HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Supplemental Tables Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Saremi, F. Articles by Raney, A. Search for Related Content PubMed PubMed Citation Articles by Saremi, F. Articles by Raney, A. Related Collections Related Article

Arterial Supply to Sinuatrial and Atrioventricular Nodes: Imaging with Multidetector CT¹

¹ From the Departments of Radiological Sciences (F.S., O.A., K.K., A.R.), Cardiology (J.N., S.V.G.), and Cardiothoracic Surgery (A.A., J.C.M.), University of California, Irvine, University of California Medical Center, 101 The City Drive, Route 140, Orange, CA 92868-3298. Received January 8, 2007; revision requested February 28; revision received March 13; accepted April 20; final version accepted June 11. Address correspondence to F.S. (e-mail: fsaremi{at}uci.edu).

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: Transverse CT images show modes of termination of sinuatrial nodal artery (arrows) relative to SVC: (a) retrocaval (47.5%), (b) precaval (42.6%), and (c) pericaval (9.9%). AAo = ascending aorta, LA = left atrium.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: Transverse CT images show modes of termination of sinuatrial nodal artery (arrows) relative to SVC: (a) retrocaval (47.5%), (b) precaval (42.6%), and (c) pericaval (9.9%). AAo = ascending aorta, LA = left atrium.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: Transverse CT images show modes of termination of sinuatrial nodal artery (arrows) relative to SVC: (a) retrocaval (47.5%), (b) precaval (42.6%), and (c) pericaval (9.9%). AAo = ascending aorta, LA = left atrium.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Left: Transverse images of coronary CT angiographic data. Right: Superior views of sculptured three-dimensional reconstruction of heart. Red arrows point to retrocaval sinuatrial nodal arteries arising from RCA (top) and from LCX artery (bottom). Approximate incision line in superior septal approach for mitral valve surgery is shown (green arrows). In retrocaval variant, artery is very close to interatrial groove and a typical surgical incision would cut through the sinuatrial nodal artery where it passes the interatrial groove toward the posterior aspect of the SVC. AAo = ascending aorta, LA = left atrium, RAA = right atrial appendage.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: (a) Anterior and (b) right anterior oblique (RAO) views of sculptured three-dimensional reconstruction of heart and related transverse images (insets) demonstrate precaval sinuatrial nodal artery arising from (a) LCX artery (white arrows) and (b) RCA (black arrows). Approximate incision line in superior transseptal approach for mitral valve surgery (green arrows) extends from right atrium (RA) toward dome of left atrium (LA) superior to interatrial septum (IAS) (red arrows). This approach is below the level of the course of the sinuatrial nodal artery (SANa) in precaval variant, in which the artery terminates anterior to the SVC. In this case, risk of injury to vessel is negligible if the incision is made with caution. AAo = ascending aorta, LV = left ventricle, RAA = right atrial appendage, RV = right ventricle.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: (a) Anterior and (b) right anterior oblique (RAO) views of sculptured three-dimensional reconstruction of heart and related transverse images (insets) demonstrate precaval sinuatrial nodal artery arising from (a) LCX artery (white arrows) and (b) RCA (black arrows). Approximate incision line in superior transseptal approach for mitral valve surgery (green arrows) extends from right atrium (RA) toward dome of left atrium (LA) superior to interatrial septum (IAS) (red arrows). This approach is below the level of the course of the sinuatrial nodal artery (SANa) in precaval variant, in which the artery terminates anterior to the SVC. In this case, risk of injury to vessel is negligible if the incision is made with caution. AAo = ascending aorta, LV = left ventricle, RAA = right atrial appendage, RV = right ventricle.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: (a) Left superior three-dimensional and (b) transverse maximum intensity projection images from CT show S-shaped sinuatrial nodal artery arising from proximal LCX artery, running posteriorly between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) (arrow). In this location, it is very close to myocardial wall and may be damaged during radiofrequency ablation or surgical maze procedure of left atrium (LA). Artery approaches SAN through transverse sinus and anterior to SVC. AAo = ascending aorta, LAD = left anterior descending artery, RAA = right atrial appendage. Orientation: A = anterior, L = left, P = posterior, R = right.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: (a) Left superior three-dimensional and (b) transverse maximum intensity projection images from CT show S-shaped sinuatrial nodal artery arising from proximal LCX artery, running posteriorly between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) (arrow). In this location, it is very close to myocardial wall and may be damaged during radiofrequency ablation or surgical maze procedure of left atrium (LA). Artery approaches SAN through transverse sinus and anterior to SVC. AAo = ascending aorta, LAD = left anterior descending artery, RAA = right atrial appendage. Orientation: A = anterior, L = left, P = posterior, R = right.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Short-axis views of coronary CT angiographic data. Arrow = right atrioventricular nodal artery arising from (a) RCA and (b) LCX artery. AAo = ascending aorta, RA = right atrium.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Short-axis views of coronary CT angiographic data. Arrow = right atrioventricular nodal artery arising from (a) RCA and (b) LCX artery. AAo = ascending aorta, RA = right atrium.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 6: CT images of relationship between atrioventricular nodal artery and base of Koch triangle (coronary sinus [CS] ostium). A, Endocardial view of right atrioventricular junction shows anatomic boundaries of Koch triangle. Triangle is oriented with central fibrous body (CFB) at apex and is demarcated by Todaro tendon posteriorly (white arrows), hinge line of septal tricuspid valve (yellow arrows) anteriorly, and coronary sinus at base. Septal isthmus (green bracket) is located at triangle base, connecting tricuspid annulus to coronary sinus ostium. B, C, Four-chamber views at level of coronary sinus ostium in two patients. Black arrows indicate atrioventricular nodal artery at level of septal isthmus. Note variable distances of atrioventricular nodal artery to surface of endocardium. There is risk of arterial coagulation during ablation procedures when artery is in close proximity to septal wall, as in B. IVC = inferior vena cava, PFO = patent foramen ovale, RV = right ventricle. Orientation: A = anterior, I = inferior, P = posterior, S = superior.

View larger version (66K): [in this window] [in a new window] [Download PPT slide]   Figure 7a: (a) Schematic representation of posterior view at CT of heart demonstrates atrial vessel supply to AVN, including right (Rt. Kugel's) and left (Lt. Kugel's) Kugel anastomotic arteries and atrioventricular nodal artery (AVNa). (b) Tilted short-axis and (c) four-chamber views show accessory branches to AVN area. In b, left Kugel anastomotic artery arising from proximal LCX artery (black arrows) is evident. In c, right Kugel anastomotic artery is shown originating from proximal RCA (black arrows). Kugel anastomotic arteries travel through epicardial fat in the atrioventricular groove, extending along the side of aorta and then behind it, and reach the interatrial septum near its junction with the interventricular septum. AAo = ascending aorta, LA = left atrium, LV = left ventricle, MV = mitral valve, RA = right atrium, RV = right ventricle, TR = tricuspid valve.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 7b: (a) Schematic representation of posterior view at CT of heart demonstrates atrial vessel supply to AVN, including right (Rt. Kugel's) and left (Lt. Kugel's) Kugel anastomotic arteries and atrioventricular nodal artery (AVNa). (b) Tilted short-axis and (c) four-chamber views show accessory branches to AVN area. In b, left Kugel anastomotic artery arising from proximal LCX artery (black arrows) is evident. In c, right Kugel anastomotic artery is shown originating from proximal RCA (black arrows). Kugel anastomotic arteries travel through epicardial fat in the atrioventricular groove, extending along the side of aorta and then behind it, and reach the interatrial septum near its junction with the interventricular septum. AAo = ascending aorta, LA = left atrium, LV = left ventricle, MV = mitral valve, RA = right atrium, RV = right ventricle, TR = tricuspid valve.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 7c: (a) Schematic representation of posterior view at CT of heart demonstrates atrial vessel supply to AVN, including right (Rt. Kugel's) and left (Lt. Kugel's) Kugel anastomotic arteries and atrioventricular nodal artery (AVNa). (b) Tilted short-axis and (c) four-chamber views show accessory branches to AVN area. In b, left Kugel anastomotic artery arising from proximal LCX artery (black arrows) is evident. In c, right Kugel anastomotic artery is shown originating from proximal RCA (black arrows). Kugel anastomotic arteries travel through epicardial fat in the atrioventricular groove, extending along the side of aorta and then behind it, and reach the interatrial septum near its junction with the interventricular septum. AAo = ascending aorta, LA = left atrium, LV = left ventricle, MV = mitral valve, RA = right atrium, RV = right ventricle, TR = tricuspid valve.