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MDCT of the S-Shaped Sinoatrial Node Artery

Farhood Saremi1, Stephanie Channual1, Amir Abolhoda2, Swaminatha V. Gurudevan3, Jagat Narula3 and Jeffrey C. Milliken2

1 Department of Radiological Sciences, University of California, Irvine, UCI Medical Center, 101 The City Dr., Route 140, Orange, CA 92868-3298.
2 Department of Cardiothoracic Surgery, University of California, Irvine, UCI Medical Center, University of California, Irvine, Orange, CA.
3 Department of Cardiology, University of California, Irvine, UCI Medical Center, University of California, Irvine, Orange, CA.


Figure 1
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  		Fig. 1A —62-year-old man with chest pain. Anatomic course of S-shaped SAN artery. Axial CT scan at level of left atrial appendage (LAA) (A) and left lateral 3D CT scans in two different projections (B and C) of heart show that on axial images, S-shaped posterior sinoatrial node (SAN) artery (large arrows, A-C) can easily be identified where it courses between LAA and left superior pulmonary vein (LSPV). Artery arises from proximal left circumflex artery and courses along lateral wall of left atrium. It usually gives off branches to atrial wall (small arrows, B) before making U-turn toward LAA-LSPV groove. In groove, SAN artery is very close to atrial wall (arrow, A) and can be damaged in surgical procedures on LAA or pulmonary vein isolation procedures. From this point, anatomic course of S-shaped SAN artery is similar to that of left SAN artery, which courses toward superior vena cava along anterior wall of left atrium. LPV = left pulmonary vein trunk, AA = ascending aorta.

 

Figure 2
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  		Fig. 1B —62-year-old man with chest pain. Anatomic course of S-shaped SAN artery. Axial CT scan at level of left atrial appendage (LAA) (A) and left lateral 3D CT scans in two different projections (B and C) of heart show that on axial images, S-shaped posterior sinoatrial node (SAN) artery (large arrows, A-C) can easily be identified where it courses between LAA and left superior pulmonary vein (LSPV). Artery arises from proximal left circumflex artery and courses along lateral wall of left atrium. It usually gives off branches to atrial wall (small arrows, B) before making U-turn toward LAA-LSPV groove. In groove, SAN artery is very close to atrial wall (arrow, A) and can be damaged in surgical procedures on LAA or pulmonary vein isolation procedures. From this point, anatomic course of S-shaped SAN artery is similar to that of left SAN artery, which courses toward superior vena cava along anterior wall of left atrium. LPV = left pulmonary vein trunk, AA = ascending aorta.

 

Figure 3
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  		Fig. 1C —62-year-old man with chest pain. Anatomic course of S-shaped SAN artery. Axial CT scan at level of left atrial appendage (LAA) (A) and left lateral 3D CT scans in two different projections (B and C) of heart show that on axial images, S-shaped posterior sinoatrial node (SAN) artery (large arrows, A-C) can easily be identified where it courses between LAA and left superior pulmonary vein (LSPV). Artery arises from proximal left circumflex artery and courses along lateral wall of left atrium. It usually gives off branches to atrial wall (small arrows, B) before making U-turn toward LAA-LSPV groove. In groove, SAN artery is very close to atrial wall (arrow, A) and can be damaged in surgical procedures on LAA or pulmonary vein isolation procedures. From this point, anatomic course of S-shaped SAN artery is similar to that of left SAN artery, which courses toward superior vena cava along anterior wall of left atrium. LPV = left pulmonary vein trunk, AA = ascending aorta.

 

Figure 4
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  		Fig. 2A —Terminal anatomic course of S-shaped sinoatrial node (SAN) artery. 85-year-old man with retrocaval (A and B) and 61-year-old woman with precaval (C and D) mode of termination of artery. Sculptured 3D CT images (A and C) and corresponding axial images (B and D) at level of superior cavoatrial junction show S-shaped SAN arteries (short arrows, A and C). Proximal courses of artery are similar in most cases. Arising from proximal left circumflex artery, S-shaped SAN artery turns posteriorly and courses in groove between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) orifices (short arrows, B and D). We found that in most cases distal artery coursed close to interatrial groove, penetrated interatrial muscle bundle, and followed its course behind superior vena cava (SVC) (retrocaval) to reach SAN area on lateral aspect of cavoatrial junction (long arrows, A and B). This variant is prone to injury in superior septal approach to mitral valve repair. In precaval mode of termination (long arrows, C and D), artery courses away from interatrial groove to reach anterior margin of superior cavoatrial junction and is less susceptible to injury. AA = ascending aorta, RSPV = right superior pulmonary vein.

 

Figure 5
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  		Fig. 2B —Terminal anatomic course of S-shaped sinoatrial node (SAN) artery. 85-year-old man with retrocaval (A and B) and 61-year-old woman with precaval (C and D) mode of termination of artery. Sculptured 3D CT images (A and C) and corresponding axial images (B and D) at level of superior cavoatrial junction show S-shaped SAN arteries (short arrows, A and C). Proximal courses of artery are similar in most cases. Arising from proximal left circumflex artery, S-shaped SAN artery turns posteriorly and courses in groove between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) orifices (short arrows, B and D). We found that in most cases distal artery coursed close to interatrial groove, penetrated interatrial muscle bundle, and followed its course behind superior vena cava (SVC) (retrocaval) to reach SAN area on lateral aspect of cavoatrial junction (long arrows, A and B). This variant is prone to injury in superior septal approach to mitral valve repair. In precaval mode of termination (long arrows, C and D), artery courses away from interatrial groove to reach anterior margin of superior cavoatrial junction and is less susceptible to injury. AA = ascending aorta, RSPV = right superior pulmonary vein.

 

Figure 6
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  		Fig. 2C —Terminal anatomic course of S-shaped sinoatrial node (SAN) artery. 85-year-old man with retrocaval (A and B) and 61-year-old woman with precaval (C and D) mode of termination of artery. Sculptured 3D CT images (A and C) and corresponding axial images (B and D) at level of superior cavoatrial junction show S-shaped SAN arteries (short arrows, A and C). Proximal courses of artery are similar in most cases. Arising from proximal left circumflex artery, S-shaped SAN artery turns posteriorly and courses in groove between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) orifices (short arrows, B and D). We found that in most cases distal artery coursed close to interatrial groove, penetrated interatrial muscle bundle, and followed its course behind superior vena cava (SVC) (retrocaval) to reach SAN area on lateral aspect of cavoatrial junction (long arrows, A and B). This variant is prone to injury in superior septal approach to mitral valve repair. In precaval mode of termination (long arrows, C and D), artery courses away from interatrial groove to reach anterior margin of superior cavoatrial junction and is less susceptible to injury. AA = ascending aorta, RSPV = right superior pulmonary vein.

 

Figure 7
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  		Fig. 2D —Terminal anatomic course of S-shaped sinoatrial node (SAN) artery. 85-year-old man with retrocaval (A and B) and 61-year-old woman with precaval (C and D) mode of termination of artery. Sculptured 3D CT images (A and C) and corresponding axial images (B and D) at level of superior cavoatrial junction show S-shaped SAN arteries (short arrows, A and C). Proximal courses of artery are similar in most cases. Arising from proximal left circumflex artery, S-shaped SAN artery turns posteriorly and courses in groove between left atrial appendage (LAA) and left superior pulmonary vein (LSPV) orifices (short arrows, B and D). We found that in most cases distal artery coursed close to interatrial groove, penetrated interatrial muscle bundle, and followed its course behind superior vena cava (SVC) (retrocaval) to reach SAN area on lateral aspect of cavoatrial junction (long arrows, A and B). This variant is prone to injury in superior septal approach to mitral valve repair. In precaval mode of termination (long arrows, C and D), artery courses away from interatrial groove to reach anterior margin of superior cavoatrial junction and is less susceptible to injury. AA = ascending aorta, RSPV = right superior pulmonary vein.

 

Figure 8
Figure 8
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  		Fig. 3 —45-year-old woman with S-shaped sinoatrial node artery (short black arrows, C) arising from right coronary artery (RCA).

A-C, Axial CT images at level of left atrial appendage (LAA) (A) and coronary sinus (B) and 3D posterior CT scan (C) of heart show rare variant found in one patient. S-shaped sinoatrial node artery originates from terminal branches of dominant right coronary artery posterior to coronary sinus (CS) (B and C) and courses along posterolateral wall of left atrium toward groove between LAA and left superior pulmonary vein (LSPV). IVC = inferior vena cava, LIPV = left inferior pulmonary vein, PLA = posterolateral artery (long black arrows, C), RA = right atrium. White arrows indicate areas of A and B that correspond to C.

 

Figure 9
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  		Fig. 4A —Findings to be differentiated from S-shaped sinoatrial node artery. S-shaped sinoatrial node artery invariably courses in groove between left atrial appendage and left superior pulmonary vein and is best localized on axial images. 65-year-old man with a history of coronary artery disease and chest pain. CT scan shows independent small atrial branch arising from left circumflex artery (not shown) and coursing in groove between left atrial appendage and left superior pulmonary vein and behind left atrium (white arrows) but not reaching sinoatrial node area. True sinoatrial node artery is left-sided artery arising from left circumflex artery (black arrows).

 

Figure 10
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  		Fig. 4B —Findings to be differentiated from S-shaped sinoatrial node artery. S-shaped sinoatrial node artery invariably courses in groove between left atrial appendage and left superior pulmonary vein and is best localized on axial images. 56-year-old woman with recanalized ligament of Marshall. CT scan shows ligament of Marshall (arrow) is recanalized because left brachiocephalic vein is occluded (not shown).

 

Figure 11
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  		Fig. 4C —Findings to be differentiated from S-shaped sinoatrial node artery. S-shaped sinoatrial node artery invariably courses in groove between left atrial appendage and left superior pulmonary vein and is best localized on axial images. 61-year-old man with persistent left superior vena cava. CT scan shows superior vena cava (arrow) partially filled by collateral vessels. Cardiac chambers are poorly filled with contrast material.

 

Figure 12
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  		Fig. 4D —Findings to be differentiated from S-shaped sinoatrial node artery. S-shaped sinoatrial node artery invariably courses in groove between left atrial appendage and left superior pulmonary vein and is best localized on axial images. 72-year-old man who has undergone coronary artery bypass graft surgery. CT scan shows typical course of saphenous vein graft to obtuse marginal artery. Graft usually courses behind left atrial appendage but with enough distance from groove (white arrow) and should not be mistaken for S-shaped sinoatrial node artery on axial images. S-shaped variant of sinoatrial node artery (black arrows) is evident.

 

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