CLINICAL STUDY: ELECTROPHYSIOLOGY
The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias
Dave T. Kim, MD*,
Angela C. Lai, BS*,
Chun Hwang, MD, FACC*,
Ling-Tao Fan*,
Hyrar S. Karagueuzian, PhD, FACC*,
Peng-Sheng Chen, MD, FACC* and
Michael C. Fishbein, MD, FACC
* Division of Cardiology, Department of Medicine at Cedars-Sinai Medical Center/UCLA, Los Angeles, California, USA
Department of Pathology and Laboratory Medicine at UCLA School of Medicine, Los Angeles, California, USA
Manuscript received January 13, 2000;
revised manuscript received March 15, 2000,
accepted April 28, 2000.
Reprint requests and correspondence: Dr. Michael C. Fishbein, Department of Pathology and Laboratory Medicine, UCLA School of Medicine, 10833 Le Conte Avenue, Los Angeles, California 90095-1732
OBJECTIVES
We sought to study the anatomy of human ligament of Marshall (LOM).
BACKGROUND
Although the LOM has been implicated in the genesis of focal atrial tachyarrhythmias, its gross anatomic and microscopic features in humans hearts have not been completely defined.
METHODS
We studied seven postmortem human hearts from five men and two women with a mean age of 52 ± 26 years. Four did not have any heart disease. One woman had dilated cardiomyopathy, and two men had chronic atrial fibrillation. A block of tissue encompassing the LOM from the coronary sinus (CS) cephalad, between the atrial appendage and left pulmonary veins, was dissected. Serial sections from this tissue were then stained with hematoxylin and eosin, trichrome, and/or tyrosine hydroxylase.
RESULTS
The LOM consists of multiple sympathetic nerve fibers, ganglia, blood vessels and multiple myocardial tracts (Marshall Bundles) insulated by fibrofatty tissue. One or more myocardial tracts was inserted directly into the left atrial free wall and CS. The distance between insertion sites was 7.8 ± 2.5 mm. Nerve fibers, some tyrosine hydroxylase positive, were present within the fibrofatty matrix and within the myocardial tracts.
CONCLUSIONS
Human LOM 1) is innervated by sympathetic nerve fibers; 2) is more complex than the LOM in canine hearts; and 3) has multiple myocardial tract insertions into the left atrial free wall and CS, forming a substrate of reentry. Radiofrequency catheter ablation from the CS may fail to reach the free wall insertion.
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Abbreviations and Acronyms
| | AF | = atrial fibrillation | | CS | = coronary sinus | | LOM | = ligament of Marshall | | LSPV | = left superior pulmonary vein | | TH | = tyrosine hydroxylase | | VOM | = vein of Marshall |
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