Post on 22-Jan-2021
©2012 MFMER | 3200268v1(2003)-1
Samuel J. Asirvatham, M.D.Mayo Clinic – Rochester
Cleveland Clinic CME Satellite SymposiumMay 9: 7:00 p.m. to 7:20 p.m.
Epicardial Anatomy and Access
Normal HeartPericardium
Opened Parietal Pericardium
RA LVRV
DIAPHRAGMATIC LINE
STERNAL ANGLE
LEFT PHRENIC NERVERIGHT PHRENIC NERVE
Avoiding “Collateral” Structures
Inferior approach
“x-ray” vision to help guide?
Syed et al Electrophysiology Clinics March 2010
RAO LAO
Normal HeartTransverse Sinus
Anterior View Left Lateral View
Ao
PA
PA
Ao
LA
Transverse Sinus
• Floor – roof of the left atrium
• Roof – pulmonary artery bifurcation
• Anterior – ascending aorta
• Posterior – descending aorta
• Access for Bachmann bundle ablation
• Opening in to aortocaval recess
RAO
Oblique Sinus• Anterior – posterior wall of left atrium
• Posterior – anterior wall of esophagus
• Left lateral – fold/vein of Marshall
• Right margin – right pulmonary vein
• Effusion can cause tamponade
• Tissue changes perceived injury to the esophagus is posterior left atrial ablation
• Access for vein of Marshall ablation
• Access for cardiac autonomic ablation
• Posterior boundary includes variable course of the vagus nerve
Normal HeartExternal Topography
Superior View
RAA
LAA
Distribution of Epicardial Fat
What Structures Can Not Be Accessed Readily from the Pericardial Space?
• Epicardial left ventricular outflow tract
• Supravalvar aortic cusps
• AV node or AV node related pathway
• Septal accessory pathways (except middle vein related)
• Often annular structures (fat, arteries)
• Bundle of His
Normal HeartExternal Topography
R Ant Oblique L Ant Oblique
RA
RV
Ao
RV
LV
Aorta
CP828946-25
Su et al., Heart 2008
Su et al., Heart 2008
Su et al., Heart 2008
Wang et al, JCE 2010
Chronic LAA ligation
Mitral
Valve
LAA
Closure
Site
LSPV
LAA
LV
Apex
RVOT
LV lateral Wall
Pericardium
External Cardiac AnatomyCardiac Chambers
Superior View
RV
LV
RA
LA
SVC
Asc
Ao
Desc Thor Ao
PA
RAA
LAA
External Cardiac AnatomyPericardium
Transverse Sinus (Ant & L Lat Views)
AoPA
PA
Ao
LA
©2012 MFMER | 3208966-56
©2012 MFMER | 3200268v1(2003)-57
Samuel J. Asirvatham, M.D.Mayo Clinic – Rochester
Cleveland Clinic CME Satellite SymposiumMay 9: 7:00 p.m. to 7:20 p.m.
Epicardial Anatomy and Access