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1 and safer catheter based procedures have come
Department of Cardiology,
Hospital Universitario Quirón-
Madrid, European University of
Madrid, Madrid, Spain
2
Department of Anatomy and
Cell Biology, University of
Extremadura, Badajoz, Spain
Correspondence to
Dr José Angel Cabrera,
Department of Cardiology,
Hospital Universitario Quirón-
Madrid, European University of
Madrid, Calle de Diego de
Velázquez. 28223 Pozuelo de
Alarcón (Madrid), Spain;
jac11339@yahoo.co.uk;
jacabrera.mad@quiron.es
To cite: Cabrera JA,
Sánchez-Quintana D. Heart
Published Online First:
[please include Day Month
Year] doi:10.1136/heartjnl-
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Education in Heart
ARRHYTHMIAS
Cardiac anatomy: what the electrophysiologist
needs to know
José Angel Cabrera,1 Damián Sánchez-Quintana2
The rapid development of interventional proce-
dures for the treatment of arrhythmias in humans,
especially the use of catheter ablation techniques,
has renewed interest in cardiac anatomy. Effective
from an improved understanding of not only the
gross anatomic details of the heart, but also some
architectural and histological features of various
cardiac regions and their neighbouring landmarks.
This article aims to provide the basic anatomic
information needed to understand mapping and
ablative procedures for the cardiac interventional
electrophysiologist.
SPATIAL LOCATIONS OF THE CARDIAC
CHAMBERS DURING AN
ELECTROPHYSIOLOGICAL STUDY
The correct attitudinal position and spatial relation-
ships of the different cardiac structures should be
understood. Viewed from the frontal aspect of the
chest, the right ventricle (RV) is the most anteriorly
situated cardiac chamber because it is located
immediately behind the sternum. The cavity of the
right atrium (RA) is anterior, while the left atrium
(LA) is the most posteriorly situated chamber.
Owing to the obliquity of the interatrial septum
(IS) plane (which is at an angle of about 65° from
the sagittal plane), and to the different levels of the
mitral and tricuspid valve (TV) orifices, the LA is
situated more posteriorly and superiorly than
the RA.
The introduction of non-fluoroscopic electroana-
tomic mapping technologies has enabled electro-
physiologists to interpret correctly the gross
morphology and attitudinal position of the cardiac
chambers during the course of a mapping proced-
ure.1 Intracardiac echocardiography has also been
used to visualise some endocardial structures such
as the oval fossa (OF) or terminal crest (TC) and to
monitor the effects of ablation. In spite of these
recent developments, conventional fluoroscopy
remains the essential guide during an electrophysio-
logical study and ablation procedure. Fluoroscopic
examination is performed using the frontal and
oblique projections. Two or more fluoroscopic
views are usually needed to define the anatomic
position in the heart and to estimate more accur-
ately the location of the exploring electrode. The
right anterior oblique (RAO) projection defines
what is anterior, posterior, superior, and inferior.
The left anterior oblique (LAO) defines the super-
ior, inferior, anterior, and posterior locations for
both the right and left atrioventricular (AV) grooves
(figures 1 and 2). The LAO is also useful to define
what is septal, permitting the differentiation
between the complex right and left paraseptal
regions. It is the preferred projection to catheterise
the coronary sinus (CS) and its continuation along
the epicardial aspect of the postero-inferior region2
(figures 1 and 2).
RA ANATOMY
The RA has four components: the venous compo-
nent, the vestibule, an appendage, and it shares the
septum with the LA.w1 The venous component is
located posterolaterally and receives the systemic
venous return from the superior caval vein (SCV),
the inferior caval vein (ICV), and the coronary
venous return from the CS. The vestibule is a
smooth muscular wall around the tricuspid orifice,
and supports the leaflets of the TV. The characteris-
tic feature of the vestibule is that it is surrounded
by the pectinate muscles of the RA. The right atrial
appendage (RAA) lies over the anterosuperior
aspect of the right AV groove and contains multiple
pectinate muscles, which arise from the TC or
crista terminalis (figures 2 and 3).
TC AND THE REGION OF THE SINUS NODE
The TC is a significant structure in several forms of
atrial tachyarrhythmias, acting as a natural barrier
to conduction in common atrial flutter. The TC is a
large muscular ridge that separates the smooth
walled venous part (venous component) from the
extensive trabeculated ( pectinated) RAA. Thus, the
C-shaped crest extends laterally and inferiorly,
turning in beneath the orifice of the inferior vena
cava (IVC) to ramify as a series of trabeculations in
the area between the IVC and the TV3 (figure 3).
The pectinate muscles, originating from the crest
and extending along the wall of the appendage
towards the vestibule of the TV, show a non-
uniform trabecular pattern in most hearts. It is rele-
vant the confluence between the TC at its origin in
the interatrial groove and the origin of another
important muscular fascicle, the interatrial
Bachmann’s bundle, which extends into the LA.3
The sinus node (SN) is the source of the cardiac
impulse. It is usually localised within the TC at its
anterolateral junction with the SCV. The SN is
crescent-like in shape with an extensive longitudinal
axis. Notably, it is not insulated by a sheath of
fibrous tissue and varies in position and length along
the crista terminalis. Sections through the SN also
show a discrete area, composed of loosely packed
myocytes, which we have termed the paranodal
areaw2 (figure 4). While in 72% of the hearts the
location of the nodal body is subepicardial, in the
1
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Education in Heart

Figure 1 (A) Simulated (gross human

specimens) and fluoroscopic right anterior
oblique (RAO) projection showing
electrode catheters placed at the right
atrial appendage, bundle of His (His),
right ventricular apex and coronary sinus
(CS). (B) Simulated and fluoroscopic left
anterior oblique (LAO) projection. The CS
runs on the atrial side of the mitral
annulus along the inferior wall of the left
atrium towards the posterior border of the
heart. Both RAO and LAO projections
define what is anterior, posterior, superior
and inferior. The LAO view serves to
demonstrate in an attitudinal orientation
the septal location permitting the
differentiation between the right and left
atrioventricular grooves. AO, aorta; CSo,
coronary sinus ostium; ICV, inferior caval
vein; LV, left ventricle; MCV; mid cardiac
vein; P; pulmonary valve; RAA, right atrial
appendage; RVA, right ventricular
appendage; RVOT, right ventricular
outflow tract; TV, tricuspid valve.

other 28% the inner aspect of the nodal body is
more subendocardial.4 Its margin is irregular with
multiple extensions interdigitating into the neigh-
bouring working atrial myocardium (figure 4). Both
inappropriate sinus tachycardia and sinus nodal
re-entrant tachycardia are arrhythmias arising from
the sino-atrial area. Box 1 shows the relevant ana-
tomic determinants for SN ablation or modification
with endocardial catheter techniques.
INFERIOR RIGHT ATRIAL ISTHMUS AND ITS
ANATOMIC DETERMINANT FOR ATRIAL
FLUTTER ABLATION
The inferior right atrial cavo-tricuspid isthmus, a
critical link for the macro-reentrant circuit of
isthmus dependent atrial flutter, is the target of cath-
eter ablation techniques that have become the treat-
ment of choice for this arrhythmia. Anatomical and
imaging studies have shown a wide range of morph-
ologies and architectural factors at the isthmus level
that may influence the feasibility of obtaining a com-
plete, transmural and permanent ablation line across
this anatomic landmark.5 w3 w4 (box 1). With the
heart in an attitudinal orientation, we identified and
measured the length of three levels of the isthmus:
paraseptal (24±4 mm), inferior (19±4 mm), and
inferolateral (30±3 mm).w3 The paraseptal isthmus
forms the base of the triangle of Koch (figures 4–6).
The inferior isthmus is also known as the ‘central
isthmus’ owing to its location between the other
two isthmuses.6 The inferior isthmus represents the
optimal target for linear ablation because this is the
site where the orifice of the ICV is closer to the TV
insertion, the wall thickness is minimal, and there is
a larger distance to the right coronary artery and
the AV node or its arterial supply6 (figure 6).
Fluoroscopically, the 6 or 7 o’clock position in the
LAO view correlates with the preferred site for
ablation.
ARCHITECTURAL INSIGHTS OF THE TRIANGLE
OF KOCH FOR CATHETER ABLATION
The triangle of Koch contains the AV node and its
inferior extensions.7 It is bordered posteriorly by a
fibrous extension from the Eustachian valve and by
a ridge called the tendon of Todaro. The anterior
border is demarcated by the attachment of the
septal leaflet of the TV (figure 4). The apex of this
triangle corresponds to the central fibrous body
(CFB) where the His bundle penetrates. The base
of the triangle is the orifice of the CS, and the ves-
tibule of the RA immediately anterior to it. The
area of the triangle is targeted for ablation of the
slow nodal pathway. In addition, it is commonly
the seat of the atrial insertions of septal and para-
septal AV accessory pathways and certain forms of
atrial tachycardia. The dimensions and spatial
orientation of this right atrial region vary consider-
ably, which is clinically relevant in the case of cath-
eter ablation procedures largely guided by anatomic
landmarksw5 (figure 5). Energy current applied
near the compact AV node must be avoided. The
induction of AV block during ablation of the slow
pathway is more likely to occur when the triangle
is small, not only because there is less space to
apply energy current safely without impinging
upon the area immediately overlying the inferior
extensions or compact node, but also because there
is little margin for error with regard to stability of
the tip of the catheterw6 (box 1).
The AV node consists of a compact portion and an
area of transitional cells. The compact portion lies

2 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154

 Downloaded from heart.bmj.com on May 20, 2014 - Published by group.bmj.com
Figure 2 (A, B) Fluoroscopic 45° right anterior oblique projection showing the
angiographic display of both the mitral valve and tricuspid valve (TV) during the
injection of radiographic contrast into the right atrium (RA) and the left ventricle (LV).
(C, D) Three dimensional spatial orientation of the cardiac chambers using the NavX
system. (E) Opened RA and left atrium (LA) in a human specimen. Note the TV
displaced apically in relation to the mitral valve (MV) and the apposition between the
inferior/medial RA and the posterior region of the LV (double white arrow in panel E).
The smooth circumferential area of atrial wall surrounding the orifice of the TV and MV
is described as the vestibule. The trabeculated wall of the RA anterior to the terminal
crest is the right atrial appendage (RAA) and contains multiple pectinate muscles
(asterisk), which arise from the crest and extends all round the vestibule. CS, coronary
sinus; ICV, inferior caval vein; LAA, left atrial appendage; LIPV, left inferior pulmonary
vein; LSPV; left superior pulmonary vein; OF, oval fossa; PA, pulmonary artery; RV, right
ventricle; RVOT, right ventricular outflow tract.
over the CFB at the apex of the triangle (figure 4).
The compact AV node contains rightward and left-
ward inferior extensions, with the right extension
close to the tricuspid annulus.8 w7 The AV node con-
tinues distally with the His bundle. During an
electrophysiological study the site of the largest His
bundle electrogram recording does not always
coincide with the antero-superior vertex of the tri-
angle.7 Therefore the position of the compact AV
node and its inferior extensions just proximal to the
His bundle vary within the landmarks of the triangle.
Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154
Education in Heart
The penetrating His bundle can readily be distin-
guished from the compact node at the point where
the conduction axis itself becomes completely sur-
rounded by tissues of the CFB.7 Thus the bundle of
His is better protected than the compact node against
radiofrequency energy.
PARASEPTAL REGION AND INFERIOR
PYRAMIDAL SPACE
The previously called posteroseptal region is in fact
inferior and paraseptal, because it is inferior to the
true atrial septum. Therefore the term ‘infero-
paraseptal’ would be more anatomically correct.
The complex inferior paraseptal region represents
the confluence of all four chambers (the so-called
inferior pyramidal space) and the CS.7 The pyram-
idal space is an area whose superior vertex is the
CFB, the lateral sides are formed by the convergence
of the left and right atria, and whose floor is the
muscular ventricular septum (VS) and left ventricle
(LV). The CS limits the base of this area, which has a
pyramidal configuration. Tissues that are continuous
with the inferior epicardial AV groove occupy the
pyramidal space together with the AV nodal artery
and the proximal CS with the middle cardiac vein
and posterior coronary vein (figure 7).
The mid septal region corresponds to the floor
of Koch’s triangle between the His recording loca-
tion and the anterior portion of the CS ostium. In
this region, because the TV is displaced apically
and inferiorly in relation to the mitral annulus,
there is an apposition between the inferomedial RA
and the posterior region of the LV (figure 7). In
addition there is no atrial septum in the region of
the His bundle at the apex of Koch’s triangle (for-
merly anteroseptal). Thus this area is more prop-
erly regarded as being supero-paraseptal (box 2).
INTERATRIAL SEPTUM AND INTERATRIAL
MUSCULAR CONNECTIONS
The true IS is the OF, a depression in the right
atrial aspect of the area traditionally considered to
be the IS. The antero-inferior buttress, which
anchors the flap valve of the OF into the AV junc-
tions, is also a septal structure. The buttress is con-
fluent with the floor of the triangle of Koch, but as
mentioned above this is not a septal area. The but-
tress, in contrast, forms a direct muscular boundary
between the atrial cavities. The remaining parts of
the ‘septal’ aspect are formed by the infolded right
atrial wall superiorly and inferiorly, and the fibro-
fatty sandwich of atrial and ventricular musculature
anteriorly9 (figure 8). The muscular fold forming
the rim of the oval foramen itself is filled with
fibro-fatty tissues of the epicardium and termed the
interatrial groove (or septal raphe). Superiorly and
posteriorly, this is the posterior interatrial groove.
On the left atrial side, the valve is usually indistin-
guishable from the parietal atrial wall apart from a
small crescent-like edge that marks the site of its
free margin, the last part of the valve to become
adherent to the rim. Transseptal punctures to access
the LA should be performed through the OF. Also
relevant is the spatial relationship between the
3
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Education in Heart
Figure 3 (A) Opened right atrium in simulated right anterior oblique view to show
the most important landmarks and its four components. Note the oval fossa (OF) and
the terminal crest which is a thick C-shaped muscular trabecula that distally ramifies to
form the pectinate muscles. The Eustachian valve (asterisks) separates the inferior vena
cava (IVC) from the inferior right atrial isthmus. The Thebesian valve (white arrow)
guards the entry into the coronary sinus. (B) Four chamber section through the heart
profiles showing the true interatrial septum (double red arrow); the remaining parts
(dotted lines) mark the superior and inferior infolding of the atrial wall and the
fibro-fatty sandwich of atrial and ventricular musculature posteriorly. (C) Short axis
section across the atrial chamber below the flap valve of the OF. Note the
atrioventricular valves, the vestibules (dotted lines), and the different shape and size of
the atrial appendages. Ao, aorta; LAA, left atrial appendage; MV, mitral valve; RAA,
right atrial appendage; RCA, right coronary artery; RVA, right ventricular apex; RVOT,
right ventricular outflow tract; SCV, superior caval vein; TC, terminal crest; TV, tricuspid
valve; VS, ventricular septum.
anterior atrial wall or the plane of the atrial septum
and the root of the aorta (figure 8). An accidental
puncture throughout the interatrial groove may
result in haemopericardium in highly anticoagu-
lated patients.
Apart from a muscular continuity at the rim and
floor of the OF, there are multiple muscular bridges
between the atrial chambers.9 The anterior right
atrial wall is mainly formed by chains of cardio-
myocytes aligned with their long axes in similar
orientation that run parallel to the AV groove
(figure 9). A prominent band of these cardiomyo-
cytes is the Bachmann’s bundle that can be traced
from the superior cavo-atrial junction leftward to
4 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154
become the superficial fibres of the LA, crossing
the anterior interatrial groove. This band is the
most prominent muscular interatrial bridge.9 w8
Additionally, in some hearts the Bachmann’s bundle
may coexist with muscular bridges across the
posteroinferior interatrial groove. Also connections
between the muscular wall of the CS and the LA
are common.9
LEFT ATRIAL ANATOMY RELEVANT
TO CATHETER ABLATION
Ablation techniques in patients with atrial fibrillation
(AF) have evolved from rather limited initial
approaches to quite extensive left atrial intervention
(box 3). From a gross anatomical viewpoint the LA
possesses a venous component that receives the pul-
monary veins (PVs), a vestibule, an appendage, and
the so-called IS (figure 8). In reality, both atriums also
possess a body. This is best seen in the LA, and is the
smooth walled component between the vestibule and
the venous component. The body of the RA is much
smaller, and represents the space between the left
venous valve, when this structure can be recognised,
and the atrial septum. The major part of the LA,
including the septal component, is smooth walled
except for the ostium of the atrial appendage and its
neighbouring structures.10 The walls of the LA can be
described as superior, posterior, left lateral, septal (or
medial), and anterior. The anterior wall that is imme-
diately inferior to the Bachmann’s bundle, located just
behind the aorta, can be very thin and measures
approximately 1–2 mm in thickness transmurally. The
superior wall, or dome, is thicker compared with the
posterior and postero-inferior walls, measuring
3.5–6.5 mm.11 12
PVS AND THEIR VENOATRIAL JUNCTIONS
The LA posterior wall is the anatomical location of
the venous component and contains the venoatrial
junctions of the PVs, with the left veins located more
superiorly than the right veins (figures 9 and 10).
The superior PVs run cranially and more anteriorly,
whereas the inferior veins have a more posterior
and lateral course. Usually the right superior PV
passes behind the junction between the RA and the
superior vena cava (SVC) whereas the inferior PVs
pass behind the intercaval area.12 The orifices of the
right PVs are directly adjacent to the plane of the
atrial septum. The most common anatomic variants
(30–35%) of the PVs ending in the LA include a con-
joined homolateral ostia of the left PVs (25% of spe-
cimens) and a supernumerary or additional right PV
(figure 10). It is important to note that: (1) the PV
ostia are not round but ovoid; (2) the PV size varies
over the cardiac cycle and respiration; and (3) the
transition from the atrial endocardium to the venous
endothelial layer is smooth with an unclear anatomic
border. Thus, identification of the PV ostia may be
difficult in some patients.
Atrial sleeves of non-uniform thickness, which
are made up of working atrial myocardium, extend
over the veno-atrial junction into the PV walls, and
are more pronounced in the superior PVs.13
Specialised cells, particularly node-like cells, were
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Education in Heart

Figure 4 (A) Lateral view of the right atrium (RA) showing the location of the sinus node (SN) (fusiform green colour). (B) The RA is shown in
right anterior oblique projection. The terminal crest arches anterior to the orifice of the superior caval vein, and the SN is located between
themselves and extends toward the inferior caval vein. (C) Histological section of the SN body (Masson trichrome stain) within a dense matrix of
connective tissue (green colour) and showing a nodal extension (arrow). (D) Endocardial view of the posterior and paraseptal walls of the RA
showing the limits of the triangle of Koch. The apex of the triangle is the central fibrous body (CFB). The atrioventricular (AV) node is illustrated in
yellow. (E) Four chamber section to show the different attachment of the mitral valve and tricuspid valve. (F) Histological section corresponding to
the location of the AV node stained with Masson trichrome. Note the semi-oval shape of the compact AV node that lies over the CFB. Ao, aorta; CS,
coronary sinus; Epi, epicardium; End, endocardium; ICV, inferior caval vein; IVS, interventricular septum; LIPV, left inferior pulmonary vein; LSPV, left
superior pulmonary vein; MV, mitral valve; PT, pulmonary trunk; RAA, right atrial appendage; RIPV, right inferior pulmonary vein; RSPV, right
superior pulmonary vein; SCV, superior caval vein; TC, terminal crest; TV, tricuspid valve.

not seen in our studies.11–13 Bridges of atrial myo-
cardium and crossing strands have been observed
connecting the superior and inferior PV, occurring
more frequently between the left veins than
between the right veins.12 w9
LATERAL RIDGE AND LEFT ATRIAL
APPENDAGE
The left lateral ridge between the orifices of the
left PVs and the mouth of the left atrial appendage
(LAA) is the most relevant structural prominence
on the LA endocardium.14 This structure is actu-
ally an infolding of the lateral atrial wall protrud-
ing into the endocardial LA surface as a
prominent crest or ridge (figure 10). The ridge
extends along the lateral wall of the LA from the
anterosuperior to the postero-inferior region.
Epicardially, this broad bundle is in continuity
with the uppermost and distal part of the intera-
trial band (Bachmann’s bundle). Within the fold
runs the remnant of the vein of Marshall, together
with abundant autonomic nerve bundles and a
small atrial artery, which in some cases is the sinus
nodal artery.14
The LAA tends to have a tubular shape with one or
several bends resembling a little finger.w10 On the
endocardial aspect, the orifice of the LAA is not per-
fectly round. Instead, it is oval in shape with a mean
long diameter of 17.4±4 mm and a short diameter of
10.9±4.2 mm.12 A complicated network of fine pec-
tinate muscles lines the endocardial aspect.w11 In
between the muscle bundles the wall is paper thin. In
some specimens (28%), muscular trabeculations can
be found extending inferiorly from the appendage to
the vestibule of the mitral valve (MV) (figure 10).
These extra-appendicular myocardial bands corres-
pond to the small posterior set of pectinate muscles
originating from the myocardial bundles to embrace
the LAA.14 In those hearts with extra-appendicular
posterior pectinate muscles, the area in between the
muscular trabeculae and the atrial wall becomes
exceptionally thin (0.5±0.2 mm), increasing the risk
of cardiac perforation during ablation in this zone.14
The isthmus of muscle between the orifice of the
inferior PV and the mitral annulus is commonly
dubbed the left atrial isthmus or mitral isthmus.w12 In
this region, the vestibule directly apposes the wall of
the great cardiac vein and its continuation, the

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Education in Heart

Box 1 Right-sided atrial tachycardia and

atypical right atrial flutter

Inappropriate sinus tachycardia: ablation along the

crista terminalis
▸ Broad location of the sinus nodal tissue
▸ Potential cooling effect of the centrally located
sinus nodal artery
▸ Thickness of the terminal crest
▸ Non-uniform pectinate trabeculations towards
the TV
▸ Risk of right phrenic nerve injury
Coronary sinus origin and near the AV node or His
region
▸ Endocardial and close anatomic proximity of
the compact AV node
▸ Variable position of the compact AV node
within the right atrial AV junction
▸ Cooling effect of the CS blood flow: proximity
to the inferior AV nodal extensions
▸ A better protected His bundle than the
compact AV node against radiofrequency
energy
Atrioventricular nodal reentrant tachycardia
▸ Dimensions and spatial orientation of the
triangle of Koch
▸ Variable location of the His bundle recording
site within the Koch’s triangle
▸ Variable position of the compact AV node and
its inferior extensions
Isthmus dependent atrial flutter
▸ Length of the cavo-tricuspid isthmus: shorter
‘central isthmus’
▸ Endocardial geometry of the isthmus: deeper
pouches (sub-Thebesian recess)
▸ Obstacles such as a large Eustachian valve/
ridge
▸ Variable content of myocardial and fibro-fatty
tissues at the ablation zone
▸ Proximity of the AV nodal artery and right
coronary artery
AV, atrioventricular; CS, coronary sinus; TV, tricuspid
vestibule.

CS10 12 (figure 10). In cases where the wall at the

transition of vein to sinus is particularly muscular, it
adds to the thickness of the isthmus. Frequently, the
venous/sinus musculature is continuous with the left
atrial wall. The mitral isthmus may also contain extra-
appendicular posterior pectinate muscles.
CORONARY SINUS
The CS, which is the continuation of the great
cardiac vein, runs on the atrial side of the true
annulus along the postero-inferior wall of the
LA.10 11 This separation from the annulus is more
pronounced in the proximal 20 mm of the CS.w13
In all specimens, the venous wall of the CS is
Figure 5 A, B) Right atrial angiograms in 45° right
anterior oblique projection showing the tricuspid valve (TV)
plane and the angiographic limits of the triangle of Koch.
The position of the ablation catheter at the site of
application of radiofrequency (RF) is shown. Note the
variable dimensions of the triangle. The risk of
atrioventricular (AV) nodal injury increases when the Koch’s
triangle is small. (C) Injection of contrast during the slow
pathway ablation. Note the exact position of the ablation
catheter close to the TV. (D) The left anterior oblique
projection demonstrates that the ablation catheter (RF) has
a septal location in relation to the interatrial groove. LAO,
left anterior oblique; RAA, right atrial appendage; RAO,
right anterior oblique; RV, right ventricle; RVOT, right
ventricular outflow tract; SCV, superior caval vein.

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Education in Heart

Figure 6 (A, B) The right inferior cavo-tricuspid isthmus is a quadrilateral area in the floor of the right atrium bounded by the inferior caval vein
and the Eustachian valve posteriorly and by the septal attachment of the tricuspid valve (STV) anteriorly. Note in panel B the complex endocardial
topography of the isthmus with thicker trabeculations from the terminal crest and a deep sub-Thebesian recess ( pouch). (C) Sagittal histological
section with Masson trichrome at the level of the central isthmus. Note the proximity of the minor coronary vein and the right coronary artery to the
endocardium of the vestibule. The section shows the variable content of myocardial and fibro-fatty tissues with a thicker anterior vestibular area.
(D, E) Right atrial angiograms in the right anterior oblique projections that show in panel D a large and deep pouch recess and in panel E a thicker
Eustachian valve and ridge, anatomic obstacles that may complicate isthmus ablation (radiofrequency). CSos, coronary sinus ostium; ICV, inferior
caval vein; OF, oval fossa; RAA, right atrial appendage; RAO, right anterior oblique; RCA, right coronary artery; RF, ablation catheter; RV, right
ventricle; TV, tricuspid valve.

surrounded by a cuff of myocardium extending
40±8 mm from the ostium.w14 Myocardial connec-
tions varying in number and morphology leave this
coronary muscle cuff and connect to the LA. The
ostium of the CS abuts the superior margin of the
right atrial-left ventricular sulcus and the inferior
paraseptal mitral annulus in the pyramidal space
(figures 7, 9 and 11). The inferior interatrial con-
nections through the CS may explain the need for
additional ablation in and on the CS to complete
left atrial ablation lines extending down to the
mitral annulus in this area for curing AF.w14

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Education in Heart
Figure 7 (A) Left atrial angiography throughout a
transseptal puncture in the left anterior oblique
projection (LAO). The LAO projection makes it possible to
define the anatomic relation between the right and left
paraseptal regions and the fluoroscopic limits of the
inferior pyramidal space. Note the variable relation of the
coronary sinus (CS) catheter and the atrial side of the
mitral annulus. (B) Heart specimen in simulated LAO
projections showing the right and left atrioventricular
(AV) groove. The convergence of the left and right atria
forms the lateral side of the inferior pyramidal space; the
superior vertex is the central fibrous body and the CS
limits the base of this space. Note the AV nodal artery
originates from the apex of the U-turn of the distal right
coronary artery and penetrates into the base of the
inferior paraseptal region (inferior pyramidal space) at
the level of the crux of the heart. (C, D) Right anterior
oblique (RAO) projection. Ablation of an inferior
paraseptal accessory pathway within the mid cardiac vein
(MCV) using the CS myocardial sleeve as connection
between the atria and ventricle. The MCV end ups in the
proximal CS and runs an inferior course before bending
anteriorly along the epicardial surface of the muscular
interventricular septum. LV, left ventricle; MV, mitral
valve; P, pulmonary trunk; RCA, right coronary artery; RF,
ablation catheter; RV, right ventricle; TV, tricuspid valve.
8 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154
Box 2 Accessory atrioventricular
connections
Left free-wall accessory pathways
▸ Fibrous tissue around the MA interposed
between the atrial and ventricular myocardium
▸ Basal cords of ventricular myocardium on the
ventricular side of MA
▸ Aortic–mitral valve continuity (anterior limit of
the left free wall)
▸ The CS as guidance for MA: variable
separation of the CS from the annulus
Right free-wall accessory pathways
▸ The TA is displaced apically in relation to the
MA
▸ Less developed fibrous tissue and frequently
discontinuous TA
▸ Acute angulation of the tricuspid leaflets
towards the ventricle
Inferior paraseptal accessory pathways
(‘posteroseptal’)
▸ Complex relation between the right and left
inferior paraseptal region
▸ Musculature over the coronary venous system:
coronary sinus diverticulum
▸ The AV nodal artery towards the compact AV
node along the inferior paraseptal area
▸ The inferior extension of the compact AV node
Supero-paraseptal accessory pathways
(‘anteroseptal’)
▸ Proximity to normal conduction system
▸ Variable extension of the central fibrous body:
the region of the His penetrating bundle
▸ Discontinuous fibrous tissue around the
tricuspid annulus (superior limit)
Mid septal accessory pathways
▸ Area between the His recording location and
the anterior portion of the CS ostium
▸ Apposition between the inferior/medial RA and
posterior region of the left ventricle
▸ Similar anatomic determinants to the slow
pathway ablation
CS, coronary sinus; MA, mitral annulus; RA, right atrium;
TA, tricuspid annulus.
The CS musculature may form extensions over
the proximal portion of the middle cardiac vein
and posterior cardiac vein. The oblique vein of
Marshall (diameter 0.4–1.8 mm), located between
the LAA and the left upper and lower PVs, runs
inferiorly along the postero-inferior atrial wall to
join the CS. In most hearts (70%), the oblique vein
is <3 mm from the endocardium of the LA and has
muscular connections to the left PVs.14
RIGHT AND LEFT VENTRICLES
In contrast to the conical morphology of the LV,
the RV is more triangular in shape when viewed
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Education in Heart

Figure 8 (A) Dissection of the posterior wall of the left atrium (LA) close to the posterior interatrial groove. The smooth walled venous component
of the LA is the most extensive. The septal aspect of the LA shows the crescentic line of the free edge of the flap valve (green dotted line) against
the rim of the oval fossa (OF). The orifices of the right superior and inferior pulmonary veins (RSPV and RIPV) are adjacent to the plane of the septal
aspect of the LA. (B) Longitudinal sections showing the orifices of the right pulmonary veins. Note the relation of the superior vena cava to the
RSPV and right pulmonary artery. (C) The dome or roof of the LA has been removed and the left atrial side of the septum can be seen by
transillumination of the OF. In the case of patent foramen oval, the LA can be accessed from the right atrium (RA) through a crevice (blue dotted
line) that is the last part of the valve to be sealed to the rim. (D) Short axis through the interatrial septum (green arrow). Note by transillumination
the so-called left atrial ridge that is a fold in the LA wall between the left atrial appendage and the left pulmonary veins. (E) Histological section
with Masson trichrome taken through the short axis of the heart to show the thin flap valve and the muscular rim of the fossa. Note the
non-uniform thickness of the left atrial wall and the close relationship of the anterior wall of the RA with the transverse sinus and aorta (Ao). ER,
Eustachian ridge; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; PT, pulmonary
trunk, RAA, right atrial appendage; RI, right inferior pulmonary vein; RPA, right pulmonary artery; RS, right superior pulmonary vein; SCV, superior
caval vein; TV, tricuspid valve.

from the front and it curves over the LV.15 The
geometry of the RV is also influenced by the
convexity of the VS toward the RV in both systole
and diastole under normal loading conditions. Both
the RV and the LV have been described as having
three components: the inlet (inflow tract), apical
trabecular, and outlet portions (outflow tract)
(figure 11). Morphologically, the RV is distin-
guished from the LV by having coarser trabeculae,
a moderator band, and a lack of fibrous continuity
between its inlet and outflow valves. The muscular
trabeculations in the apical part of the RV are
coarser than those in the LV.15 16 The apical trabe-
culations of the LV are fine and display a criss-cross
pattern. The inlets also differ notably in the normal
ventricles, as do the outlets. Thus, the TV, posses-
sing inferior, septal and antero-superior leaflets, has
extensive chordal attachments to the VS, and is
supported by notably eccentric papillary muscles.
The MV possesses two leaflets, located anteriorly
and posteriorly but positioned obliquely within the
LV, and closing along a solitary zone of apposition.
The anterior leaflet of the MV is separated from
the septum by the subaortic vestibule, having
fibrous continuity with two of the leaflets of the
aortic valve.
ANATOMY OF THE OUTFLOW TRACTS:
IMPLICATION FOR ABLATION OF VENTRICULAR
TACHYCARDIAS
Premature ventricular contractions, ventricular
tachycardias (VTs) and initiating beats for ventricu-
lar fibrillation have all been localised at the level of
the right and left ventricular outflow tracts (RVOT
and LVOT).w15 w16 Absence of structural heart
disease is the rule with these arrhythmias.17
The majority of RVOT tachycardias originate in
the superior, septal and anterior aspects of the
infundibulum just underneath the pulmonary valve
(box 3). The RVOT (outlet portion of the RV or the
infundibulum) is a muscular structure of variable
length (range 13–24 mm) that supports the semi-
lunar leaflets of the pulmonary valve.15 Its posterior
and inferior part consists of a prominent muscular
crest, called the supraventricular crest (SC), that
separates the inflow and outflow components of the
RV (figure 11). The SC is in contact with the poster-
ior part of the LVOT, as it inserts into the

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Figure 9 (A–C) In these specimens the epicardium has been removed to show the arrangement of the myocardial strands in the superficial parts
of the walls. In panel A an interatrial muscle bundle or Bachmann bundle is present in this heart. Panel B is a view of the roof and posterior wall of
the left atrium (LA) showing the myocardial strands (septopulmonary bundle) in the region between the left and right pulmonary veins (PVs). Panel
C is a view of the posterior wall of the LA with transillumination to demonstrate the non-uniform myocardial thickness of the LA wall. (D) Cross
histological section stained with elastic van Gieson of the LA, PVs and the superior vena cava. Also note the variable myocardial content of the
walls of the LA and the epicardial location of vegetative nerves and ganglia. (E) Cross histological section of the left PVs stained with Masson
trichrome. Note the inter-PV myocardial connections (arrow) between the superior and inferior veins. Ao, aorta; Epi, epicardium; ICV, inferior caval
vein; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LPA, left pulmonary artery; LSPV, left superior pulmonary vein; LV, left ventricle;
RAA, right atrial appendage; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein; SCV, superior caval vein.

interventricular septum. On the septal aspect, this
crest inserts between the limbs of the septomarginal
trabeculation (SMT), or septal band.15 This muscu-
lar strap reinforces the septal surface of the RV,
breaking up at the apex to form the moderator band
and the anterior papillary muscle. The moderator
band incorporates the right bundle branch, as con-
duction tissue fibres move towards the apex of the
ventricle before entering the anterior papillary
muscle.16 The septo-parietal trabeculations take
their origin from the anterior margin of the SMT
and run round the parietal ventricular wall of the
infundibulum.15 These trabeculations show a vari-
able extension (between five and 22 trabeculations)
and thickness (range 2–10 mm) along the right and
left septo-parietal wall of the RVOT.
All these structures are absent from the LV, where
the outlet (LVOT) is much more reduced in size
because of the fibrous continuity between two of
the leaflets of the aortic valve and the aortic leaflet
of the MV. Therefore, in the LV there is no muscu-
lar separation between inflow and outflow tracts.16
Although the two ventricular outlets have
important differences in their structure, they also
have one feature in common, namely the semilunar
attachment of their leaflets. Because of the semi-
lunar shape of the pulmonary leaflets this valve
does not have a ring-like annulus.15 16 The semi-
lunar hinges of the arterial valve leaflets extend
proximally beyond the anatomic ventriculo-arterial
junction, such that crescents of myocardium are
incorporated into the bases of all three valvar
sinuses of the pulmonary valve, and into two of the
three aortic sinuses of Valsalva (figure 11). We
observed in histological sections the existence of
myocardial extensions or myocardial remnants on
the epicardial aspect above the sinotubular junction
in 20% of human specimens, showing continuity
with the myocardium of the RVOT (figure 11).
These extensions could justify the existence of idio-
pathic supravalvular tachycardia.
PERICARDIAL SPACE AND NEIGHBOURING
STRUCTURES OF THE HEART
The heart and its adjoining great vessels are
enclosed in a sac, the parietal (fibrous) pericar-
dium.w17 Superiorly, the fibrous pericardium is con-
tinuous with the adventitia of the great vessels.
Within the fibrous pericardium there is a delicate
double layered membrane known as the serous

10 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154

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Education in Heart

Box 3 Atrial fibrillation and left atrial

flutter. Ventricular tachycardias

Dimensions and non-uniform myocardial thickness

of the LA
▸ Variant anatomy of the PVs: length of the
common pulmonary trunk
▸ Inter-PVs myocardial connections (some
epicardially located)
▸ Endocardial ridges: the left atrial ridge and the
interpulmonary isthmus (PV carina)
▸ Extra-appendicular pectinate muscles (mitral
isthmus and vestibule)
▸ Cooling effect by the intramyocardial atrial
arteries
▸ Autonomic nervous system on the epicardial
surface of the LA wall
▸ Fibrous tissue around the mitral annulus
▸ Proximity with phrenic nerves, oesophagus,
vagus nerve and left circumflex artery
▸ The true atrial septum: transseptal punctures to
access the LA
– Spatial orientation of the interatrial groove
and plane of the atrial septum
– Thickness of the flap valve: fibrous/muscular
rim (septum primun)
– Patent foramen oval/aneurysmal oval fossa
– Relation with the aortic root and transverse
pericardial sinus
Ventricular outflow tract tachycardias
▸ Myocardial extension above the anatomic
ventriculo-arterial junctions
▸ Proximity of the AV conduction: aortic–mitral
valve continuity (LVOT)
▸ Extension of the supraventricular crest (RVOT)
▸ Variable septo-marginal and septo-parietal
trabeculations (RVOT)
Epicardial ablation
▸ Overlying epicardial fat: varying presence of
epicardial adipose tissue
▸ Proximity to epicardial coronary vessels, Figure 10 (A) Three dimensional reconstruction of the
left atrium (LA) and pulmonary veins using the NavX
pericardiophrenic vessels and phrenic nerve
system from data obtained with a 32 slice multidetector
▸ Local variation of pericardial reflections CT scanner to show conjoined ostia, a common variant
AV, atrioventricular; LA, left atrium; LVOT, left ventricular seen in up to 25% of cases, on the left side, and a
outflow tract; PV, pulmonary vein; RVOT, right ventricular separate right middle pulmonary vein (PV), which drains
outflow tract. the middle lobe of the lung. (B) Human necropsy
specimen showing the superior and posterior walls of the
LA were anchored by the entrance of one PV at each of
the four corners. (C, D) Endocardial left atrial wall in two
pericardium. One layer of the serous pericardium is postmortem heart specimens showing prominent left
fused to the fibrous pericardium while the other lateral ridges, extending in panel C (transillumination) to
layer lines the outer surface of the heart and con- the inferior margin of the left inferior pulmonary vein
tinues over the surfaces of the vessels as the visceral and in panel D (asterisk) to the inferior margin of the left
pericardium. Over the great vessels, the junctions superior pulmonary vein. Note in panels C and D the
between the two layers are the pericardial reflec- extra-appendicular posterior pectinate muscles extending
inferiorly from the left appendage toward the vestibule of
tions. The pericardial cavity is the space between the mitral valve (red arrows), and note the thinnest
the layers of the serous pericardium. muscular wall in between the muscular trabeculae. CS,
There is a small area behind the lower left half coronary sinus; LAA, left atrial appendage; LIPV, left
of the body of the sternum and the sternal ends of inferior pulmonary vein; LSPV, left superior pulmonary
the left fourth and fifth costal cartilages where the vein; RIPV, right inferior pulmonary vein; RSPV, right
fibrous pericardium is in direct contact with the superior pulmonary vein.

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Education in Heart

Figure 11 (A) Window dissection of a

heart prepared by removing the anterior
superior wall of the right ventricle (RV).
The three components of the RV are
revealed: the inlet (tricuspid valve (TV)),
apical trabecular, and right ventricular
outflow tract (RVOT) or infundibulum.
Note the location of the supraventricular
crest and septomarginal trabeculation
(SMT). The body of the SMT continues as
an important muscular strand, the
moderator band, to the anterior papillary
muscle and the parietal wall of the RV.
(B) Sagittal section through the parietal
wall of the left ventricle that shows the
subaortic outflow tract and how the
papillary muscles of the mitral valve
closely face each other. (C) The anterior
wall of the RV is opened to show the
leaflets of the pulmonary trunk mainly
supported by the RVOT; however, at the
level of their commissures the leaflets are
attached to the pulmonary artery trunk.
The SMT (septal band) consists of a body
and two limbs anterior and posterior. The
anterior limb extends along the
infundibulum (blue dotted arrow) and the
posterior limb runs toward the TV (yellow
dotted arrow). The septo-parietal
trabeculations take their origin from the
anterior margin of the SMT and extend
along the parietal ventricular wall of the
infundibulum. (D) Left ventricular
endocardial view to show the
membranous septum by transillumination.
This is the point of emergence of the left
bundle of His. The yellow arrows show the
mitro-aortic continuity. (E) Cross
histological section stained with Masson
trichrome through the left and the right
atria. Note the anatomic relation of the
RVOT with the subaortic outflow. Also
note the close proximity to the epicardial
coronary vessel, the left phrenic nerve and
the left atrial appendage, relevant during
the epicardial approach for arrhythmia
ablation. (F) Histological section of the
pulmonary valve stained with Masson
trichrome shows the attachment of the
pulmonary leaflet. Note the myocardial
extension above the sinotubular junction.
Ao, aorta; CS, coronary sinus; DA,
descending artery; L, left coronary sinus;
LA, left atrium; LCx, left circumflex artery;
LV, left ventricle; MV, mitral valve; NC,
non-coronary sinus; PA, pulmonary artery;
PT, pulmonary trunk; R, right coronary
sinus; SC, supraventricular crest; SCV,
superior caval vein.

thoracic wall. This area allows the pericardial space
to be accessed.w18 The pericardial cavity has two
main sinuses and several recesses.18 These are not
complete compartments but represent extensions of
the cavity. The transverse sinus is delineated anteri-
orly by the posterior surface of the ascending aorta
and pulmonary trunk bifurcation and posteriorly
by the anterior surface of the atria (figure 12). The
oblique sinus, a large cul-de-sac behind the LA, is
formed by the continuity between the reflections
along the PVs and caval veins.18 The right and left
pulmonary venous recesses are at the back of the
LA between the superior and inferior PVs on each
side, indenting the side walls of the oblique sinus to
a greater or lesser extent. The pericardial reflec-
tions at the veins, particularly the PVs, are varied

12 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154

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Education in Heart

Figure 12 (A) Schematic drawing showing the superior, transverse and oblique sinuses. The fibrous pericardium is coloured in orange and the
parietal layer of the serous pericardium in blue. The white area represents the reflections where the serous pericardium is continuous with the
fibrous pericardium. (B) This dissection of a cadaver viewed from the front shows the transverse and oblique sinuses following removal of the heart.
(C–E) Cross sections in three different specimens to show the close anatomic relationship of the oesophagus with the posterior left atrial wall (D)
and the right and left veno-atrial junction (D and E). (F) The course of the right phrenic nerve is closely related to the superior cavo-atrial junction
and the orifice of the right superior pulmonary vein. (G) The left phrenic nerve in its course has a close anatomic relationship with the left atrial
appendage and the lateral wall of the left ventricle to penetrate into the left part of the diaphragm close to the apex of the ventricle. Ao, aorta; Es,
oesophagus; ICV, inferior caval vein; LA, left atrium; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary
vein; LV, left ventricle; PT, pulmonary trunk; RB, right bronchus; RIPV, right inferior pulmonary vein; RPA, right pulmonary artery; RSPV, right superior
pulmonary vein; SCV, superior caval vein.

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Education in Heart
and they can restrict access around the veins.18 The
inferior and superior aortic recesses are extensions
from the transverse sinus. The superior recess lies
between the ascending aorta and the RA, whereas
the inferior recess between the aorta and the LA
extends to the level of the aortic valve.
The close anatomic vicinity of the cardiac cham-
bers to important structures and the regional distri-
bution of the autonomic nervous system elements
that may be affected by interventional manoeuvres
should also be understood by the electrophysiolo-
gist (figures 11 and 12). Preganglionic parasympa-
thetic and postganglionic sympathetic fibres come
together into the fat pads of fatty tissues, and gan-
glionated plexuses populate the subepicardium.
Abundant nerves and ganglions of the autonomic
nervous system are present at the junction between
the PVs and the LA with differential patterns of
innervation.w19 w20
The oesophagus descends in virtual contact with
the posterior wall of the LA (figure 12). Behind the
posterior left atrial wall is a layer of fibrous pericar-
dium and fibro-fatty tissue of irregular thickness that
contains oesophageal arteries and the vagus nerve
plexus.19 Understanding the course of the oesopha-
gus is essential to reduce the risk of atrio-oesophageal
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14 Cabrera JA, et al. Heart 2013;00:1–15. doi:10.1136/heartjnl-2011-301154
fistula during the left atrial ablation procedure.
Thermal injury during endocardial LA may also
involve the peri-oesophageal nerves,w21 resulting in
an acute pyloric spasm and gastric hypomotility as an
extracardiac adverse effect of AF ablation.
The right phrenic nerve has a close anatomic
relationship with the SVC and the right PVs20
(figure 12). Consequently, catheter ablation techni-
ques aimed at modifying the SN function at the
lateral RA, and AF ablation at the orifice and adja-
cent area of the right superior PV, carry a certain
risk of injuring the right phrenic nerve.20 Our
study on cadavers also revealed that the course of
the left phrenic nerve and its accompanying peri-
cardiophrenic vessels in the fibrous pericardium
were overlying the atrial appendage in the majority
of cases20 w22 (figures 11 and 12).
Acknowledgements The authors thank Drs Gonzalo Pizarro and
Margarita Murillo for their contribution to the preparation of this
article.
Contributors Hospital Universitario Quirón-Madrid, Universidad de
Extremadura.
Competing interests In compliance with EBAC/EACCME
guidelines, all authors participating in Education in Heart have
disclosed potential conflicts of interest that might cause a bias in
the article. The authors have no competing interests.
Patient consent Obtained.
Ethics approval Bioethics and Biosafety Committee of the
University of Extremadura (Badajoz, Spain).
Provenance and peer review Commissioned; externally peer
reviewed.
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2003;14:422–30.
▸ This review explores the anatomy of the pericardial space and the
anatomic variants that may be encountered in this approach to
the heart.
19 Sánchez-Quintana D, Cabrera JA, Climent V, et al. Anatomic
relations between the esophagus and left atrium and relevance for
ablation of atrial fibrillation. Circulation 2005;112:1400–5.
▸ This study reveals the characteristics of the non-uniform thickness
of the posterior left atrial wall and the variable fibro-fatty layer
between the wall and the oesophagus which are risk factors that
must be considered during the ablation procedure.
20 Sánchez-Quintana D, Cabrera JA, Climent V, et al. How close
are the phrenic nerves to cardiac structures? Implications for
cardiac interventionalists. J Cardiovasc Electrophysiol
2005;16:309–13.
▸ This study clarifies the spatial relationships between the
phrenic nerves and important cardiac structures which is essential
to reduce risks during epicardial and endocardial catheter
ablation.
15
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Cardiac anatomy: what the

electrophysiologist needs to know
José Angel Cabrera and Damián Sánchez-Quintana

Heart published online January 25, 2013

doi: 10.1136/heartjnl-2011-301154

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References This article cites 18 articles, 11 of which can be accessed free at:
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Notes

Advance online articles have been peer reviewed, accepted for publication, edited and
typeset, but have not not yet appeared in the paper journal. Advance online articles are
citable and establish publication priority; they are indexed by PubMed from initial
publication. Citations to Advance online articles must include the digital object identifier
(DOIs) and date of initial publication.

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

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