Anatomical relevance of ablation to the pulmonary artery root: Clinical implications for characterizing the pulmonary sinus of Valsalva and coronary artery

Abstract

Both the left and RASs are intimately related to the aortic root. The LAS is more often close to LMCA, LAD, and the LASV. The anterior sinus is more frequently related to LAD than LMCA. This information may help heighten operator awareness of safety for increasingly performed complex procedures in this area.

Living anatomy of the pulmonary root

“…In our clinical experience, such intracardiac echocardiography allows real time assessment of the relationship between the pulmonary valvar sinuses and the coronary arteries. In this regard, this study by Dong et al clearly shows how an ablation catheter that is wedged tightly within the left adjacent pulmonary valvar sinus can be in close proximity to the main stem of the left coronary artery and the proximal segment of the left anterior descending artery. With a catheter in this location, it is certainly possible to injure the coronary arteries, especially when using high contact force with irrigated ablation.…”

“…The processes of dissection required to reveal these relationships are likely to introduce errors when attempts are made to take measurements between anatomic landmarks. As Dong et al show, these features can be demonstrated with exquisite accuracy using virtual dissection of computed tomographic datasets, with the measurements made with comparable accuracy and the illustrations being self‐explanatory. It should be also noted that the authors distinguish clearly between the valvar sinuses and the leaflets that they support.…”

“…These are the points at which the semilunar hinges of the valvar leaflets are attached adjacent to each other at the sinutubular junctions. There can be deviation in this alignment when either arterial root is rotated, as discussed by Dong et al . The white dotted line in the right‐hand panel shows the free‐standing infundibular sleeve, which lifts the leaflets of the pulmonary root away from the base of the ventricular cone [Color figure can be viewed at wileyonlinelibrary.com]…”

“…In the current issue of the Journal, Dong et al offer support for the premise that analysis of computed tomographic datasets now provides the gold standard for demonstration of cardiac anatomy . Not only does the technique permit relationships to be shown with accuracy not achievable in the autopsy room, it also has the inestimable advantage of showing the anatomy in attitudinally appropriate fashion .…”

“…In this instance, dissections of anatomic specimens are helpful, since they show how the semilunar hinge lines cross the anatomic infundibulo‐pulmonary junction (Figure , left–hand panel). Dong et al point to the significance of the attachments of the semilunar hinges of the leaflets in incorporating myocardium at the bases of each of the 3 sinuses of the pulmonary root . In their Figure , they correctly show how the nadirs of attachment of these hinges form the anatomic infundibulo‐pulmonary junction.…”