Elongated ascending aorta predicts a short distance between his-bundle potential recording site and coronary sinus ostium☆

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Structured abstract

Background

When performing catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT), it can be difficult to maintain a safe distance from the His recording site to avoid AV block in patients with a short distance between this recording site to the coronary sinus (CS) ostium (small triangle of Koch [TOK]). In this study, we sought to identify parameters predicting small TOK and test these parameters in patients undergoing AVNRT catheter ablation.

Methods

Twenty-eight patients who underwent catheter ablation of atrial fibrillation using a three-dimensional (3D) electroanatomical mapping system (EAM) with computed tomography (CT) merge (23 males; mean age, 65.8±12.1 years) were included. The shortest distance between the CS ostium and His recording sites (His-CSd) was measured on the EAM. Aortic (Ao) unfolding in chest X-ray scan, Ao angle to the LV, Ao length, Ao to the right ventricular distance, size of the Valsalva in the CT scan, and parameters of echocardiogram were evaluated. The identified parameters were subsequently tested as predictors for small TOK in patients undergoing AVNRT ablation.

Results

The size of TOK was associated with Ao length ( r = −0.70, p<0.01), left ventricular end-systolic dimension (LVDs) ( r = −0.51, p<0.01), and Ao unfolding. In patients with AVNRT, only Ao unfolding predicted a smaller TOK.

Conclusions

Small TOK was associated with longer Ao, larger LVDs, and Ao unfolding. Of these, Ao unfolding was associated with smaller TOK in patients with AVNRT.

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Most cited references 10

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Mechanical factors in arterial aging: a clinical perspective.

Michael F O'Rourke, Junichiro Hashimoto (2007)

The human arterial system in youth is beautifully designed for its role of receiving spurts of blood from the left ventricle and distributing this as steady flow through peripheral capillaries. Central to such design is "tuning" of the heart to arterial tree; this minimizes aortic pressure fluctuations and confines flow pulsations to the larger arteries. With aging, repetitive pulsations (some 30 million/year) cause fatigue and fracture of elastin lamellae of central arteries, causing them to stiffen (and dilate), so that reflections return earlier to the heart; in consequence, aortic systolic pressure rises, diastolic pressure falls, and pulsations of flow extend further into smaller vessels of vasodilated organs (notably the brain and kidney). Stiffening leads to increased left ventricular (LV) load with hypertrophy, decreased capacity for myocardial perfusion, and increased stresses on small arterial vessels, particularly of brain and kidney. Clinical manifestations are a result of diastolic LV dysfunction with dyspnea, predisposition to angina, and heart failure, and small vessel degeneration in brain and kidney with intellectual deterioration and renal failure. While aortic stiffening is the principal cause of cardiovascular disease with age in persons who escape atherosclerotic complications, it is not a specific target for therapy. The principal target is the smooth muscle in distributing arteries, whose relaxation has little effect on peripheral resistance but causes substantial reduction in the magnitude of wave reflection. Such relaxation is achieved through regular exercise and with the vasodilating drugs that are used in modern treatment of hypertension and cardiac failure.

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Age-associated elongation of the ascending aorta in adults.

Koichiro Hayashi, Marcel Tamaoki, Hirofumi Tanaka … (2008)

To determine whether human aorta lengthens with aging and to evaluate the impact of the hypothesized aortic elongation on pulse wave velocity (PWV) measurements. Although it is generally thought that the aorta becomes tortuous with aging, there has been no systematic study to date in healthy adults to determine if this is so. Such age-related aortic elongation may be a confounding factor for the PWV measurement in elderly people. Arterial lengths were computed by the 3-dimensional transverse magnetic resonance image arterial tracing of the aorta and carotid and iliac arteries in 256 apparently healthy adults (age 19 to 79 years). The ascending aorta was greater with advancing age (r = 0.72), whereas the lengths of the descending aorta and carotid and iliac arteries were not associated with age. The elongation of the ascending aorta was associated with the corresponding increases in aortic PWV (beta = 0.50) and brachial/aortic pulse pressure ratio (beta = 0.24), which is an index of pulse wave amplification. The straight distance between carotid and femoral sites (car-fem), the most popular arterial length measurement, overestimated the aortic length measured with the magnetic resonance image by approximately 25%. The most accurate arterial length estimation was the distance obtained by subtracting carotid length from the car-fem, with <5% difference from the magnetic resonance image-measured length. Because the ascending aorta was omitted or subtracted from the length estimation in PWV, the impact of age-related elongation of the aorta on PWV was small. The aorta lengthens with age, even in healthy humans, due primarily to the elongation of the ascending aorta. Age-related aortic elongation has little impact on PWV measurements, as the ascending aorta, which undergoes lengthening with age, is not included in the arterial length measurements.

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Morphology of the human atrioventricular node is age dependent: a feature of potential clinical significance.

K Waki, S. H. Kim, Reinhard Becker (2000)

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. 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. 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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Author and article information

Contributors

Kyoko Soejima

Journal

Journal ID (nlm-ta): J Arrhythm

Journal ID (iso-abbrev): J Arrhythm

Title: Journal of Arrhythmia

Publisher: Elsevier

ISSN (Print): 1880-4276

ISSN (Electronic): 1883-2148

Publication date PMC-release: 27 April 2017

Publication date (Print): August 2017

Publication date (Electronic): 27 April 2017

Volume: 33

Issue: 4

Pages: 318-323

Affiliations

[a ]Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan

[b ]Department of Radiology, Kyorin University School of Medicine, Tokyo, Japan

Author notes

[* ]Correspondence to: Kyorin University Hospital, Department of Cardiology, 6-20-2 Shinkawa, Mitaka-city, Tokyo, 181-8611, JAPAN. Fax: +0422 47 5512. skyoko@ 123456ks.kyorin-u.ac.jp

Article

Publisher ID: S1880-4276(17)30050-9

DOI: 10.1016/j.joa.2017.04.002

PMC ID: 5529593

PubMed ID: 28765763

SO-VID: 7e432596-e5fd-43a2-ae5a-0b39187f8c79

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 19 February 2017

Date revision received : 15 March 2017

Date accepted : 3 April 2017

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