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An Atlas of Left Atrium for Electrophysiology Beginners

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An Atlas of Left Atrium for Electrophysiology Beginners An Atlas of Left Atrium for Electrophysiology Beginners ISBN: 978-1-946628-17-6 1 An Atlas of Left Atrium for Electrophysiology Beginners Cismaru Gabriel* Department of Cardiology, Rehabilitation Hospital-Iuliu Hatieganu University of Medicine and Pharmacy, Romania *Corresponding Author Department of Cardiology, Electrophysiological laboratory, Rehabilitation Hospital-Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania Published By : Juniper publishers Inc. United States March 25, 2019 2 Gabriel Cismaru M.D., PhD., Dr. Cismaru Gabriel received his doctorate in medicine from the “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj- Napoca in 2016 and earned his MD degree from the same university in 2005. After completing his residency in cardiology, Dr. Cismaru began his electrophysiology fellowship at the Institute Lorrain du Coeur et des vaisseaux Louis Mathieu, Nancy-France. In 2011 started to work at the Electrophysiology Laboratory of the Rehabilitation Hospital Cluj-Napoca. He has authored or coauthored The new advances in cardiac arrhythmias techniques increased the success rate of complete treatment peer-reviewed articles, book chapters in the field of electrophysiology and cardiac pacing. centers. Knowing the anatomy of the left atrium is a cornerstone for the EP beginner. The topic is of great interestfor patients to electrophysiologists suffering from arrhythmias. dealing with Catheter catheter ablation ablation of atrial of all fibrillation types of left is routinely atrial arrhythmias performed (atrial in EP fibrillation, atrial tachycardia, atrial flutter, premature atrial contractions). An Atlas of Left Atrium for Electrophysiology Beginners List of Contents S.No. Content Page No. 1 Foreword 5 2 Introduction 6 3 Chapter 1: Anatomy of the Left Atrium 7-19 3.1. Gross anatomical structure of the left atrium 8-13 3.2. Fossa ovalis 13-14 3.3. Pulmonary veins 14-15 3.4. The mitral isthmus 15 3.5. Left atrial appendage 15-16 3.6. Relationship of the left atrium with other anatomical structures esophagus 16-17 3.6.1. The Phrenic Nerves 17 3.6.2. Aorta 18-19 4 Chapter 2: Ray Anatomy of the Left Atrium 20-26 5 Chapter 3: Transthoracic Echographic Anatomy of the Left Atrium 27-36 6 Chapter 4 : Transesophageal Echographic Anatomy of the Left Atrium 37-48 7 Chapter 5: Intracardiac Echographic Anatomy of the Left Atrium 49-71 8 Chapter 6: Computed Tomography of the Left Atrium 72-87 9 Chapter 7: Image integration 88-105 10 Conclusion 105-106 11 References 106 An Atlas of Left Atrium for Electrophysiology Beginners An Atlas of Left Atrium for Electrophysiology Beginners Foreword The goal of electrophysiology education is to prevent and treat arrhythmias. In this regard, atrial leftfibrillation atrial anatomy. is the most rewarding arrhythmia to educate beginners, since it is very frequent and leads to thrombotic complications: stroke and acute limb ischemia. The cornerstone of atrial fibrillation ablation is The beginning electrophysiologist is frequently confronted by a paradox: diagrams that illustrate the left atrium in many arrhythmia books in a simplified, artwork, cartoon-like manner is easy to understand, but helpdifficult bridge to relate the gap to thebetween real anatomy. the more In simplistic turn anatomical diagrams photographs and the complex fail to anatomicalshow some structureimportant of features the left atriumand relationships as seen on with the anatomyneighbouring table. structures. CT images This are inatlas color filled because with echo they and were CT integrated images was with prepared in three- to dimensional mapping systems, and each heart chamber was colored differently. The training of the young electrophysiologist is mostly focused of how to interpret electrograms and makes the anatomy of the heart the fundament of electrophysiologist. As the left atrium is the origin of arrhythmia mechanisms. However, the origin of arrhythmias in specific structures of the heart chambers to review the anatomy of the left atrium as viewed during imaging examinations: echocardiography or computedatrial arrhythmias tomography. such as:A special focal atrial chapter tachycardia, is dedicated perimitral to the imageatrial flutter,integration atrial technique fibrillation, of the the book left atrial aims navigation inside the left atrium and pulmonary veins. computed tomography which is widely used nowadays for catheter ablation of atrial fibrillation as it permits This book is dedicated to fellows in training and allied health professionals and not for experienced operators. If you think that the book is too easy for you, it means that you know already too much. It is not intended for experts in electrophysiology. Everybody wants to be an expert but forgets that several steps need to be made, and electrophysiology should be learned step by step without missing the beginner stage. Being a beginner. What a wonderful thing to be! There is no need to look like you know everything. You have a long journey full of new things to discover. Stop waiting. Start with the Beginner’s Atlas. 5 An Atlas of Left Atrium for Electrophysiology Beginners Introduction for Atrialnon-pharmacological fibrillation is an treatment,arrhythmia likeincompletely catheter-based understood. radiofrequency Many cardiac ablation diseases or cryoablation.can lead to atrial The cornerstonefibrillation, and of an the ablation pathogenesis technique of consiststhe arrhythmia in targeting is multifactorial. the junction betweenNewer techniques left atrium have and pulmonarydeveloped veins. Left atrium has different shapes depending on the diameter and volume from discoid if non-dilated to spherical in severe dilated forms and the pulmonary veins may present anomalies of shape and number evaluated by different imagistic approaches: 2 D echo, transesophageal echo, intracardiac echo, computed tomographymaking the ablationand detail more the importancedifficult. We of discuss the neighboring in the following structures chapters in the thecatheter anatomy ablation of the technique. left atrium This function is particularly relevant for patients with congestive heart failure or in patients with diastolic heartThe failure. left atrium modulates the left ventricular filling contributing to about 30% of the cardiac output. Because of the receptors that can be found at the atrial level it acts like a volume sensor, and also a “barometer” of the diastolic function of the left ventricle. The left atrium also secrets the natriuretic peptides and communicates with the renin-angiotensin-aldosteron system pathway. In the last years the left atrium was demonstrated to be a biomarker in cardiovascular diseases. 6 An Atlas of Left Atrium for Electrophysiology Beginners An Atlas of Left Atrium for Electrophysiology Beginners Chapter 1 7 An Atlas of Left Atrium for Electrophysiology Beginners Anatomy of the Left Atrium Gross anatomical structure of the left atrium The left atrium is one of the 4 chambers of the heart: left ventricle, left atrium, right ventricle and right and posterior the descendant aorta. Superior to the left atrium the bifurcation of the pulmonary trunk can atrium (Figure 1.1). It is a posterior structure, that has anterior the left ventricle with the ascending aorta be seen, having 2 branches: left pulmonary artery and right pulmonary artery (Figure 1.2). Figure 1.1: Three-D reconstruction of the left atrium, right atrium, left ventricle, right ventricle and aorta. From an inferior view the left atrium is in the posterior part of the left ventricle. Please note that LIPV is in contact with the descendant aorta and the RSPV is behind the superior vena cava. Figure 1.2: Three-D reconstruction of the heart and great vessels. From a posterior view, left atrium lies behind the left ventricle and aorta lies behind the left atrium. In fact, the left atrium is an anatomical structure between ascendant and descendant aorta. The RSPV is behind the superior vena cava and the LIPV in front of the descendant aorta. The left atrial appendage is near the left pulmonary artery. The left atrium is derived from the primitive atrium, part of the heart tube. The single common pulmonary vein drains into the primitive atrium which expands taking parts from the vein. By evolution of the single pulmonary vein, 4 veins appear which open into the left atrium. This part of the LA derived from 8 An Atlas of Left Atrium for Electrophysiology Beginners An Atlas of Left Atrium for Electrophysiology Beginners the primitive pulmonary vein remains smooth, while the left auricle becomes rough and trabeculated being derived from the primitive atrium. The left atrium has 4 different parts: a) the posterior part called venous part that receives blood from the four pulmonary veins; b) the vestibule which continues with the mitral ring and mitral valve; this level clot formation appears; c) the left atrial appendage, a structure that is important for stroke prevention as most of the time at atrium presents 5 distinct walls: anterior, superior, lateral, septal and posterior. The anterior wall comes d) the septal portion of the LA with the interatrial septum and the fossa ovalis (Figure 1.3-1.7). The left into contact with the posterior wall of the ascendant aorta (Figure 1.8-1.14). Figure 1.3: Posterior all the left atrium. Four veins are visible: 2 on the right side and 2 on the left side. Superior veins have a larger diameter compared to inferior veins. In the anterior region of the left atrium, LAA is present. Figure 1.4: Three-D reconstruction of the left atrium. Superior view. The left atrial appendage is an anterior structure; in can be seen in front of the LSPV. 9 An Atlas of Left Atrium for Electrophysiology Beginners Figure 1.5: Three D reconstruction of the left atrium. Anterior wall of the L. In front of the image the mitral valve can be seen. Mitral annulus has 2 important diameters: a latero-lateral diameter and an antero-posterior diameter. Figure 1.6: Three-D reconstruction of the left atrium. Septal wall of the LA represented by the interatrial septum and fossa ovalis.
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