Cardiac Conduction System: Delineation of Anatomic Landmarks With Multidetector CT

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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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Most cited references 54

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Gross and microscopic anatomy of the human intrinsic cardiac nervous system

J. Armour, David Murphy, Bing-Xiang Yuan … (1997)

The extent and locations of intrinsic cardiac ganglia on the human heart were investigated to facilitate studying their function. The locations and number of major intrinsic cardiac ganglia were determined in six human hearts by means of microdissection following methylene blue staining. Light and electron microscopic analyses were performed on right atrial and cranial medial ventricular ganglia obtained from 12 other human hearts. Gross anatomy: Collections of ganglia associated with nerves, i.e., ganglionated plexuses, were observed consistently in five atrial and five ventricular regions. Occasional ganglia were located in other atrial and ventricular regions. Atrial ganglionated plexuses were identified on 1) the superior surface of the right atrium, 2) the superior surface of the left atrium, 3) the posterior surface of the right atrium, 4) the posterior medial surface of the left atrium (the latter two fuse medially where they extend anteriorly into the interatrial septum), and 5) the inferior and lateral aspect of the posterior left atrium. Ventricular ganglionated plexuses were located in fat 1) surrounding the aortic root, 2) at the origins of the right and left coronary arteries (the latter extending to the origins of the left anterior descending and circumflex coronary arteries), 3) at the origin of the posterior descending coronary artery, 4) adjacent to the origin of the right acute marginal coronary artery, and 5) at the origin of the left obtuse marginal coronary artery. Microscopic anatomy: Ganglia ranged in size from those containing a few neurons to large ganglia measuring up to 0.5 x 1 mm. The human heart is estimated to contain more than 14,000 neurons. Neuronal somata varied in size and shape. Many axon terminals in intrinsic cardiac ganglia contained large numbers of small, clear, round vesicles that formed asymmetrical axodendritic synapses, whereas a few axons contained large, dense-cored vesicles. The human intrinsic cardiac nervous system is distributed more extensively than was considered previously, most of its ganglia being located on the posterior surfaces of the atria and superior aspect of the ventricles. Each ganglion therein contains a variety of neurons that are associated with complex synaptology.

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Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy.

Wei-Shiang Lin, Ching-Tai Tai, Ming-Hsiung Hsieh … (2003)

Most of the ectopic beats initiating paroxysmal atrial fibrillation (PAF) originate from the pulmonary vein (PV). However, only limited data are available on PAF originating from the non-PV areas. Two hundred forty patients with a total of 358 ectopic foci initiating PAF were included. Sixty-eight (28%) patients had AF initiated by ectopic beats (73 foci, 20%) from the non-PV areas, including the left atrial posterior free wall (28, 38.3%), superior vena cava (27, 37.0%), crista terminalis (10, 3.7%), ligament of Marshall (6, 8.2%), coronary sinus ostium (1, 1.4%), and interatrial septum (1, 1.4%). Catheter ablation eliminated AF with acute success rates of 63%, 96%, 100%, 50%, 100%, and 0% in left atrial posterior free wall, superior vena cava, crista terminalis, ligament of Marshall, coronary sinus ostium, and interatrial septum, respectively. During a follow-up period of 22+/-11 months, 43 patients (63.2%) were free of antiarrhythmic drugs without AF recurrence. Ectopic beats initiating PAF can originate from the non-PV areas, and catheter ablation of the non-PV ectopy has a moderate efficacy in treatment of PAF.

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Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart.

N Pauziene, Dainius H. Pauza, R Stropus … (2000)

Concomitant with the development of surgical treatment of cardiac arrythmias and management of myocardial ischemia, there is renewed interest in morphology of the intrinsic cardiac nervous system. In this study, we analyze the topography and structure of the human epicardiac neural plexus (ENP) as a system of seven ganglionated subplexuses. The morphology of the ENP was revealed by a histochemical method for acetylcholinesterase in whole hearts of 21 humans and examined by stereoscopic, contact, and bright-field microscopy. According to criteria established to distinguish ganglionated subplexuses, they are epicardiac extensions of mediastinal nerves entering the heart through discrete sites of the heart hilum and proceeding separately into regions of innervation by seven pathways, on the courses of which epicardiac ganglia, as wide ganglionated fields, are plentifully located. It was established that topography of epicardiac subplexuses was consistent from heart to heart. In general, the human right atrium was innervated by two subplexuses, the left atrium by three, the right ventricle by one, and the left ventricle by three subplexuses. The highest density of epicardiac ganglia was identified near the heart hilum, especially on the dorsal and dorsolateral surfaces of the left atrium, where up to 50% of all cardiac ganglia were located. The number of epicardiac ganglia identified for the human hearts in this study ranged from 706 up to 1,560 and was not correlated with age in most heart regions. The human heart contained on average 836 +/- 76 epicardiac ganglia. The structural organization of ganglia and nerves within subplexuses was observed to vary considerably from heart to heart and in relation to age. The number of neurons identified for any epicardiac ganglion was significantly fewer in aged human compared with infants. By estimating the number of neurons within epicardiac ganglia and relating this to the number of ganglia in the human epicardium, it was calculated that approximately 43,000 intrinsic neurons might be present in the ENP in adult hearts and 94,000 neurons in young hearts (fetuses, neonates, and children). In conclusion, this study demonstrates the total ENP in humans using staining for acetylcholinesterase, and provides a morphological framework for an understanding of how intrinsic ganglia and nerves are structurally organized within the human heart. Copyright 2000 Wiley-Liss, Inc.

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Author and article information

Journal

Journal ID (nlm-ta): Indian Pacing Electrophysiol J

Journal ID (publisher-id): Indian Pacing Electrophysiol J

Title: Indian Pacing and Electrophysiology Journal

Publisher: Indian Heart Rhythm Society

ISSN (Electronic): 0972-6292

Publication date Collection: Nov-Dec 2009

Publication date (Electronic): 01 November 2009

Volume: 9

Issue: 6

Pages: 318-333

Affiliations

Department of Radiological Sciences of University of California, Irvine

Author notes

Address for correspondence: Farhood Saremi, MD, Department of Radiological Sciences, University of California Irvine, UCI Medical center, 101 The City Drive, Route 140, Orange, CA 92868-3298. E-mail: fsaremi@ 123456uci.edu

Article

Publisher ID: ipej090318-00

PMC ID: 2766580

PubMed ID: 19898655

SO-VID: 3038447c-81d7-4de7-b8e8-f968f75e54d4

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cardiac Conduction System: Delineation of Anatomic Landmarks With Multidetector CT

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Abstract

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Cardiovascular Innovations and Applications

Most cited references 54

Gross and microscopic anatomy of the human intrinsic cardiac nervous system

Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy.

Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart.

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