Right atrial appendage and vestibule: further anatomical insights with implications for invasive electrophysiology

Despite recognition that understanding gross anatomy of the right atrium is important in the era of invasive electrophysiology, areas such as the right atrial appendage (RAA) wall or the vestibule are not fully appreciated. The aim of this study was to conduct an anatomical assessment focusing on these structures to gain further insights into electrophysiological procedures.

Forty-four normal human hearts were examined macro- and microscopically.

Inside the RAA, two prominent muscle bundles; the crista terminalis (CT) and the sagittal bundle (SB) were identified. The medial wall at which the CT originated from and its surrounding area was the thickest part adjacent anteriorly to the thin aortic mound, suggesting non-uniform wall thickness of this area. Histological sections revealed that myocardial strands of the SB connected the CT and RAA tip, implying preferential anterior conduction of the sinus impulse. The vestibule had a thin myocardium with extensive fat covering along the epicardial side of the tricuspid annulus. The proximal portion of the right coronary artery (RCA) was relatively distant from the annulus, followed by gradual shortening of the distance from the endocardium to the RCA, which led to a very close relationship (<3.0 mm) at the inferior annulus.

Non-uniform wall thickness and muscle fibre orientation in the RAA should be taken into consideration during lead/catheter positioning. The RCA proximity in the inferior portion of the vestibule and the deeper fatty plane of the anterior atrioventricular groove are important anatomical features relevant to accessory pathway ablation.