumRight Atrium

(A) is a simulated right anterior oblique view of the inside of the right atrium displayed by incising the lateral atrial wall and reflecting it back.


Eustachian valveEustachian valve The eustachian valve, guarding the entrance of thThe eustachian valve, guarding the entrance of th

e inferior caval vein, is variably developed. e inferior caval vein, is variably developed. Usually it is a triangular flap of fibrous or fibro-mUsually it is a triangular flap of fibrous or fibro-m

uscular tissue that inserts medially to the eustacuscular tissue that inserts medially to the eustachian ridge, or sinus septum, which is the border bhian ridge, or sinus septum, which is the border between the oval fossa and the coronary sinus etween the oval fossa and the coronary sinus

In some cases, the valve is particularly large and In some cases, the valve is particularly large and muscular, posing an obstacle to catheters passed muscular, posing an obstacle to catheters passed from the inferior caval vein to the inferior part of from the inferior caval vein to the inferior part of the right atrium. the right atrium.

Triangle of Koch: demarcated by the tendon of Todaro posteriorly, the tricuspid valve anteriorly, the coronary sinus inferiorly and the

central fibrous body (O) at the apex.


slow pathway slow pathway

Triangle of KochTriangle of Koch


sinus nodesinus node

Thebesian valveThebesian valve

A small crescentic flap, usually guardA small crescentic flap, usually guards the orifice of the coronary sinus. s the orifice of the coronary sinus.

Frequently, the valve is fenestrated. Frequently, the valve is fenestrated. An imperforate valve completely covAn imperforate valve completely cov

ering the orifice is very rare. ering the orifice is very rare.

A 12 lead ECG in a case of typical type I atrial flutter.

Waldo A L Heart 2000;84:227-227

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

(a) Right anterior oblique view of internal structures of RA and (b) right anterior oblique endocardial views (right image is magnified to show detail) of right atrioventricular junction

show boundaries of Koch triangle ( ) and RA CTI. The CTI lies between ...☆

Saremi F et al. Radiology 2008;247:658-668

©2008 by Radiological Society of North America

Left: atrial activation in typical atrial flutter (AFL).

Waldo A L Heart 2000;84:227-227


Schematic of the right atrium, as viewed in the right anterior oblique projection, illustrates the hypothesized reentrant circuit in typical atrial flutter (arrows) and the role of the

eustachian valve and ridge in forming a line of conduction block between...

Nakagawa H et al. Circulation 1996;94:407-424

Copyright © American Heart Association

Targets for typical or reverse typical atrial flutter ablation.

Waldo A L Heart 2000;84:227-227


Photographs of the right atrial septum taken in the right anterior oblique projection in two autopsy hearts to illustrate the anatomic relationship of the eustachian valve (EV) and

eustachian ridge (ER) to the inferior vena cava (IVC), coronary sinus ostium...


Sinus of KeithSinus of Keith

The atrial wall inferior to the orifice of the The atrial wall inferior to the orifice of the coronary sinus is usually pouch-like. coronary sinus is usually pouch-like.

It is often described as the sinus of Keith, oIt is often described as the sinus of Keith, or the sub-eustachian sinus. r the sub-eustachian sinus.

It forms the posterior part of the so-called It forms the posterior part of the so-called ‘flutter’ or ‘lateral’ isthmus, betwee‘flutter’ or ‘lateral’ isthmus, between the inferior caval vein and the tricuspid vn the inferior caval vein and the tricuspid valve alve

Orthogonal fluoroscopic views showing the positions of the 20 pole Halo catheter and the two pacing electrodes at the low lateral right atrium (LLRA) and coronary sinus ostium

(CSO).

Lin J et al. Heart 1999;81:73-81


Radiographs in the right anterior oblique projection (A) and left anterior oblique projection (B) show the positions of the multielectrode catheters in the right atrial appendage (RAA), His

bundle region (HB), around the tricuspid annulus (TA), along the eu...



Radiographs in the right anterior oblique projection show the ablation catheter (ABL) positions during ablation along the septal isthmus, beginning at the tricuspid annulus at the

level of the posterior margin of the coronary sinus ostium (A) and extending ...



Echocardiographic images of the ER and CTI

Echocardiographic images of a pouch on the CTI

Cavotricuspid isthmus angiography

Da Costa A et al. Eur Heart J 2006;27:1833-1840

The terminal crestThe terminal crest

(A) Opened right atrium in simulated right anterior oblique view to show the horseshoe shaped terminal crest (double dotted line).

Sánchez-Quintana D et al. Heart 2002;88:406-411

(A–C) Endocardial aspects of the lateral wall of the right atrium opened and displayed in the same orientation as fig 1B.

Sánchez-Quintana D et al. Heart 2002;88:406-411

Outflow tractOutflow tract

Right or LeftRight or Left

J Am Coll Cardiol. 2002;39(3):500-508.

Anatomic location of the origin of the arrhythmia, with corresponding 12-lead electrocardiographic morphology.

Note the different morphology in leads V1 and V2 with respect to the anatomic origin.

L = left coronary aortic sinus; N = noncoronary aortic sinus; R = right coronary aortic sinus; RVO

T = right ventricular outflow tract.

J Am Coll Cardiol. 2002;39(3):500-508.

Radiographic views of the mapping catheter (Map) at the successful ablation site in the left coronary sinus cusp. The mapping catheter was located below the ostium of the left main coronary artery).

Successful ablation from Successful ablation from aortic sinus cuspaortic sinus cusp

Health & Medicine

Cardiac Anatomy_20120909_中區