Correlative Anatomy for the Electrophysiologist, Part I: The Pericardial Space, Oblique Sinus, Transverse Sinus

Abstract

There is an increasing need for invasive electrophysiologists to appreciate the exact anatomy of the epicardial space and the coronary veins. The location of the epicardial fat, the complementary relationship with the main cardiac veins, and the location of sensitive structures (arteries, phrenic nerve, esophagus) have become required knowledge for electrophysiologists, and accessing the epicardial space with this thorough knowledge of the pericardial sinuses and recesses is essential to allow radiographic correlation during catheter manipulation. In this review, we briefly describe the anatomy of the pericardial space and then discuss the specific correlation for the invasive electrophysiologist, highlighting epicardial access, catheter navigation, and avoidance of collateral injury with specific attention to the important recesses of the pericardial space, their regional anatomy, and radiographic correlation when navigating catheters to these locations. We also discuss the anatomy of the main cardiac veins in the context of catheter mapping and ablation of the epicardial substrate through the venous system and without subxiphoid pericardial access. In Part I of this two-part series, we discuss the regional anatomy of the pericardial space, oblique sinus, and transverse sinus.

Protecting the right phrenic nerve during catheter ablation: Techniques and anatomical considerations

“…We feel that this is largely related to the fact that the RPN may be immediately adjacent to pericardial reflections and recesses where positioning a large balloon is difficult 8, 9. In this situation, as was the case with our patient, inflating a balloon may not completely solve the problem.…”

ICE Imaging of the Left Atrial Appendage

“…The CS itself has no direct anatomic relationship with the LAA . However, the great cardiac vein (GCV) and proximal anterior interventricular vein (AIV) lie in proximity in a complex fashion, sequentially, with various parts of the LAA.…”

“…The RVOT is the most anterior structure in the normal human heart, while the LAA is the most anterior structure of the LA and in fact lies alongside and to the left of the distal RVOT and PA. The distal PA and LPA then course directly superior and the posterosuperiorly to the LAA roof, separated only by the transverse sinus of the pericardial space . Inferior branches of the LPA (lingula and lower lobes) are located left and lateral to the LAA.…”

Epicardial Ventricular Tachycardia

“…), which is also used to enter the epidural space when administering epidural anesthesia (typically approximately 100 mm in overall length and a 1.5-mm outer diameter). 9,15 Inadvertent RV puncture is not rare, but is usually benign if only the needle or wire has entered the chamber in a patient who is not anticoagulated. The puncture needle approaches the site with a shallow angle in order to penetrate the skin and slide under the rib cage.…”