BACKGROUND The coronary sinus (CS) and its branches may play a role in the genesis of various arrhythmias. Applications of radiofrequency energy within the CS may be necessary. Atrio-esophageal fistula has been recognized as a complication of ablation along the posterior left atrial wall.OBJECTIVES The purpose of this study was to describe the in vivo topographic anatomy of the CS, esophagus, and coronary arteries using computed tomography (CT).METHODS Helical contrast CT of the heart with three-dimensional and endoscopic reconstructions was performed in 50 patients (28 men and 22 women mean age 54 +/- 10 years), The images were reformatted to determine the relationships among the CS. adjacent blood vessels, and esophagus and to determine the nature and thickness of surrounding tissue layers.RESULTS Mean CS ostium diameter was 12 4 mm. and mean thickness of the periosteal fat layer wits 3 2 mm. In 40 of the 50 patients (80%). the esophagus was adjacent to the CS, starting 24 +/- from the ostium, and remained in contact for a mean length of 7 +/- 5 mm. Mean thickness of the fat layer between the esophagus and CS was 1 +/- 1 mm, and mean thickness of the anterior wall of the esophagus was 3 +/- 2 mm. In 10 patients (20%). there wits no contact between the esophagus and CS, In 40 patients (80%), the right coronary artery was less than 5 mm front the CS (minimum distance 1 +/-1 mm) over a mean length of 17 +/- 11 mm, In all patients, the circumflex artery wits less than 5 mm from the CS (minimum distance 1 +/- 0.4 mm) over a mean length of 16 +/- 9 mill in patients with right-dominant coronary circulation and over it mean length of 86 +/- 11 mm in patients with left-dominant coronary circulation.CONCLUSION The CS often lies very close to the esophagus and coronary arteries. During radiofrequency energy ablation in the CS, caution should be exercised to prevent injury to surrounding structures.

Background: The coronary sinus (CS) may play a role in initiation and/or perpetuation of atrial fibrillation (AF). Applications of radiofrequency energy within the CS may be necessary to eliminate AF. The purpose of this study was to describe the topographic anatomy of the CS in vivo in relation to adjacent structures, particularly the esophagus and the coronary arteries, using computerized tomography (CT).

BACKGROUND:The effects of left atrial (LA) circumferential ablation on LA function in patients with atrial fibrillation (AF) have not been well described. OBJECTIVES:The purpose of this study was to determine the effect of LA circumferential ablation on LA function. METHODS:Gated, multiphase, dynamic contrast-enhanced computed tomographic (CT) scans of the chest with three-dimensional reconstructions of the heart were used to calculate the LA ejection fraction (EF) in 36 patients with paroxysmal (n = 27) or chronic (n = 9) AF (mean age 55 +/- 11 years) and in 10 control subjects with no history of AF. Because CT scans had to be acquired during sinus rhythm, a CT scan was available both before and after (mean 5 +/- 1 months) LA circumferential ablation (LACA) in only 10 patients. A single CT scan was acquired in 8 patients before and in 18 patients after LACA ablation. Radiofrequency catheter ablation was performed using an 8-mm-tip catheter to encircle the pulmonary veins, with additional lines along the mitral isthmus and the roof. RESULTS:In patients with paroxysmal AF, LA EF was lower after than before LACA (21% +/- 8% vs 32 +/- 13%, P = .003). LA EF after LA catheter ablation was similar among patients with paroxysmal AF and those with chronic AF (21% +/- 8% vs 23 +/- 13%, P = .7). However, LA EF after LA catheter ablation was lower in all patients with AF than in control subjects (21% +/- 10% vs 47% +/- 5%, P < .001). CONCLUSION:During medium-term follow-up, restoration of sinus rhythm by LACA results in partial return of LA function in patients with chronic AF. However, in patients with paroxysmal AF, LA catheter ablation results in decreased LA function. Whether the impairment in LA function is severe enough to predispose to LA thrombi despite elimination of AF remains to be determined.

Background: The effects of left atrial catheter ablation (LACA) on left atrial (LA) transport function in patients with atrial fibrillation (AF) have not been well-described. The purpose of this study was to examine left atrial transport function with multiphase-dynamic-CT scans before and after LACA.

Background— During left atrial (LA) catheter ablation, an atrioesophageal fistula can develop as a result of thermal injury of the esophagus during ablation along the posterior LA. No in vivo studies have examined the relationship of the esophagus to the LA. The purpose of this study was to describe the topographic anatomy of the esophagus and the posterior LA by use of CT. Methods and Results— A helical CT scan of the chest with 3D reconstruction was performed in 50 patients (mean age, 54±11 years) with atrial fibrillation before an ablation procedure. Consecutive axial and sagittal sections of the CT scan were examined to determine the relationship, size, and thickness of the tissue layers between the LA and the esophagus. The mean length and width of the esophagus in contact with the posterior LA were 58±14 and 13±6 mm, respectively. The esophagus had a variable course along the posterior LA. The esophagus was close (10±6 mm from the ostia) and parallel to the left-sided pulmonary veins (PVs) in 56% of patients and had an oblique course from the left superior PV to the right inferior PV in 36% of patients. The mean thicknesses of the posterior LA and anterior esophageal walls were 2.2±0.9 and 3.6±1.7 mm, respectively. In 98% of patients, there was a fat layer between the esophagus and the posterior LA. However, this layer was often discontinuous. Conclusions— The esophagus and posterior LA wall are in close contact over a large area that may often lie within the atrial fibrillation ablation zone, and there is marked variation in the anatomic relationship of the esophagus and the posterior LA. Both the esophageal and atrial walls are quite thin. However, a layer of adipose tissue may serve to insulate the esophagus from thermal injury, explaining why atrioesophageal fistulas are rare.

OBJECTIVES The purpose of this study was to determine the effect of left atrial circumferential ablation on the size of the left atrium and pulmonary veins (PVs).BACKGROUND The long-term effects of left atrial circumferential ablation on left atrial and PV size and anatomy have not been analyzed in quantitative fashion.METHODS PV and left atrial sizes were analyzed in 41 consecutive patients (mean age 54 +/- 12 years) with paroxysmal (n = 25) or chronic (n = 16) atrial fibrillation. Computed tomography of the chest with three-dimensional reconstruction was performed before and 4 2 months after left atrial circumferential ablation. Left atrial circumferential ablation was performed to encircle the PVs 1 to 2 cm from the ostia, using a power output of 70 W. Additional ablation lines were created in the posterior left atrium and mitral isthmus. Radiofrequency energy also was delivered within the circles and at the PV ostia in 51% of patients at a reduced power output of 35 W.RESULTS At 6 months, 36 patients (88%) were in sinus rhythm without antiarrhythmic drug therapy, including 3 patients (7%) who developed persistent left atrial flutter and underwent subsequent successful ablation of atrial flutter. There was a 15 +/- 16% decrease in left atrial volume (P < .01) and 10 +/- 35% decrease in PV ostial area (P < .01), without focal narrowing, in patients with a successful outcome. Focal PV stenosis did not occur in any of the 41 patients.CONCLUSIONS Maintenance of sinus rhythm after left atrial circumferential ablation is associated with reduced left atrial and PV ostial size. Left atrial circumferential ablation for atrial fibrillation does not cause PV stenosis. (C) 2004 Heart Rhythm Society. All rights reserved.

Pulmonary Vein Anatomy. Introduction: The anatomic arrangement of pulmonary veins (PVs) is variable. No prior studies have quantitatively analyzed the effects of segmental ostial ablation on the PVs. The aim of this study was to determine the effect of segmental ostial radiofrequency ablation on PV anatomy in patients with atrial fibrillation (AF). Methods and Results: Three‐dimensional models of the PVs were constructed from computed tomographic (CT) scans in 58 patients with AF undergoing segmental ostial ablation to isolate the PVs and in 10 control subjects without a history of AF. CT scans were repeated approximately 4 months later. PV and left atrial dimensions were measured with digital calipers. Four separate PV ostia were present in 47 subjects; 3 ostia were present in 2 subjects; and 5 ostia were present in 9 subjects. The superior PVs had a larger ostium than the inferior PVs. Patients with AF had a larger left atrial area between the PV ostia and larger ostial diameters than the controls. Segmental ostial ablation resulted in a 1.5 ± 3.2 mm narrowing of the ostial diameter. A 28% to 61% focal stenosis was present 7.6 ± 2.2 mm from the ostium in 3% of 128 isolated PVs. There were no instances of symptomatic PV stenosis during a mean follow‐up of 245 ± 105 days. Conclusion: CT of the PVs allows identification of anatomic variants prior to catheter ablation procedures. Segmental ostial ablation results in a significant but small reduction in ostial diameter. Focal stenosis occurs infrequently and is attributable to delivery of radiofrequency energy within the PV. (J Cardiovasc Electrophysiol, Vol. 14, pp. 150‐155, February 2003)

Young infants produce a variety of spontaneous arm and leg movements in the first few months of life. Coordination of leg joints has been extensively investigated, whereas arm joint coordination has mainly been investigated in the sitting position in the context of early reaching and grasping. The current study investigated arm and leg joint coordination of movements produced in the supine position in 10 fullterm infants aged 6, 12 and 18 weeks. Longitudinal comparisons within limbs (intralimb) as well as between limbs (interlimb, ipsilateral and contralateral) were made as well as an exploration of differences in the development for boys and girls. The relationship between the joint angles was examined by measuring pair-wise cross-correlation functions for the angular displacement curves of the leg (hip, knee and ankle) and arm (shoulder, elbow and wrist) joints of both the right and left side. Both the arms and legs were found to follow a similar pattern of intralimb coordination, although the leg joints were more tightly coupled than the arm joints, particularly the proximal with the middle joint. In support of earlier findings, differences in the development of the right and left side were identified. In addition, gender differences in joint coordination were found for both intralimb and interlimb coordination. This contrasts with the view that gender differences in motor development may be primarily a result of environmental influences.