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Miniseries 1-Part III: 'Behind the scenes' in the triangle of Koch

Lookup NU author(s): Professor Bob Anderson


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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: AIMS: To take full advantage of the knowledge of cardiac anatomy, structures should be considered in their correct attitudinal orientation. Our aim was to discuss the triangle of Koch in an attitudinally appropriate fashion. METHODS AND RESULTS: We reviewed our material prepared by histological sectioning, along with computed tomographic datasets of human hearts. The triangle of Koch is the right atrial surface of the inferior pyramidal space, being bordered by the tendon of Todaro and the hinge of the septal leaflet of the tricuspid valve, with its base at the inferior cavotricuspid isthmus. The fibro-adipose tissues of the inferior pyramidal space separate the atrial wall from the crest of the muscular interventricular septum, thus producing an atrioventricular muscular sandwich. The overall area is better approached as a pyramid rather than a triangle. The apex of the inferior pyramidal space overlaps the infero-septal recess of the subaortic outflow tract, permitting the atrioventricular conduction axis to transition directly to the crest of the muscular ventricular septum. The compact atrioventricular node is formed at the apex of the pyramid by union of its inferior extensions, which represent the slow pathway, with the septal components formed in the buttress of the atrial septum, thus providing the fast pathway. CONCLUSIONS: To understand its various implications in current cardiological catheter interventions, the triangle of Koch must be considered in conjunction with the inferior pyramidal space and the infero-septal recess. It is better to consider the overall region in terms of a pyramidal area of interest.

Publication metadata

Author(s): Tretter JT, Spicer DE, Sanchez-Quintana D, Back Sternick E, Farre J, Anderson RH

Publication type: Article

Publication status: Published

Journal: EP Europace

Year: 2022

Volume: 24

Issue: 3

Pages: 455-463

Print publication date: 01/03/2022

Online publication date: 06/01/2022

Acceptance date: 02/11/2021

ISSN (print): 1099-5129

ISSN (electronic): 1532-2092

Publisher: Oxford University Press


DOI: 10.1093/europace/euab285

PubMed id: 34999775


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