Koch's triangle and coronary sinus anatomy assessed by three-dimensional electroanatomical mapping in paediatric patients with junctional tachycardiaBoiteux, Viscogliosi, Boissiere
et alArch Cardiovasc Dis (2025)
Abstract: Three-dimensional electroanatomical mapping has become an essential tool in paediatric electrophysiology to precisely identify areas involved in arrhythmias. Anatomical variations in Koch's triangle, especially fluoroscopic enlargement of the coronary sinus ostium, have been found more frequently in patients with atrioventricular nodal reentrant tachycardia (AVNRT) than in those with atrioventricular reentrant tachycardia (AVRT). This finding is consistent with easier coronary sinus cannulation during electrophysiology procedures in patients with AVNRT.To explore anatomical differences in the coronary sinus and Koch's triangle between children with AVNRT and AVRT using three-dimensional system acquisitions.We conducted a single-centre retrospective study of paediatric patients undergoing a catheter ablation procedure for AVNRT or AVRT. Detailed anatomy of the coronary sinus ostium, global morphology and Koch's triangle properties was assessed via catheter-based intracardiac three-dimensional electroanatomical mapping, and compared.Forty-four children were enrolled (22 in each group). The median age was 14.6 (interquartile range [IQR] 10.9-16.2) years. The coronary sinus ostium area and diameter were similar in the AVNRT and AVRT groups: area, 1.0 (IQR 0.7-1.2) vs. 1.2 (IQR 0.5-1.6) cm/m2, respectively (P=0.71; 95% confidence interval of median difference -0.3 to 0.3); diameter, 1.0 (IQR 0.8-1.5) vs. 1.1 (IQR 0.9-1.4) cm/m2, respectively (P=0.56; 95% confidence interval of median difference -0.2 to 0.2). Five patients (22.7%) in each group had a coronary sinus with a windsock morphology. There was no difference in the Koch's triangle area between the AVNRT and AVRT groups: 1.4 (IQR 1.1-2.0) vs. 1.6 (IQR 1.3-1.9) cm2/m2, respectively (P=0.37; 95% CI of median difference -0.2 to 0.5).Our findings suggest no difference in coronary sinus anatomy between these two junctional tachycardias. A potential explanation is the limited ability of three-dimensional mapping technologies to accurately define complex intracardiac structures.Copyright © 2025 Elsevier Masson SAS. All rights reserved.
Novel pacing maneuvers for mapping the upstream insertion of unidirectional accessory pathwaysMurphy, Przybylowicz, Lozano Garcia
et alHeart Rhythm (2025)
Abstract: Anatomic characterization of unidirectional accessory pathways (APs) is inherently limited to the localization of the downstream insertion site. The inability to define the full anatomic course of unidirectional pathways can limit the safety and effectiveness of ablation in the setting of complex pathways, slanted pathways, unstable catheter positioning at downstream insertions, or insertions near the conduction system.We aimed to develop novel pacing maneuvers to localize upstream insertions of unidirectional APs.Two methods were evaluated: localizing the shortest transit time from roving pacing sites to a fixed reference in the opposite chamber (upstream transit mapping); and identifying the site at which the latest atrial or ventricular extrastimulus reset atrioventricular reciprocating tachycardia (late reset mapping). Unidirectional APs were included to test utility and feasibility of the techniques, and bidirectional APs were included to test anatomic accuracy.A total of 13 patients were included, 8 unidirectional APs and 5 bidirectional APs. Blind side mapping was successfully performed in all cases and showed excellent spatial correlation to conventional mapping methods (mean, 4.2 mm; SD, 1.3 mm) as well as to the site of successful ablation (mean, 2.5 mm; SD, 2.9 mm). The upstream transit mapping method was critical for successful ablation after conventional techniques proved inadequate in 2 cases.Two novel methods, upstream transit mapping and late reset mapping, were used to localize the previously unmappable upstream insertions of unidirectional pathways. These methods expand the diagnostic toolbox to facilitate successful ablation in challenging cases.Copyright © 2025 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
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