Fluoroscopic Cardiac Anatomy for Catheter Ablation of Tachycardia

Abstract

The understanding of cardiac anatomy is crucial for the interventional arrhythmologist. In spite of the introduction of several nonfluroscopic navigational tools, some of them capable of reconstructing a computer-based surrogate of the endocardial surface of the heart cavities, simple fluoroscopy with or without the aid of angiographic techniques is still the most widely used method to guide mapping and ablation procedures. In some instances, fluoroscopic and angiographic methods have no possible replacement to unravel certain arrhythmologically useful anatomic landmarks. New interpretations of cardiac architecture show the need to challenge some traditional anatomic views, like the concept of septums within the heart. The fluoroscopic anatomy also needs to be reconsidered in the light of the new attitudinally oriented nomenclature. This article presents an overview of the fluoroscopic anatomy of the heart. When pertinent, some anatomical concepts are discussed in more detail like the triangle of Koch, the pyramidal space, and the interatrial groove. In the sections on the atria and on the ventricles, the authors focus on the anatomic information that is relevant for mapping and ablation from a fluoroscopic viewpoint, providing some hints on how best to depict the morphological features from the stance of the interventional arrhythmologist. The Visible Human Slice and Surface Server using data sets from the Visible Human Male and Female Project, has been used to facilitate the understanding of the fluoroscopic anatomy.

Optimal angulations for obtaining an en face view of each coronary aortic sinus and the interventricular septum: Correlative anatomy around the left ventricular outflow tract

“…Taken together, these results imply that the angles for the perpendicular and parallel views of the IVS are around RAO 50 and LAO 40 , respectively, which is also consistent with previous reports (Farr e et al, 2002;Mond et al, 2007;Farr e et al, 2010). The present findings could also be applied for a procedural target around the interatrial septum, which is nearly parallel to the IVS (Gonzalez et al, 2001), and the coronary sinus and atrioventricular annulus, which are nearly perpendicular to the IVS (De Ponti et al, 1998;Gonzalez et al, 2001;Farr e et al, 2002). The estimated optimal angulation for obtaining the en face view of the interatrial septum is approximately RAO 45-50 , similar to that for the nearly parallel IVS.…”

“…Third, as there are wide variations in the cardiac structural anatomy, including shape, size, rotation, and deviation in the thoracic cavity, the image intensifier angulations should be individually adjusted (Gonzalez et al, 2001;Farr e et al, 2002). Fourth, although the basic information provided in this study can be useful for a procedure performed under fluoroscopic support, additional support with nonfluoroscopic equipment, including transesophageal or intracardiac echocardiography and 3-D electroanatomical mapping, is also useful for real-time accurate determination of the region of interest (Lin et al, 2008;Yamada et al, 2008a;Yamada et al, 2010a;Letsas et al, 2011).…”

“…Because approaches based on the QRS-wave morphology during an arrhythmia and endocardial or epicardial pacing are inductive, the correct recognition of the fluoroscopic anatomy for defining the exact site of the electrode position should be a fundamental practice. However, each catheter laboratory has their preference of an image intensifier angulation (Farr e et al, 2002;Farr e et al, 2010) that may be adjusted conventionally for the interventricular septum (IVS). Furthermore, the fluoroscopic recognition and definition of the anatomy around the left ventricular outflow tract seems to vary between cases, especially around the left coronary aortic sinus (CAS), and between operators (Daniels et al, 2006;Kumagai et al, 2008;Lin et al, 2008;Yamada et al, 2008a;Steven et al, 2009;Zhang et al, 2009;Yamada et al, 2010a;Yamada et al, 2010b;Letsas et al, 2011;Chen et al, 2012), in part, due to the morphological complexity of the left ventricular outflow tract.…”

Incidence and Mechanism of Dislocated Fast Pathway in Various Forms of Atrioventricular Nodal Reentrant Tachycardia

“…The anatomical location of these pace mapping sites suggestive of an AV annulus of the A-TOK was confirmed by simultaneous recording of atrial and ventricular electrograms, relative to the coronary sinus catheter and the images obtained by biplane contrast right atriography. 15 Pace mapping was performed at a rate of 100 beats/min. The catheter positions during pacing were checked by biplane fluoroscopy.…”

Creation of the Chinese visible human data set

“…With the coming of the digital era, digital visible human data are in demand in various fields related to human morphology, including medicine, human artificial organ research, movie and television program production, advertisement making, and the aerospace industry (Bifulco, 2002;Farre, 2002). It is difficult, however, to digitize the human body because of its intricacy.…”