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©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
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Normal HeartPericardium
Opened Parietal Pericardium
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RA LVRV
DIAPHRAGMATIC LINE
STERNAL ANGLE
LEFT PHRENIC NERVERIGHT PHRENIC NERVE
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Avoiding “Collateral” Structures
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Inferior approach
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“x-ray” vision to help guide?
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Syed et al Electrophysiology Clinics March 2010
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RAO LAO
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Normal HeartTransverse Sinus
Anterior View Left Lateral View
Ao
PA
PA
Ao
LA
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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
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RAO
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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
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Normal HeartExternal Topography
Superior View
RAA
LAA
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Distribution of Epicardial Fat
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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
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Normal HeartExternal Topography
R Ant Oblique L Ant Oblique
RA
RV
Ao
RV
LV
Aorta
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CP828946-25
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Su et al., Heart 2008
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Su et al., Heart 2008
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Su et al., Heart 2008
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Wang et al, JCE 2010
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Chronic LAA ligation
Mitral
Valve
LAA
Closure
Site
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LSPV
LAA
LV
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Apex
RVOT
LV lateral Wall
Pericardium
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External Cardiac AnatomyCardiac Chambers
Superior View
RV
LV
RA
LA
SVC
Asc
Ao
Desc Thor Ao
PA
RAA
LAA
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External Cardiac AnatomyPericardium
Transverse Sinus (Ant & L Lat Views)
AoPA
PA
Ao
LA
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©2012 MFMER | 3208966-56
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©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