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Ann Thorac Surg 2003;76:732-735
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

The clinical anatomy of the sinus node artery

Denis Berdajs, MDa*, Lajos Patonay, MD, DDa, Marko I. Turina, MDb

a Institute of Anatomy, Histology, and Embryology, Laboratory for Applied and Clinical Anatomy, Semmelweis University Budapest, Budapest, Hungary
b Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland

Accepted for publication March 4, 2003.

* Address reprint requests to Dr Berdajs, University Hospital Zürich, Department of Cardiovascular Surgery, Rämistrasse 100, CH-8091 Zürich, Switzerland
e-mail: denis_berdajs{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Our basic aim was to describe the topographic relation between the sinus node artery and the superior posterior border of the interatrial septum with regard to the sinus node dysfunction that follows the superior transseptal approach to the mitral valve.

METHODS: During our study 50 human hearts without previous pathologic alterations were analyzed. The position of the sinus node and the course of the sinus node artery were investigated. For identification of the origin of the artery, selective coronary angiograms were performed. The course of sinus node artery and its topographic relation to the interatrial septum was identified by the dry dissections of the hearts. Based on histologic and dry dissected specimens the exact position of the sinus node was determined.

RESULTS: We found that the sinus node artery originates from the right coronary artery in 66% of examined cases and from the left coronary artery in 34% of cases. The sinus node artery crosses the superior posterior border of the interatrial septum in 54% of cases.

CONCLUSIONS: Our results were compared with clinical studies focusing the incidence of the sinus rhythm disturbance after the superior transseptal approach. The incidence of rhythm disturbance varies from 52% to 60% of cases. Comparing our morphologic and clinical results we can state that the risk for intraoperative damage to the sinus node artery during the superior transseptal approach to the mitral valve is high.


   Introduction
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 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The sinus node artery (SNA) is an integral part of the sinus node (SN), which is the natural pacemaker of the heart. The SNA originates from the right or left coronary arteries. The anatomy of the artery has been described by many anatomic works [5, 7, 8] but only a few existing references refer to the course of the artery and its topographic relation to the atrial walls [8].

Sinus node dysfunctions are frequent in patients who have undergone cardiosurgical procedures, which involve a manipulation of atrial walls. This is especially true in the case of the superior transseptal approach to the mitral valve where the superior posterior border of the interatrial septum is divided [1, 2]. The occurrence of postoperative rhythm disturbance reachs as high as 53% of investigated cases [5, 6]. The observed postoperative arrhythmias of the sinus node were presumed to be caused by the damage of the SNA [4]. Owing to the lack of anatomic evidence for the correlation between the course of the SNA and the operating area, the above mentioned presumption was not confirmed until now.

To clarify the anatomic possibility for SNA damage we studied the course of the artery, emphasizing its relation to the superior posterior border of the interatrial septum.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
During our study 50 human hearts from cadavers aged 20 to 70 years were analyzed. The left and right coronary orifices were separately cannulated and 30 mL of radiopaque material was injected into the coronary arteries. As contrast material we used 70% density barium sulfate suspension. This medium penetrated into the precapillary arterioles without filling the capillaries. Coronary angiographs were taken on Gevaert Structurix D2 plates from 150 cm and the exposure time was adjusted to 3.2 mAs and the kV set at 40. The origin of the SNA was determined by the selective coronary angiograms. Subsequently the injected hearts were placed into 4% formaline solution for 1 month followed by a bath in a solution consisting of 25% isopropyl alcohol, 20% propylene glycol, 0.5% glutaraldehyde, and 5% benzyl alconium chloride. After the preserving procedure, dry dissection of the SNA was performed. The course of the SNA was dissected from its origin up to the sinus node.

Two major groups of the right SNA were distinguished based on the origin of the artery, proximal or distal to the right marginal branch. The arteries originating proximal to the marginal branch were divided into three subtypes. By using the histologic method the exact position of the sinus node was determined.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Anatomy of the sinus node artery
We found 33 (66%) specimens in which the right SNA and 17 (34%) specimens in which the left SNA vascularized the sinus node (Table 1, Fig 1). In the first group of the right SNA there were 31 cases. In this group the artery originated proximal to the right marginal branch (Table 1, Fig 1A, B, C, Fig 2). Considering its connection to the superior posterior border of the interatrial septum and to the SVC the following three subtypes of this group were determined.


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  		Table 1. Percentage Distribution for Right and Left Sinus Node Arteries

 


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  		Fig 1. Schematic presentation of the route of the sinus node artery. (A–D) The right type of sinus node vascularization. (A–C) Sinus node arteries that are given off proximal to the right marginal branch. (E) The left type of the sinus node vascularization. (B, E) The distal part of the artery passes on the left side of superior vena cava; therefore the superior posterior border of the interatrial septum is crossed. The dashed line indicates the incision of the right and left atrium in the superior transseptal approach. (1 = superior vena cava; 2 = aorta; 3 = sinus node; 4 = sinus node artery; 5 = right auricula.)

 


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  		Fig 2. Coronary angiogram shows the right type of sinus node vascularization. The origin of the sinus node artery (SNA) is proximal to the right marginal branch. The end branches of the SNA encircle the superior vena cava both from the left and right sides and anastomose within the sinus node. In this way they are modeling an anastomotic ring around the superior vena cava. (1 = sinus node artery; 2 = anastomotic ring of the end branches of sinus node artery; 3 = right marginal branch; 4 = right coronary artery; 5 = left coronary artery.)

 
In the first subtype there were 19 cases (Table 1). The SNA passed along the anterior surface of the right atrium toward the orifice of the superior vena cave (SVC). Reaching the orifice of the SVC, the SNA encircled it from the right side (Fig 1A). When the SNA reached the lateral wall of the right atrium, the artery coursed posteroinferiorly toward the sinus node.

The second subtype consisted of 10 cases (Table 1). The initial course of the artery was the same as described in the previous case. As the SNA reached the orifice of the SVC, the SVC was bypassed from the left side (Fig 1B, Fig 3). Reaching the border between the left and right atrium the SNA crossed the posterior interatrial sulcus to arrive at the sinus node from the left side.



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  		Fig 3. The dry dissected heart with the right subtype of the sinus node artery. The artery’s course is inspected from the right side. Note that the superior posterior border of the interatrial septum (on the left side of the superior vena cava) is crossed. (1 = sinus node artery; 2 = right auricle; 3 = superior vena cava; 4 = aorta; 5 = sinus node artery.)

 
In the third subtype 2 cases were listed (Table 1). The artery also passed along the anterior wall of the right atrium. Reaching the orifice of SVC, the artery divided itself into two branches (Fig 1C, Fig 2). The branches encircled the SVC both from the left and right sides and anastomosed within the substance of the sinus node.

In the second group of the right SNA were classified 2 cases. In this group the origin of the SNA was distal to the right marginal branch (Table 1). The artery ran along the posterior aspect of the right atrium and adjoined the sinus node (Fig 1D).

The left SNA branches off either from the trunk of the left coronary artery or the left circumflexal branch. In all 17 cases the artery passed along the anterior surface of the left atrium toward the border of the left and right atrium. The artery crossed the posterior interatrial sulcus (Fig 1E) and encircled the SVC from the left side.

Sinus node anatomy
On the dry dissected hearts the position of the sinus node was found in the superior part of the terminal grove. Macroscopically the only pronounced landmark of the sinus node was the SNA, which runs through the center of the node. By the histologic investigation of the superior part of the terminal groove the position of the sinus node, observed by the dry dissections, was confirmed. The fact that the SNA is located in the center of the node is proven by histologic sections (Fig 4).



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  		Fig 4. Histologic specimen of sinus node. The myocardium is surrounding the sinus node and is quite different from the structure observed in the node. The sinus node artery is located in the center of sinus node. (1 = sinus node; 2 = myocardium; 3 = sinus node artery.)

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The good exposure of the mitral valve and its subvalvular apparatus play a key role in the success of mitral valve surgery. The visualization of the mitral valve in difficult situations such as a small left atrium, redone operations, or a patient with a deep chest can be critical. To overcome this problem several alternative surgical techniques have been described such as the superior approach [13, 14] and various transseptal approaches [15–18]. Kon and associates [1] reported that optimal visualization of the mitral valve was obtained by the superior transseptal approach, which assumption was confirmed by other authors as well [2, 4]. Although the efficacy of this approach is widely accepted, its safety with regard to the preservation of sinus node function remains controversial as the SNA could be injured [11–13].

The interest shown in the blood supply of the heart conducting system is not new. Hadeiselimovi studied the vessels of sinus node, atrioventricular node, and His bundle on 200 hearts [7]. He detected the SNA arising from the right coronary artery in 60% of cases and the left coronary artery in 40%. Despite the great number of cases and different methods that he was using the course of the SNA was not described. Further interest in sinus node blood supply and in the course of the SNA intensified the evaluation of the superior transseptal approach to the mitral valve [8–10]. The major complication in the early postoperative days are sinus arrest, atrial fibrillation, flutter, and junctional rhythm [3–6]. The rhythm disturbances in the early postoperative period are considered as reflecting the damage to the SNA.

With regard to the mentioned complications Bokeriya and coworkers [8] studied the anatomy of the SNA on 70 hearts. They discovered that the artery arose from the right coronary artery in 61.4% and from the left coronary artery in 38.4% of cases. To describe the course of the SNA, the SVC was chosen as an important landmark although the relation between the artery’s course and the posterior superior border of the interatrial septum, which is related to the operating area, was not determined.

In our study we described the topographic relation between SNA and the interatrial septum. Our results concerning the SNA origin are similar to the results of Hadeiselimovi and Bokeriya (Table 1). To describe the course of the SNA, the SVC and the posterior interatrial sulcus were chosen as important landmarks. Since the posterior interatrial sulcus indicates the superior posterior border of the interatrial septum, the relationship between the operating area and the artery was determined.

We determined that the superior posterior border of the interatrial septum was crossed in all 17 cases of the left SNA (34%; Fig 1E). In the case of the right SNA the same phenomena was not so obvious. The morphologic variations of the right SNA demonstrated a wider morphologic spectrum, which prevents us from giving a general description of its course. The interatrial septum was crossed by those arteries whose origin was proximal to the right marginal branch. These arteries, after they reached the dome of the right atrium, passed along the left side of the SVC (Fig 1B, E). Consequently the superior posterior border of the septum was crossed before the SNA reached the sinus node. The above-mentioned two courses were observed in 10 cases of the right SNA and in all 17 cases of the left SNA (Table 1). Based on our results we can state that the superior posterior border of the interatrial septum was crossed in 27 cases, meaning that 54% of all studied arteries are crossing the operating area that is used in the superior transseptal approach to the mitral valve.

These morphologic data show that the superior posterior border of the interatrial septum is crossed frequently. Therefore damages to the sinus node blood supply become very probable during the superior transseptal approach to the mitral valve. Our morphologic assumptions on the potential damage to the SNA are supported by two independent but similar clinical studies. Alfieri and colleagues [4] and Tambeur and associates [5] studied the incidence of sinus rhythm disturbances that might follow the superior transseptal approach. They reported that during the early postoperative electrocardiographic monitoring 53% [4] and 52% [5] of patients, who were in sinus rhythm before the operation, exhibited atrial arrhythmias. Moreover in other reports 60% of the patients exhibited sinus node rhythm disturbances [6].

Our opinion is that the intraoperative damage of SNA can be avoided if surgeons identify the artery on the coronary arteriograms performed before the operation. Owing to the identification of the artery’s branching point and its relation to the SVC, the course of the artery and its position to the superior posterior border of the interatrial septum can be determined.

In cases in which the probability is high that the artery might cross the superior posterior border of the interatrial septum, the superior transseptal approach should be avoided. Above all, if the incision is restricted to the area of the septum, the sinus node blood supply could be preserved in all cases of the described types. Restriction of the approach is possible by revealing the septum borders and by introducing endoscopic techniques to this procedure. Such endoscopic restriction of this approach would enable the surgeon to gain an optimal view of the valve and its subvalvular apparatus.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Kon N.D., Tucker W.Y., Mills A.S., Lavender S.W., Cordell A.R. Mitral valve operation via an extended transeptal approach. Ann Thorac Surg 1993;55:1413-1417.[Abstract]
  2. Guadino M., Alessandrini F., Glieca F., et al. Conventional left atrial versus superior septal approach for mitral valve replacement. Ann Thorac Surg 1997;63:1123-1127.[Abstract/Free Full Text]
  3. Kovacs S.G., Szabados S. Superior-septal approach to the mitral valve. Ann Thorac Surg 1994;57:521-522.[Medline]
  4. Alfieri O., Sandrelli L., Pardini A., et al. Optimal exposure of the mitral valve through an extended vertical transseptal approach. Eur J Cardiothorac Surg 1991;5:294-299.[Abstract]
  5. Tambuer L., Meyns B., Flameng W., Daenen W. Rythm disturbances after mitral valve surgery: comparison between left atrial and extended transseptal approach. Cardiovasc Surg 1996;4:820-824.[Medline]
  6. Shin H., Yozu R., Higashi S., Kawada S. Sinus node function after mitral valve surgery using the superior septal approach. Ann Thorac Surg 2001;71:587-590.[Abstract/Free Full Text]
  7. Hadeiselimovi H. Vascularization of the conducting system in the human heart. Acta Anat 1978;102:105-110.[Medline]
  8. Bokeriya L.A., Mikhailin S.L., Revishvili A.S. Anatomical variants of sinoatrial and atrioventricular node arteries. Cor Vasa 1984;26(3):220-228.[Medline]
  9. Anderson K.R., Ho S.Y., Anderson R.H. Location and vascular supply of sinus node in human heart. Br Heart J 1979;41:28-32.[Abstract/Free Full Text]
  10. Vearhagen L., Van der Hauwaert L.G. Arterial blood supply of the human sinus node. Br Heart J 1967;29:801-806.[Free Full Text]
  11. Smith C.R. Efficacy and safety of the superior-septal approach to the mitral valve. Ann Thorac Surg 1993;55:1357-1358.[Medline]
  12. Arsivala S., Parikh P., Dixit S., Agney M., Kole S., Saksen D. Combined supero-transeptal approach to the mitral valve. Ann Thorac Surg 1992;53:180-181.
  13. Meyer B.W., Verska J.J., Lindesmith G.G., Jones J.C. Open repair of mitral valve lesions. The superior approach. Ann Thorac Surg 1965;1:453-457.
  14. Saksena D.C., Tucker B.L., Lindesmith G.G., Nelson R.M., Stiles Q.R., Meyer B.W. The superior approach to the mitral valve. A review of clinical experiences. Ann Thorac Surg 1971;12:146-153.[Medline]
  15. Pezzella A.T., Effler D.B., Levy I.E. Operative approaches to the left atrium and mitral valve apparatus. Tex Heart Inst J 1983;10:119-123.
  16. Brawley R.K. Improved exposure of the mitral valve in patients with small left atrium. Ann Thorac Surg 1980;29:179-181.[Abstract]
  17. Bowman FO Jr, Malm JR. The transeptal approach to the mitral valve repair 1965;90329–31
  18. Balasundaram S.G., Duran C. Surgical approaches to the mitral valve. J Cardiac Surg 1990;5:163-169.[Medline]



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