Variable Arrangement of the Atrioventricular Conduction Axis Within the Triangle of Koch

Cabrera, José Ángel; Anderson, Robert H.; Macías, Yolanda; Nevado-Medina, J; Porta‐Sánchez, Andreu; Rubio, José M.; Sánchez‐Quintana, Damián

doi:10.1016/j.jacep.2019.12.004

Cited by 52 publications

(49 citation statements)

References 17 publications

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“…Cabrera et al in their study also found a marked variation in length of the membranous septum with a mean length of 4.6 ± 1.5 mm (1‐9) 7 . The mean length of the interventricular membranous septum was 0.85 ± 0.62 mm (0.1‐2).…”

Section: Av Conduction Axismentioning

confidence: 75%

“…The mean distance of the penetrating His bundle from the right endocardial surface was 0.8 ± 0.4 mm (0.3‐2.5). The mean length, width, and thickness of the penetrating His bundle was 2.6 ± 0.7 mm (1.4‐4.7), 3.7 ± 1.14 mm (2.5‐5.6), and 1.4 ± 0.5 mm (0.5‐2.2), respectively 7 . These findings have important implications in His bundle pacing (HBP), as discussed later.…”

Section: Av Conduction Axismentioning

confidence: 76%

“…CT, terminal crest; SN, sinus node. Figure obtained from Stephenson et al 1 (https://creativecommons.org/licenses/by/4.0/) [Color figure can be viewed at wileyonlinelibrary.com]…”

Section: Sinoatrial Nodementioning

confidence: 99%

“…The compact AV node is a vital component of the ToK. In an elegant study of 41 autopsied normal human hearts, Cabrera et al 7 reported that the mean distance of the compact AV node from the RA endocardium was 0.5 ± 0.2 mm (0.2‐1.0). The mean length, width, and thickness of the compact AV node was 3.5 ± 1.2 mm (2.5‐5.5), 4.5 ± 1.1 mm (2.5‐7.4), and 1.2 ± 0.3 mm (0.8‐1.8), respectively.…”

Section: Av Conduction Axismentioning

confidence: 99%

“…CSO, coronary sinus os; LA, left atrium; LBB, left bundle branch; LPO, left posterior oblique; LV, left ventricle; MV, mitral valve; N, noncoronary cusp; OF, oval fossa; R, right coronary cusp; RAO, right anterior oblique; RVA, right ventricle apex; RVOT, right ventricular outflow tract; STV, septal leaflet of the tricuspid valve. Figure obtained with permission from Cabrera et al 13 (https://creativecommons.org/licenses/by‐nc‐nd/4.0/) [Color figure can be viewed at wileyonlinelibrary.com]…”

Section: Av Conduction Axismentioning

confidence: 99%

See 4 more Smart Citations

Anatomy of the cardiac conduction system

Padala

Cabrera

Ellenbogen

2020

Pacing Clinical Electrophis

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The specialized cardiomyocytes that constitute the conduction system in the human heart, initiate the electric impulse and result in rhythmic and synchronized contraction of the atria and ventricles. Although the atrioventricular (AV) conduction axis was described more than a century ago by Sunao Tawara, the anatomic pathway for propagation of impulse from atria to the ventricles has been a topic of debate for years. Over the past 2 decades, there has been a resurgence of conduction system pacing (CSP) by implanting pacing leads in the His bundle region in lieu of chronic right ventricular pacing that is associated with worse clinical outcomes. The inherent limitations of implanting the leads in the His bundle region has led to the emergence of left bundle branch area pacing in the past 3 years as an alternative strategy for CSP. The clinical experience from performing CSP has helped electrophysiologists gain deeper insight into the anatomy and physiology of cardiac conduction system. This review details the anatomy of the cardiac conduction system, and highlights some of the recently published articles that aid in better understanding of the AV conduction axis and its variations, the knowledge of which is critical for CSP. The remarkable evolution in technology has led to visualization of the cardiac conduction system using noninvasive, nondestructive high‐resolution contrast‐enhanced micro‐computed tomography imaging that may aid in future CSP. We also discuss from anatomical perspective, the differences seen clinically with His bundle pacing and left bundle branch area pacing.

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Section: Av Conduction Axismentioning

confidence: 75%

Section: Av Conduction Axismentioning

confidence: 76%

“…CT, terminal crest; SN, sinus node. Figure obtained from Stephenson et al 1 (https://creativecommons.org/licenses/by/4.0/) [Color figure can be viewed at wileyonlinelibrary.com]…”

Section: Sinoatrial Nodementioning

confidence: 99%

Section: Av Conduction Axismentioning

confidence: 99%

Section: Av Conduction Axismentioning

confidence: 99%

See 3 more Smart Citations

Anatomy of the cardiac conduction system

Padala

Cabrera

Ellenbogen

2020

Pacing Clinical Electrophis

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Noninvasive Visualization of the Atrioventricular Conduction System Using Cardiac Computed Tomography

Khoshknab,

Zghaib,

et al. 2024

JAMA Cardiol

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ImportanceNoninvasive localization of the compact atrioventricular node and the proximal specialized conduction system (AVCS) would enhance planning for transcatheter aortic valve and complex or congenital heart disease surgical procedures.ObjectiveTo test the hypothesis that preprocedure contrast-enhanced cardiac computed tomography (CECT) can accurately localize the AVCS by identification of the fat that insulates the conductive myocardium.Design, Setting, and ParticipantsThis was a prospective cohort study that took place at an academic tertiary care center. Included in the study were patients with CECT acquired less than 1 month before atrial fibrillation ablation and electroanatomic localization of the His electrogram signal on electroanatomic mapping (EAM) between January 2022 and January 2023.ExposuresPreprocedure CECT.Main Outcomes and MeasuresThe distance from the His electrogram signal to the fat segmentation encompassing the AVCS on CECT, after registration of the images to EAM.ResultsAmong 20 patients (mean [SD] age, 66 [10] years; 15 male [75%]) in the cohort, the mean (SD) attenuation of the AVCS fat segmentation was 2.9 (21.5) Hounsfield units. The mean (SD) distance from the His electrogram to the closest AVCS fat voxel was 3.3 (1.6) mm.Conclusions and RelevanceResults of this cohort study suggest that CECT could accurately localize the fatty tissue that insulates the AVCS from surrounding atrial and ventricular myocardium and may enhance the efficacy and safety of procedures targeting the conduction system and structures in its proximity.

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The atrioventricular conduction axis and the aortic root—Inferences for transcatheter replacement of the aortic valve

et al. 2021

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Conduction problems still occur following transcatheter aortic valvar replacement.With this in mind, we have assessed the relationship of the conduction axis to the aortic root. We used serial histological sections, made perpendicular to the base of the triangle of Koch in nine hearts, and perpendicular to the aortic root in 11 hearts.We first defined the extent of the fibrous tissues forming the boundaries of an infero-septal recess of the subaortic outflow tract, found in all datasets but one.When the recess was present, the axis penetrated through its rightward wall, giving rise to the left bundle branch prior to entering the outflow tract. The axis itself was usually on the crest of the ventricular septum, but could be deviated leftward or rightward. Its proximity to the virtual basal plane reflected the angulation of the muscular septum. On average, the superior edge of the left bundle was within 3.3 mm of the hinge of the right coronary leaflet, with a range from 0.4 to 10.2 mm. The arrangement was markedly different in the case lacking an infero-septal recess. Our findings necessitated a redefinition of the right fibrous trigone and the central fibrous body. The atrioventricular conduction axis, having entered the aortic root, is usually closest at the hinge of the right coronary leaflet. Knowledge of the depth of the infero-septal recess, and the angulation of the muscular ventricular septal, may help to avoid conduction problems following transcatheter implantation of the aortic valve.

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Variable Arrangement of the Atrioventricular Conduction Axis Within the Triangle of Koch

Cited by 52 publications

References 17 publications

Anatomy of the cardiac conduction system

Anatomy of the cardiac conduction system

Noninvasive Visualization of the Atrioventricular Conduction System Using Cardiac Computed Tomography

The atrioventricular conduction axis and the aortic root—Inferences for transcatheter replacement of the aortic valve

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