Revisiting right anterior oblique projections for the triangle of Koch: implications from computed tomography
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(2020) 20:383
RESEARCH ARTICLE
Open Access
Revisiting right anterior oblique projections for the triangle of Koch: implications from computed tomography Yanjing Wang1 , Lin Liu1 , Robert Lakin2 , Nazari Polidovitch2 , Guohui Liu3,4,5 , Hongliang Yang3,4,5 , Ming Yu3,4,5 , Mingzhou Yan3,4,5 , Dong Zhao3,4,5 , Peter H. Backx2 , Huan Sun3,4,5*† , Yuquan He3,4,5*† and Ping Yang3,4,5
Abstract Background: Variability in the anatomy and orientation of the triangle of Koch (TK) complicates ablation procedures involving the atrioventricular (AV) node. We used CT angiography (CTA) to assess the anatomical TK orientation, the CS ostium direction, and the relationship between the two, and we validated an individualized CSguided projection during ablation procedures. Methods: In 104 patients without structural heart disease undergoing computed tomography (CT) angiography, TK orientations were determined in relation to the coronary sinus ostium (CSo) as well as two standard right anterior oblique (RAO) projection angles (30o and 45o) commonly used in ablation procedures. Results: A CS-guided RAO projection (RAOCS) was shown to best track the orientation of the TK compared to RAO30° and 45°, with TK orientation strongly correlating with the CSo direction (r = 0.86, P < 0.001). In addition, the mean relative difference between the angle of the CSo and TK orientation was 5.54 ± 0.48°, consistent with a reduction in the degree of image shortening compared to traditional RAOs. Moreover, in vivo validation following ablation revealed that using a CS-guided projection limited the degree of on-screen image shortening compared to both the RAO30° and 45° in 25 patients with catheter ablation procedures. Conclusion: In hearts with a normal structure, the CSo direction offers a reliable predictor of the TK orientation which can be used to guide the projection of the TK during ablation procedures. Keywords: Ablation, Anatomy, Triangle of Koch’s, AVNRT, Cardiac CT
Background Understanding the anatomical structure of the Triangle of Koch (TK) is critical for electrophysiologists, especially for ablation procedures involving the atrioventricular node (AVN) such as atrioventricular node reentry tachycardia (AVNRT) [1–3]. Current methods for * Correspondence: [email protected]; [email protected] † Huan Sun and Yuquan He contributed equally to this work. 3 Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province 130033, China Full list of author information is available at the end of the article
estimating the TK anatomy during electrophysiology (EP) studies routinely use fluoroscopy images generated at right anterior oblique (RAO) projection angles of 30° or 45°, which may poorly align with the TK orientation and thereby limit spatial resolution [3], cause image shortening and then may influence the precise localization of the catheter. Unfortunately, the anatomic relationship of the TK to the other cardiac structures is highly variable between patients [4]. Thereby, taking a fixe
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