Topographic characteristics of the left atrial medial isthmus

BACKGROUND: The purpose of this study was to provide detailed topography of the left atrial medial isthmus (situated between the right inferior pulmonary vein ostium and the medial part of the mitral annulus). METHODS: Two hundred human hearts (Caucasian, 22.5% females, 48.7 +/- 4.9 years old) were investigated. RESULTS: The mean length of the medial isthmus was 42.4 +/- 8.6 mm. Additionally, the medial isthmus line was divided by the oval fossa into three sections with equal mean lengths (upper: 14.2 +/- 7.2 vs middle: 14.1 +/- 6.1 vs lower: 14.9 +/- 4.6 mm; P > .05). The left upper section of the atrial wall was thinner than the lower section (2.5 +/- 1.1 vs 3.4 +/- 1.6 mm; P < .0001). This study noted three separate spatial arrangements of the isthmus line. Type I (54.5%) had an oval fossa located outside the isthmus line; type II (32.5%) had an oval fossa crossed by the isthmus line, and type III (13.0%) had an oval fossa rim located tangentially to the isthmus line. In 68.5% of the examined specimens, the isthmus area had a smooth surface. Conversely, the remaining 31.5% had additional structures within its borders such as diverticula, recesses, and tissue bridges. CONCLUSION: This study is the first to describe the morphometric and topographical features of the left atrial medial isthmus. Interventions within the medial isthmus line should be performed cautiously, especially when they are transected by the oval fossa (32.5%). Careful navigation of the area is also recommended due to the possibility of existent additional structures. The latter could lead to catheter entrapment during ablation procedures.