Architecture of the atrial musculature in and around the triangle of Koch: its potential relevance to atrioventricular nodal reentry

INTRODUCTION: Recent studies suggest that atrial fibers in the approaches to the AV node form part of the dual pathways recognized electrophysiologically in patients with AV nodal reentrant tachycardia (AVNRT). Our aim was to determine, by gross dissection, the arrangement of the superficial musculature in the area of the triangle of Koch in normal hearts and in hearts with documented AVNRT, hoping to ascertain anatomic features that might contribute to the debate. METHODS AND RESULTS: We used blunt dissection to study the architecture of the superficial atrial musculature in 16 autopsied hearts from adults who died of noncardiac disease. A well-defined pattern of architecture of muscle fibers was found in the region of the triangle of Koch, showing marked variations in 7 of the 16 specimens. The relationship of these fibers to the histologically specialized AV node was confirmed by histology in three cases. Two hearts from patients with known AVNRT, treated by ablation in one, were examined further histologically. These sections showed that the site of ablation was well distant from the histologically discrete AV node. CONCLUSION: The variability in the arrangement of the superficial atrial muscle fibers in the area of the triangle of Koch may be one of the factors influencing the route for impulses entering the AV node. Lesions that ablate nodal reentry are within these atrial fibers rather than the histologically specialized AV node.