Left Atrial Anatomy Revisited by Siew Yen Ho, José Angel Cabrera, and Damian Sanchez-Quintana Circ Arrhythm Electrophysiol Volume 5(1):220-228 February 14, 2012 Copyright © American Heart Association, Inc. All rights reserved.

A, Dissection through the atria with parts of the anterior walls removed and viewed from a left anterior perspective to show the components of the left atrium and its relatively smooth endocardial surface. A, Dissection through the atria with parts of the anterior walls removed and viewed from a left anterior perspective to show the components of the left atrium and its relatively smooth endocardial surface. B, This dissection of the atria viewed from the back shows the close relationship of the aortic root to the atria, including the atrial septum. C, This specimen viewed from the left shows the posterior location of the left atrium and its relationship to cardiac and extracardiac structures. Asterisk marks the location of the coronary sinus. Eso indicates esophagus; LAA, left atrial appendage; LI, left inferior; LS, left superior; PV, pulmonary vein; RI, right inferior; RS, right superior; RAA, right atrial appendage; and Tr, trachea. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, Heart sectioned and viewed from simulated left anterior perspective to show the course of the coronary sinus(CS) relative to the left atrium(LA). A, Heart sectioned and viewed from simulated left anterior perspective to show the course of the coronary sinus(CS) relative to the left atrium(LA). The area of fibrous continuity between aortic and mitral valves lies between the open triangles. B, This dissection shows the inferior aspect of the heart with the epicardium of the left atrium and left ventricle removed. The insertion of the ligament of Marshall (LoM) marks the junction between great cardiac vein (gcv) and the coronary sinus. Note the musculature around the CS and LoM compared with the mainly bare wall (pale color) of the gcv. C, This histological section in a similar plane to the heart in A is stained in Masson trichrome stain, which displays muscle as red and fibrous tissue as green. The CS has a muscular sleeve and is separated from left atrial wall by a narrow space (**) that may be traversed by myocardial strands. ICV indicates inferior caval vein. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, The epicardium has been removed from this heart. A, The epicardium has been removed from this heart. This view from the back shows the “classic” pattern of 4 pulmonary veins entering the left atrium and the relationship of the right superior pulmonary vein (RS) to the posterior aspect of the junction between the superior caval vein (SCV) and the right atrium. The right inferior pulmonary vein (RI) passes behind the intercaval area. Note the sleeves of atrial muscle continuing around the pulmonary veins and the SCV. Bare venous walls appear pale in color. B, This view from the left and posterior perspective shows the proximity of the left superior pulmonary vein (LS) to the left atrial appendage (LAA), and it has a longer muscle sleeve than the left inferior pulmonary vein (LI). C, Removal of the posterior wall of the left atrium shows the entrances of the pulmonary veins without discrete veno-atrial junctions. D, This histological section in Masson trichrome stain shows the thicker atrial wall becoming thinner at the entrances of the veins to form the muscular sleeves, which taper toward the lungs. Note the interpulmonary “ridge” (arrow) and the epicardial fibro-fatty tissues (*) containing abundant nerve bundles. ICV indicates inferior caval vein. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, Left atrial appendage and its junction with the left atrium are viewed from left and posterior perspective. A, Left atrial appendage and its junction with the left atrium are viewed from left and posterior perspective. B, This view of the endocardial surface is transilluminated to demonstrate the thinness of the walls of the appendage and the atrium wall in the vicinity of the os. LSPV indicates left superior pulmonary vein; RSPV, right superior pulmonary vein. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, This longitudinal cut through the left atrium and left ventricle shows endocardial surface of the wall of the atrial component indistinguishable from the anterior and posterior walls other than for the crescent-like margin (open arrow). A, This longitudinal cut through the left atrium and left ventricle shows endocardial surface of the wall of the atrial component indistinguishable from the anterior and posterior walls other than for the crescent-like margin (open arrow). Note the location of the coronary sinus relative to the inferior wall. B, This longitudinal cut through the 4 cardiac chambers shows the atrial septum in profile. The floor of the oval fossa (open arrow) is the true septum. Asterisks mark the levels of attachments of the tricuspid and mitral valves at the septum. The inferior pyramidal space (small arrow) is covered by the vestibule of the right atrium. C, This histological section taken through the short axis of the heart shows the thin flap valve (open arrow) and the muscular rim of the fossa (small arrows). Note the uneven thickness of the left atrial wall. D, This view of the septal component shows a patent foramen ovale (open arrow). Its opening is behind the anterior wall of the left atrium and the transverse pericardial sinus. CS indicates coronary sinus; ICV, inferior caval vein; SCV, superior caval vein; LI, left inferior; LS, left superior; PV, pulmonary vein; RI, right inferior; and RS, right superior pulmonary veins. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, This is a view of the roof and posterior wall of the left atrium with transillumination to demonstrate the thinner parts of the walls. A, This is a view of the roof and posterior wall of the left atrium with transillumination to demonstrate the thinner parts of the walls. The epicardium has been removed to show the arrangement of the myocardial strands (broken arrows) in the superficial parts of the walls. B, This view of the posterior and inferior walls shows abrupt changes in orientation of the myocardial strands (broken arrows). An interatrial muscle bundle is present in this heart (double-headed arrow). C, This view of the left side shows the myocardial strands in the region between the left superior (LS) and left inferior (LI) pulmonary veins (arrow). D, Muscle bridges (arrows) between the superior and inferior pulmonary veins connect obliquely or directly superior-inferiorly. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A and B, Endocardial perspectives viewing the os of the left atrial appendage and the orifices of the left pulmonary veins to show examples of the variations in topography of the left atrial “ridge” (white arrows). A and B, Endocardial perspectives viewing the os of the left atrial appendage and the orifices of the left pulmonary veins to show examples of the variations in topography of the left atrial “ridge” (white arrows). C, This section in similar orientation shows a rounded profile of the fold that forms the “ridge” (open arrow). There is a small artery (arrow) in the fold. LC indicates left common; LI, left inferior; and LS, left superior pulmonary veins. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, This cut shows in profile the mitral isthmus between the mitral annulus and the orifice of the left inferior pulmonary vein (LI). A, This cut shows in profile the mitral isthmus between the mitral annulus and the orifice of the left inferior pulmonary vein (LI). B, This corresponding histological section shows the irregular thickness of the atrial wall and the relationship to the great cardiac vein. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A, This dissection viewed from the front displays the Bachmann bundle and its bifurcating branches leftward and rightward (broken arrows). A, This dissection viewed from the front displays the Bachmann bundle and its bifurcating branches leftward and rightward (broken arrows). The dotted shape marks the site of the sinus node. B, This view from above shows the Bachmann bundle crossing the interatrial groove as a distinct bundle. C, This histological section in comparable display to B shows the Bachmann bundle and its rightward extensions toward the sinus node (dotted area). D, This dissection of the posterior and inferior parts of the interatrial groove shows multiple muscle bridges (arrows) connecting the 2 atria. LAA indicates left atrial appendage; ICV, inferior caval vein; SCV, superior caval vein; LI, left inferior; LS, left superior; PV, pulmonary vein; RI, right inferior; and RS, right superior pulmonary veins. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.

A and B, Specimens viewed from the tilted right superior and posterior perspectives, respectively, to show the courses of the esophagus (eso) and descending aorta relative to the left atrium (LA). A and B, Specimens viewed from the tilted right superior and posterior perspectives, respectively, to show the courses of the esophagus (eso) and descending aorta relative to the left atrium (LA). C and D, Right and left views, respectively, show the courses of the phrenic nerves. RB indicates right bronchus; RPA, right pulmonary artery; SCV, superior caval vein; RI, right inferior; RM, right middle; and RS, right superior pulmonary veins. Siew Yen Ho et al. Circ Arrhythm Electrophysiol. 2012;5:220-228 Copyright © American Heart Association, Inc. All rights reserved.