Posterior Extensions of the Human Compact Atrioventricular Node

Inoue, Shigeaki; Becker, Anton E.

doi:10.1161/01.cir.97.2.188

Cited by 269 publications

(40 citation statements)

References 20 publications

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“…Transferring this into the clinical context, an AVNRT would be missed in 22 out of 100 patients if CS stimulation only were used, and an AVNRT would be missed in 8 out of 100 patients if only pacing from the HRA were used. While some studies have addressed the effect of anatomically different pacing sites on AVN conduction physiology [1][2][3][4][5][6][7][8], to the best of our knowledge there is no previous study with relevant patient numbers having systematically addressed the issue of AVNRT induction in correlation to pacing site. The observations presented in our study may thus motivate electrophysiologists to choose an additional pacing site when a clinically documented pSVT cannot be induced during EPS.…”

Section: Discussionmentioning

confidence: 99%

“…However, the obtained outcomes cannot be reliably referred to AVNRT patients because of their marginal participation in those studies. Moreover, different right (high, mid, or low) and left atrial pacing sites (via different CS sites, a persistent foramen ovale or a transseptal puncture) and EPS protocols seem to be the possible reason for conflicting results [1][2][3][4][5][6][7][8]. In all mentioned studies LA stimulation resulted in shorter AH intervals than did RA stimulation.…”

Section: Anterograde Avn Transmission During Pacingmentioning

confidence: 99%

“…While AVN transmission during RA pacing is well established and takes place via the rightward AVN extensions located in the region of the triangle of Koch (ToK) [5,9,10,13], AVN transmission during LA pacing remains controversial. The rightward anterior extension, considered as an electrophysiological substrate for the FP, travels from the anterior limbus of the fossa ovalis along the tendon of Todaro with the ERAA usually recorded at the same site recording the His bundle potential, in the apex of the ToK [4,9,13,[16][17][18][19]. The rightward posterior extension, which represents the electrophysiological substrate for the SP, travels within the ToK along the septal leaflet of the tricuspid annulus (TA) with the ERAA usually recorded between the TA and CS ostium, in the base of the ToK [9,12,13,19].…”

Section: Anterograde Avn Transmission During Pacingmentioning

confidence: 99%

“…Previous reports have documented that the site of atrial stimulation can affect AVN function and the ability to initiate dual AVN pathways and AVNRT [1][2][3][4][5][6][7][8].…”

Section: Electrophysiological Properties Of the Av Junction And Inducmentioning

confidence: 99%

“…Clinical studies in humans have shown the site of atrial stimulation to influence atrioventricular (AV) conduction times and refractory periods, the demonstration of dual atrioventricular nodal (AVN) pathways, and induction of AVN reentry [1][2][3][4][5][6][7][8]. These studies often found conflicting results that could be explained by different atrial pacing sites and the electrophysiological study (EPS) protocol applied.…”

Section: Introductionmentioning

confidence: 99%

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The effect of atrial pacing site on electrophysiological properties of the atrioventricular junction and induction of atrioventricular nodal reentry in patients with typical atrioventricular nodal reentrant tachycardia

Kiedrowicz

Kaźmierczak²,

Wielusiński³

2017

Kardiol Pol

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A b s t r a c tBackground: Clinical studies in humans have shown the site of atrial stimulation to influence atrioventricular (AV) conduction times and refractory periods, the demonstration of dual AV nodal (AVN) pathways, and induction of AVN reentry. These studies often found conflicting results. Moreover, among enrolled patients a minority of them were found to have AVN reentrant tachycardia (AVNRT). Aim:The purpose of this study was to investigate the effect of right and left atrial pacing on the electrophysiological properties of the AV junction in the typical AVNRT population.Methods: Ninety-two consecutive patients with typical AVNRT were included. Atrial pacing was performed from the high right atrium (HRA) and the left atrium via the proximal coronary sinus (CS). Results:Stimulation from either the HRA or the CS could result in dual AVN physiology and AVNRT. No site-dependent differences in the ease of induction of dual AVN pathways with variability of initiation from either site were found. However, AVNRT was easier to induce from the HRA. With CS pacing the leftward but not the rightward AVN approaches were the entry point to the AV node because of significantly shorter AH conduction times compared to HRA pacing. Conduction over the leftward AVN extensions could initiate the tachycardia with significantly shorter critical AH interval compared to conduction over the rightward AVN extensions; however, the AH interval during AVNRT and its cycle length were not significantly different. Conclusions:Rightward and leftward AVN extensions are regular features of the AV node. Their different electrophysiological properties lead to variation in the demonstration of discontinuous AVN conduction and AVNRT during right and left atrial pacing. Despite the observation that the left AVN extensions could compose the entry point to the reentrant circuit, there is no evidence that they constitute the critical component of sustained typical AVNRT.

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Section: Discussionmentioning

confidence: 99%

Section: Anterograde Avn Transmission During Pacingmentioning

confidence: 99%

Section: Anterograde Avn Transmission During Pacingmentioning

confidence: 99%

“…Previous reports have documented that the site of atrial stimulation can affect AVN function and the ability to initiate dual AVN pathways and AVNRT [1][2][3][4][5][6][7][8].…”

Section: Electrophysiological Properties Of the Av Junction And Inducmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

The effect of atrial pacing site on electrophysiological properties of the atrioventricular junction and induction of atrioventricular nodal reentry in patients with typical atrioventricular nodal reentrant tachycardia

Kiedrowicz

Kaźmierczak²,

Wielusiński³

2017

Kardiol Pol

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The AV junction region of the heart: A comprehensive study correlating gross anatomy and direct three-dimensional analysis. Part I. Architecture and topography

Racker

1999

Anat. Rec.

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There is little detailed knowledge of the architecture of the AV junction region, the cytoarchitecture of the AV node or of its atrial connections. In the present study, the gross anatomy and topography of intracardiac structures in 21 adult canine hearts were photographically compared in whole and dissected hearts and tissue blocks and serial histologic sections made in three orthogonal planes. There are seven major new findings: 1) A coronary sinus fossa exists at the crux of the heart. It separates the right medial atrial wall (MAW) superoposterior region from the left atrium, its floor is the coronary sinus, and it carries the medial atrionodal bundle and proximal AV bundle on its right wall. 2) The posterior MAW forms two isolated bridges of myocardium as it surrounds the coronary sinus ostium, is isolated from the sinus venarum with crista terminalis and interatrial septum-by the floor of the inferior vena cava, and the narrow bridges link the posterior atrial wall to the mid MAW. 3) The tendon of Todaro has both epicardial and endocardial exposures, terminates in the superoposterior MAW and its medial aspect is adjacent sequentially to the medial atrionodal bundle and proximal AV bundle. 4) Only ordinary myocardium contacts the anulus fibrosus. 5) The ventricular septum's shoulder is humped shape posteriorly, is completely overlaid by anular myocardium and the medial leaflet and is joined by struts of papillary muscle. 6) The membranous septum joins the anterior ventricular septum to the crista supraventricularis, forms part of the posterior noncoronary and right aortic valve sinus walls and encases the right bundle branch. 7) The specialized conduction tissues, the superior, medial and lateral atrionodal bundles, the proximal AV bundle, AV node, distal AV bundle and right bundle branch are subjacent to MAW epicardium outside the right atrium, share regular intracardiac relationships with topographic landmarks and the medial atrionodal bundle, terminal superior atrionodal bundle, the proximal AV bundle and AV node are aligned to the medial leg of Koch's triangle. Thus, atrial myocardium of the AV junction region is that of the MAW. The floor of the inferior vena cava forms a natural barrier to impulse transmission along the full extent of the posterior MAW. The specialized tissues are outside of the MAW. Anatomic landmarks form reliable topographic landmarks for the specialized AV junction region tissues. A knowledge of the association of the specialized conduction tissues with specific regions of the MAW is useful in localizing the tissues and along with the coronary sinus fossa provides several extracardiac approaches.

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Anatomy of the human atrioventricular junctions revisited

2000

Self Cite

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There have been suggestions made recently that our understanding of the atrioventricular junctions of the heart is less than adequate, with claims for several new findings concerning the arrangement of the ordinary working myocardium and the specialised pathways for atrioventricular conduction. In reality, these claims are grossly exaggerated. The structure and architecture of the pathways for conduction between the atrial and ventricular myocardium are exactly as described by Tawara nearly 100 years ago. The recent claims stem from a failure to assess histological findings in the light of criterions established by Monckeberg and Aschoff following a similar controversy in 1910. The atrioventricular junctions are the areas where the atrial myocardium inserts into, and is separated from, the base of the ventricular mass, apart from at the site of penetration of the specialised axis for atrioventricular conduction. There are two such junctions in the normal heart, surrounding the orifices of the mitral and tricuspid valves. The true septal area between the junctions is of very limited extent, being formed by the membranous septum. Posterior and inferior to this septal area, the atrial myocardium overlies the crest of the ventricular septum, with the atrial component being demarcated by the landmarks of the triangle of Koch. The adjacent structures, and in particular the so‐called inferior pyramidal space, were accurately described by McAlpine (Heart and Coronary Arteries, 1975). Thus, again there is no need for revision of our understanding. The key to unravelling much of the alleged controversy is the recognition that, as indicated by Tawara, the atrioventricular node becomes the atrioventricular bundle at the point where the overall axis for conduction penetrates into the central fibrous body. There are also marked differences in arrangement, also described by Tawara, between the disposition of the conduction axis in man as compared to the dog. Anat Rec 260:81–91, 2000. © 2000 Wiley‐Liss, Inc.

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Posterior Extensions of the Human Compact Atrioventricular Node

Abstract: The human compact AV node contains rightward and leftward posterior extensions, with the right extension close to the tricuspid annulus. It is tempting to speculate that these extensions are involved in "slow pathway" conduction.

Cited by 269 publications

References 20 publications

The effect of atrial pacing site on electrophysiological properties of the atrioventricular junction and induction of atrioventricular nodal reentry in patients with typical atrioventricular nodal reentrant tachycardia

The effect of atrial pacing site on electrophysiological properties of the atrioventricular junction and induction of atrioventricular nodal reentry in patients with typical atrioventricular nodal reentrant tachycardia

The AV junction region of the heart: A comprehensive study correlating gross anatomy and direct three-dimensional analysis. Part I. Architecture and topography

Anatomy of the human atrioventricular junctions revisited

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