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J Chest Surg

Published online July 20, 2022

Copyright © Journal of Chest Surgery.

Surgical and Electrical Anatomy of the Inter-Nodal and Intra-Atrial Conduction System in the Heart

Jeong-Wook Seo, M.D., Ph.D. 1,2, Jung-Sun Kim, M.D., Ph.D. 3, Myung-Jin Cha, M.D., Ph.D. 4, Ja Kyoung Yoon, M.D. 5, Min-Ju Kim, M.D., Ph.D. 1, Hsuan-Ming Tsao, M.D. 6, Chang-Ha Lee, M.D., Ph.D. 7, Seil Oh, M.D., Ph.D. 8

1Department of Pathology, Incheon Sejong Hospital, Incheon; 2Department of Pathology, Seoul National University; 3Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine; 4Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul; 5Department of Pediatrics, Bucheon Sejong Hospital, Bucheon, Korea; 6Department of Internal Medicine, National Yang Ming Chiao Tung University and NYCU Hospital, Yilan, Taiwan; 7Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon; 8Cardiac Electrophysiology Lab Seoul National University Cardiovascular Center, Department of Internal Medicine, Seoul National University, Seoul, Korea

Correspondence to:Jeong-Wook Seo
Tel 82-32-546-9503
Fax 82-32-546-9504
E-mail jwseo@snu.ac.kr
ORCID
https://orcid.org/0000-0003-0242-1805

This article was presented at the Asia Pacific Cardiovascular Intervention and Surgery (APCIS) 2020 on September 19, 2020. A short summary of this paper was published in the APHRS Newsletter on November 20, 2020. The video of this article at APCIS2020 is available at https://www.youtube.com/watch?v=Mxm5_E9v-pc&t=1452s.

Received: April 20, 2022; Revised: May 23, 2022; Accepted: June 24, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

An anatomical understanding of the atrial myocardium is crucial for surgeons and interventionists who treat atrial arrhythmias. We reviewed the anatomy of the inter-nodal and intra-atrial conduction systems. The anterior inter-nodal route (#1) arises from the sinus node and runs through the ventral wall of the atrial chambers. The major branch of route #1 approaches the atrioventricular node from the anterior aspect. Other branches of route #1 are Bachmann’s bundle and a vestibular branch around the tricuspid valve. The middle inter-nodal route (#2) begins with a broad span of fibers at the sinus venarum and extends to the superior limbus of the oval fossa. The major branch of route #2 joins with the branch of route #1 at the anterior part of the atrioventricular node. The posterior inter-nodal route (#3) is at the terminal crest and gives rise to many branches at the pectinate muscles of the right atrium and then approaches the posterior atrioventricular node after joining with the vestibular branch of route #1. The branches of the left part of Bachmann’s bundle and the branches of the second inter-nodal route form a thin myocardial network at the posterior wall of the left atrium. These anatomical structures could be categorized into major routes and side branches. There are 9 or more anatomical circles in the atrial chambers that could be structural sites for macro re-entry. The implications of normal and abnormal structures of the myocardium for the pathogenesis and treatment of atrial arrhythmias are discussed.

Keywords: Cardiac conduction system, Cardiac arrhythmia, Bachmann’s bundle, Atrial flutter, Atrial fibrillation, Maze procedure, Radiofrequency ablation

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J Chest Surg

Published online July 20, 2022

Copyright © Journal of Chest Surgery.

Surgical and Electrical Anatomy of the Inter-Nodal and Intra-Atrial Conduction System in the Heart

Jeong-Wook Seo, M.D., Ph.D. 1,2, Jung-Sun Kim, M.D., Ph.D. 3, Myung-Jin Cha, M.D., Ph.D. 4, Ja Kyoung Yoon, M.D. 5, Min-Ju Kim, M.D., Ph.D. 1, Hsuan-Ming Tsao, M.D. 6, Chang-Ha Lee, M.D., Ph.D. 7, Seil Oh, M.D., Ph.D. 8

1Department of Pathology, Incheon Sejong Hospital, Incheon; 2Department of Pathology, Seoul National University; 3Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine; 4Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul; 5Department of Pediatrics, Bucheon Sejong Hospital, Bucheon, Korea; 6Department of Internal Medicine, National Yang Ming Chiao Tung University and NYCU Hospital, Yilan, Taiwan; 7Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon; 8Cardiac Electrophysiology Lab Seoul National University Cardiovascular Center, Department of Internal Medicine, Seoul National University, Seoul, Korea

Correspondence to:Jeong-Wook Seo
Tel 82-32-546-9503
Fax 82-32-546-9504
E-mail jwseo@snu.ac.kr
ORCID
https://orcid.org/0000-0003-0242-1805

This article was presented at the Asia Pacific Cardiovascular Intervention and Surgery (APCIS) 2020 on September 19, 2020. A short summary of this paper was published in the APHRS Newsletter on November 20, 2020. The video of this article at APCIS2020 is available at https://www.youtube.com/watch?v=Mxm5_E9v-pc&t=1452s.

Received: April 20, 2022; Revised: May 23, 2022; Accepted: June 24, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

An anatomical understanding of the atrial myocardium is crucial for surgeons and interventionists who treat atrial arrhythmias. We reviewed the anatomy of the inter-nodal and intra-atrial conduction systems. The anterior inter-nodal route (#1) arises from the sinus node and runs through the ventral wall of the atrial chambers. The major branch of route #1 approaches the atrioventricular node from the anterior aspect. Other branches of route #1 are Bachmann’s bundle and a vestibular branch around the tricuspid valve. The middle inter-nodal route (#2) begins with a broad span of fibers at the sinus venarum and extends to the superior limbus of the oval fossa. The major branch of route #2 joins with the branch of route #1 at the anterior part of the atrioventricular node. The posterior inter-nodal route (#3) is at the terminal crest and gives rise to many branches at the pectinate muscles of the right atrium and then approaches the posterior atrioventricular node after joining with the vestibular branch of route #1. The branches of the left part of Bachmann’s bundle and the branches of the second inter-nodal route form a thin myocardial network at the posterior wall of the left atrium. These anatomical structures could be categorized into major routes and side branches. There are 9 or more anatomical circles in the atrial chambers that could be structural sites for macro re-entry. The implications of normal and abnormal structures of the myocardium for the pathogenesis and treatment of atrial arrhythmias are discussed.

Keywords: Cardiac conduction system, Cardiac arrhythmia, Bachmann’s bundle, Atrial flutter, Atrial fibrillation, Maze procedure, Radiofrequency ablation

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