Translational anatomy of the left atrium and esophagus as relevant to the pulmonary vein antral isolation for atrial fibrillation
Pulmonary vein antrum isolation by radiofrequency ablation has become a preferred treatment for atrial fibrillation. The aim of our research is to study the anatomy of the PVantrum and its related structures with special emphasis on the esophageal relation to the various components of the antrum, as thermal injury is a common complication.
Mediastinal contents were extracted “en bloc” from 30 human formalin fixed adult cadavers to study the posterior wall of the left atrium along with the esophagus.
The pulmonary antrum was measured. Each pulmonary ostium was assessed for circumference and muscle thickness. The esophagus was related to the left superior ostium in 90% of cases. The esophagus was traced on the atrial wall in each case; the distance from endocardium was measured at five equidistant lines. AV node distance from the right inferior pulmonary vein was 5 cm. The atrioventricular part of the membranous septum measured 4.2 mm.
For antral isolation the ablation lines are about 3 cm superior, 3.5 cm inferior and about 1 cm apart. The esophagus is ~ 12 mm away at the superior and ~ 7 mm away at the inferior ablation line. On the left ablation line this distance would diminish from 15 to 7 mm. The pulmonary ostial circumference is ~ 5 cm with muscle thickness varying from 0.7 to 4 mm. The left ostia need more ablative power as they have a 60% (1 mm) thicker muscle coat. Care should be taken while ablating round the left superior ostium as the esophagus lies 1–3 cm behind it in 90% of the cases.
KeywordsLeft atrial anatomy Pulmonary antrum Esophagus Atrial fibrillation Radiofrequency ablation
We would like to acknowledge all the body donors for their valuable contribution.
TG: project development, data analysis, manuscript writing/editing. NC: data collection. AR: data collection. DS: management.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
The experiments comply with the current laws of the country in which they were performed. The project was approved by the Institute Ethical Committee.
- 3.Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot NMSN, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T (2017) HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 14(10):e275–e444CrossRefPubMedPubMedCentralGoogle Scholar
- 7.Kottkamp H, Piorkowski C, Tanner H, Kobza R, Dorszewski A, Schirdewahn P, Gerds-Li JH, Hindricks G (2005) Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol 16:146–150CrossRefPubMedGoogle Scholar
- 11.Martinek M, Bencsik G, Aichinger J, Hassanein S, Schoefl R, Kuchinka P, Nesser HJ, Purerfellner H (2009) Esophageal damage during radiofrequency ablation of atrial fibrillation: impact of energy settings, lesion sets, and esophageal visualization. J Cardiovasc Electrophysiol 20:726–733CrossRefPubMedGoogle Scholar
- 12.Modi SK, Modi R (2017) Atrial fibrillation in India: is it a tide rising or a tsunami? Austin J Cardiovasc Dis Atheroscler 4(1):1030–1031Google Scholar
- 13.Pappone C, Oreto G, Rosanio S, Vicedomini G, Tocchi M, Gugliotta F, Salvati A, Dicandia C, Calabro MP, Mazzone P, Ficarra E, Di Gioia C, Gulletta S, Nardi S, Santinelli V, Benussi S, Alfieri O (2001) Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 104:2539–2544CrossRefPubMedGoogle Scholar
- 14.Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC, Manguso F, Torracca L, Benussi S, Alfieri O, Hong R, Lau W, Hirata K, Shikuma N, Hall B, Morady F (2004) Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation 109:2724–2726CrossRefPubMedGoogle Scholar