Anatomic characteristics of the mitral isthmus region: The left atrial appendage isthmus as a possible ablation target

Hołda, Mateusz K.; Koziej, Mateusz; Hołda, Jakub; Tyrak, Kamil; Piątek, Katarzyna; Bolechała, Filip; Klimek‐Piotrowska, Wiesława

doi:10.1016/j.aanat.2016.11.011

Cited by 16 publications

(39 citation statements)

References 25 publications

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“…These proportions are reversed for the middle (2.1 ± 0.7 vs.3.0 ± 1.5 mm, P < 0.0001) and inferior (or mitral annulus) sectors (1.8 ± 0.6 vs.2.7 ± 1.3 mm, P < 0.0001) (Hołda et al, ). Moreover, in 95.5% of cases, the LAA isthmus is devoid of additional, differently‐organized muscular and membranous structures (e.g., crevices, recesses, muscular bridges) while they are present in the mitral isthmus in 34.5% of hearts (Hołda et al, ). The main fear associated with procedures inside or around the LAA is the risk of perforation because of the very thin walls of the appendage (Cabrera et al, ).…”

Section: Discussionmentioning

confidence: 99%

“…The mean myocardial thickness inside the LAA measured in this study was 1.9 ± 0.7 mm (0.5–3.6 mm), which is comparable to the thickness at the mitral annulus end of the LAA isthmus and the pulmonary vein end of the mitral isthmus. It should also be emphasized that the article‐thin atrial wall, which is usually observed in the mitral isthmus area (especially inside the crevices or recesses), rarely appears within the LAA isthmus region, where the wall is significantly thicker (Cabrera et al, ; Hołda et al, ). Also, in the region of the cavotricuspid isthmus, we should expect a very thin area within the posterior (or membranous) part of the isthmus (Klimek‐Piotrowska et al, ).…”

Section: Discussionmentioning

confidence: 99%

“…Recently, an additional ablation line was proposed, the LAA isthmus, located between the LAA ostium and the mitral valve annulus. This line has two major advantages over the mitral isthmus line: it is significantly shorter and has considerably fewer unwanted structures that can entrap the catheter or cause it to adhere incompletely (Hołda et al, ). Other lines (e.g., the superolateral mitral isthmus line) are also located near the LAA ostium base (Maurer et al, ).…”

Section: Introductionmentioning

confidence: 99%

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Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line

Hołda

Strona

et al. 2018

Clinical Anatomy

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Electric isolation of the left atrial appendage (LAA) and linear ablations in the area of the LAA base are gaining popularity. However, very little is known about the myocardial architecture and the presence of epicardial blood vessels within this region, which could significantly influence the course of such procedures. We examined 200 autopsied hearts (22.5% females, 46.7 ± 16.8 years old). The LAA isthmus (i.e., the line between the LAA ostium and the mitral annulus) was cut longitudinally. The myocardium was thickest at the LAA end of the isthmus (2.4 ± 0.7 mm) followed by its middle sector (2.1 ± 0.7 mm) inside the LAA, 5 mm from its ostium (1.9 ± 0.7 mm), and the mitral annulus end of the isthmus (1.8 ± 0.6 mm) (P < 0.0001). At least one artery was found in 96.5% of all samples (89.5% were single branched, 7% had two branches). The great cardiac vein was found in 77.0% and the left marginal vein in 2.5%. The artery was interposed between the endocardium and the great cardiac vein in 31.5% of cases. The smallest distance between the endocardium and the artery was 0.5 mm and between the endocardium and the vein was 0.7 mm. In total, we were able to distinguish fifteen different types of vascular arrangements within the LAA isthmus line in this study. The myocardium within the LAA isthmus is thickest at its LAA end. The left circumflex coronary artery branches are the most frequently‐occurring vessels within the isthmus and are present in almost all cases, while the great cardiac vein is present in three quarters of hearts. Clin. Anat. 31:1024–1030, 2018. © 2018 Wiley Periodicals, Inc.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line

Hołda

Strona

et al. 2018

Clinical Anatomy

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“…However, alternative locations are also used in the invasive treatment of AF and perimitral flutter. The most important ones include the left atrial medial isthmus, the superolateral mitral isthmus, the isthmus of the left atrial appendage, as well as the roof, the anteromedial, and anterolateral lines of the atrium …”

Section: Introductionmentioning

confidence: 99%

Topographic characteristics of the left atrial medial isthmus

Piątek‐Koziej

Hołda

Bolechała

et al. 2019

Pacing Clinical Electrophis

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Background The purpose of this study was to provide detailed topography of the left atrial medial isthmus (situated between the right inferior pulmonary vein ostium and the medial part of the mitral annulus). Methods Two hundred human hearts (Caucasian, 22.5% females, 48.7 ± 4.9 years old) were investigated. Results The mean length of the medial isthmus was 42.4 ± 8.6 mm. Additionally, the medial isthmus line was divided by the oval fossa into three sections with equal mean lengths (upper: 14.2 ± 7.2 vs middle: 14.1 ± 6.1 vs lower: 14.9 ± 4.6 mm; P > .05). The left upper section of the atrial wall was thinner than the lower section (2.5 ± 1.1 vs 3.4 ± 1.6 mm; P < .0001). This study noted three separate spatial arrangements of the isthmus line. Type I (54.5%) had an oval fossa located outside the isthmus line; type II (32.5%) had an oval fossa crossed by the isthmus line, and type III (13.0%) had an oval fossa rim located tangentially to the isthmus line. In 68.5% of the examined specimens, the isthmus area had a smooth surface. Conversely, the remaining 31.5% had additional structures within its borders such as diverticula, recesses, and tissue bridges. Conclusion This study is the first to describe the morphometric and topographical features of the left atrial medial isthmus. Interventions within the medial isthmus line should be performed cautiously, especially when they are transected by the oval fossa (32.5%). Careful navigation of the area is also recommended due to the possibility of existent additional structures. The latter could lead to catheter entrapment during ablation procedures.

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“…However, the “2C3L” strategy may also be complicated and time-consuming, especially in patients with unfavorable anatomical conditions. This in turn may also be associated with increased doses of radiation (5, 6). …”

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confidence: 99%

Radiationless transseptal puncture

Hołda¹

2017

Anatol J Cardiol

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Anatomic characteristics of the mitral isthmus region: The left atrial appendage isthmus as a possible ablation target

Cited by 16 publications

References 25 publications

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line

Topographic characteristics of the left atrial medial isthmus

Radiationless transseptal puncture

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