1421

Clinical Review
Editor: Stephen C. Hammill, M.D.

Correlative Anatomy for the Electrophysiologist, Part I:

The Pericardial Space, Oblique Sinus, Transverse Sinus
NIRUSHA LACHMAN, Ph.D.,∗ FAISAL F. SYED, M.B.Ch.B.,† AMMAR HABIB, M.D.,†
SURAJ KAPA, M.D.,‡ SUSAN E. BISCO, M.A.,¶ K. L. VENKATACHALAM, M.D.,§
and SAMUEL J. ASIRVATHAM, M.D., F.A.C.C., F.H.R.S.¶,∗∗
From the ∗ Department of Anatomy, Mayo Clinic, Rochester, Minnesota, USA; †Department of Internal Medicine, Mayo Clinic,
Rochester, Minnesota, USA; ‡Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, USA; ¶Division
of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; §Division of Cardiovascular Diseases,
Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA; and ∗∗ Department of Pediatrics and Adolescent Medicine, Mayo
Clinic, Rochester, Minnesota, USA

The Pericardial Space, Oblique Sinus, Transverse Sinus. There is an increasing need for
invasive electrophysiologists to appreciate the exact anatomy of the epicardial space and the coronary
veins. The location of the epicardial fat, the complementary relationship with the main cardiac veins, and
the location of sensitive structures (arteries, phrenic nerve, esophagus) have become required knowledge
for electrophysiologists, and accessing the epicardial space with this thorough knowledge of the pericardial
sinuses and recesses is essential to allow radiographic correlation during catheter manipulation. In this
review, we briefly describe the anatomy of the pericardial space and then discuss the specific correlation
for the invasive electrophysiologist, highlighting epicardial access, catheter navigation, and avoidance of
collateral injury with specific attention to the important recesses of the pericardial space, their regional
anatomy, and radiographic correlation when navigating catheters to these locations. We also discuss the
anatomy of the main cardiac veins in the context of catheter mapping and ablation of the epicardial
substrate through the venous system and without subxiphoid pericardial access. In Part I of this two-
part series, we discuss the regional anatomy of the pericardial space, oblique sinus, and transverse sinus.
(J Cardiovasc Electrophysiol, Vol. 21, pp. 1421-1426, December 2010)

pericardial space, arrhythmia, catheter ablation, oblique sinus, transverse sinus

Introduction In this review, we discuss the detailed anatomy of the peri-

Arrhythmogenic substrate has traditionally been ap-
proached endocardially with radiofrequency ablation proce-
dures. However, the focus of automatic tachycardias, as well
as critical slow zones for reentrant arrhythmia, may be lo-
cated epicardially. Invasive electrophysiologists increasingly
utilize the epicardial space, as well as the coronary veins, to
map and target such substrates for definitive therapy.1-3
In addition, nonablation procedures, including percuta-
neous left atrial appendage (LAA) ligation and percutaneous
subxiphoid pacemaker lead implantations, involve accessing
the epicardial space.3 As a result, the invasive electrophysiol-
ogist requires a detailed knowledge of the regional anatomy
of the pericardial space and coronary veins.
No disclosures.
Address for correspondence: Samuel J. Asirvatham, M.D., Division of Car-
diovascular Diseases, Department of Internal Medicine, Mayo Clinic Col-
lege of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Fax:
507-255-2520; E-mail: asirvatham.samuel@mayo.edu
Manuscript received 14 May 2010; Revised manuscript received 11 June
2010; Accepted for publication 23 June 2010.
doi: 10.1111/j.1540-8167.2010.01872.x
cardial space and coronary venous system (CVS). For each
of these structures, we present a general anatomic overview
and then discuss in depth specific regional anatomy followed
by the related electrophysiology/anatomy correlation. Since
epicardial access is a prerequisite for subsequent navigation,
mapping, and ablation in the epicardial space, we discuss
specific anatomic issues related to obtaining epicardial ac-
cess with a focus on avoiding complications and enabling
the interventionalist to troubleshoot difficulties encountered
when attempting subxiphoid pericardial access and subse-
quent epicardial fluoroscopy-guided navigation.
Pericardial Space
Anatomy
The pericardial cavity is a potential space between the
parietal and visceral layers of the serous pericardium. It is
continuous with the epicardium and reflects around the roots
of the great vessels and onto the visceral surface of the fibrous
pericardium (Fig. 1), which is continuous with the adventi-
tia of the great vessels superiorly and related posteriorly to
the bronchi, esophagus, descending thoracic aorta, and me-
diastinal surface of each lung. The phrenic nerves descend
1422 Journal of Cardiovascular Electrophysiology Vol. 21, No. 12, December 2010
between it and the mediastinal pleural layers that adhere to
its lateral sides.
The oblique sinus, a recess located behind the left atrium,
is formed as the pericardium envelopes the pulmonary veins
and venae cavae. Within it lies the vein of Marshall, con-
nected by the fetal remnant of the duct of Couvier to the
highest left intercostal vein, drain into the coronary sinus.
The transverse sinus is located superior to the heart be-
tween the arterial mesocardium, which envelopes the as-
cending aorta and pulmonary trunk anteriorly, and the ve-
nous mesocardium, which covers the superior vena cava
(SVC), left atrium, and pulmonary veins posteriorly and
inferiorly.
The identification of pericardial recesses on Multidetector
CT has reemphasized the clinical importance of accurate un-
derstanding of the anatomical configuration of the transverse
and oblique sinus. Truong et al. have presented a description
of transverse pericardial recesses relative to its relation above
and below the aorta and to the left and right pulmonary ar-
teries.4 In addition, a postcaval recess has been identified as
an extended space along the lateral aspect of the SVC.5 The
oblique sinus presents right and left pulmonary venous re-
cesses located between the superior and inferior pulmonary
veins that project superiorly and medially behind the left
atrium with resulting indentations into the side walls of the
oblique sinus.4
Epicardial Access
The technique for safely accessing the normal pericardial
space for the purposes of epicardial intervention was first
described by Sosa and colleagues using a modification of the
traditional method.6 This approach allows free access to the
entire ventricular surfaces, the right atrium, and the majority
of the left atrium.7
For ablation procedures, it is best to first position the
intracardiac catheters, which can help identify the right ven-
tricular apex anteriorly and coronary sinus posteriorly. With
the patient positioned horizontally, skin entry is usually made
approximately 2 cm below the subxiphoid process. A blunt-
tipped 18-guage Tuohy epidural needle is directed posteriorly
Figure 1. Anatomy of the pericardium in
the epicardial space. The left panel (A)
shows a “window” of the parietal peri-
cardium (arrow) cut away. Note the ex-
tensive epicardial fat adhered to the vis-
ceral pericardium. The right panel (B) has
the heart removed, showing the visceral
pericardium posteriorly and around the
great vessels. The white arrow points to
the oblique sinus and the yellow arrow to
the transverse sinus (see text for details).
toward the left shoulder under fluoroscopic guidance, adjust-
ing the angle of entry according to whether an anterior or
posterior approach is preferred. Once the needle traverses
the skin, subcutaneous tissue, and diaphragm, small volumes
of contrast are injected as it approaches the cardiac border.
The contrast is seen to pool in the extrapericardial tissue until
the needle enters the potential pericardial space, when further
injection of contrast outlines the pericardium as a thin film
surrounding the cardiac silhouette.3,6
During this stage, there is potential for damage to im-
portant surrounding structures that include the myocardium,
great vessels, coronary arteries, lungs, mediastinum, esoph-
agus, liver, diaphragmatic vessels, and phrenic nerves. How-
ever, with relevant expertise serious complications are rare,
and the most frequently reported complications of epicardial
ablation are pericarditis and hemopericardium.3,8-10
One potential complication, myocardial puncture, is usu-
ally identified by the aspiration of blood, and, as long as it
is identified at the stage of needle entry, the needle can be
gently withdrawn with negative syringe suction until cessa-
tion of bloody return. Certain steps can be taken to minimize
the risk of this occurring. Fluoroscopy is used to determine
proximity to the cardiac border and an oblique entry into the
pericardial space. As the needle contacts the myocardium,
there is tactile feedback and possibly ectopics as the needle
tip irritates the ventricle. Monitoring for a current of injury
from a crocodile clip attached to the shaft of the needle
can identify myocardial entry and possibly prevent damage.
Likewise, liver laceration during needle entry can be avoided
in most cases by pushing the liver gently out of the way with
one hand as the other advances the needle, and maintaining
the course of the needle once the subcutaneous tissues are
traversed.9,10
Occasionally, the wire can enter into the extrapericardial
space. One technique to avoid this involves monitoring for
a current of injury from the needle to identify myocardial
entry and advancing the wire when the needle is partially
withdrawn back into the pericardial space. Coronary arterial
damage during pericardial access is rare and can be mini-
mized by directing the needle away from the ventricular sep-
tum. Diaphragmatic vessel injury is also rare but may cause
 Lachman et al.
Figure 2. Fluoroscopic images (Panel
A: RAO, Panel B: LAO) illustrating the
relationship of the epicardial space to
the ventricular outflow tracts. The arrow
points to an ablation catheter placed in
the supravalvar LVOT and the asterisk
to an ablation/mapping catheter placed
in the RVOT. Note that the entire RVOT
overlies the LVOT precluding access to
the LVOT from the epicardial space, ex-
cept for a small portion that may be ac-
cessed via the transverse sinus (see text).
RAO = right anterior oblique; LAO = left
anterior oblique; LVOT = left ventricular
outflow tract; RVOT = right ventricular
outflow tract.
life-threatening hemoperitoneum, requiring blood transfu-
sion and surgery.7,9,10
Once in the pericardial space, guidewire placement is
monitored fluoroscopically to ensure that inadvertent entry
into the right ventricle or the extrapericardial space has not
occurred. Pericardial placement of the wire is confirmed by
observing the wire wrapping around the cardiac silhouette,
traversing chamber boundaries as it crosses both right and
left cardiac borders. It is important to ensure pericardial wire
placement before the needle is withdrawn over the wire and
the sheath introduced.
While the subxiphoid is the most widely used approach,
accessing the pericardium across the esophagus,11,12 the left
lower lobe bronchus,13 the right atrium,14,15 and the anterior
mediastinum (reached from a needle directed substernally
from a subxiphoid puncture)16 has been done in experimental
animal work or patients with pericardial effusion. Some of
these alternate accesses may have potential for future clinical
application in epicardial intervention.
Fluoroscopic Anatomic Correlation
The right anterior oblique (RAO) and left anterior oblique
(LAO) positions project the heart in its anatomic sagittal and
coronal planes such that in RAO, the left and right sides are
superimposed but there is good atrioventricular differenti-
ation, whereas in LAO there is left-right differentiation but
the atria and ventricles are superimposed. The coronary sinus
catheter marks the mitral valve annulus from the interatrial
septum medially. These landmarks can be used to determine
the position of the epicardial catheter as it is navigated within
the pericardial space.17
Once a catheter is inserted into the pericardial space, it
can be moved freely laterally, anteriorly, and inferiorly over
various parts of the ventricle ranging from the right ventric-
ular outflow tract (RVOT) to the posterior crux.7 Damage
to the coronary arteries during ablation is a major concern,
particularly when it becomes necessary to ablate at the base
of the heart or septum, for example, in the case of acces-
sory pathways that could not otherwise be ablated with an
endocardial or intravenous approach. Fluoroscopic identifi-
cation of anatomic landmarks, supplemented by intracardiac
catheters, including retrograde placement at the aortic root,
will help in avoiding this.
The mitral and tricuspid annuli are intimately related to
the major arteries and veins of the heart. The mitral annulus
is outlined by the coronary sinus catheter and the tricuspid
The Pericardial Space, Oblique Sinus, Transverse Sinus 1423
annulus identified by the endoluminal RV catheter, while the
septum is defined fluoroscopically by the His catheter. Any
remaining doubt regarding proximity to a coronary artery
should prompt performing coronary angiography. It is im-
portant to also appreciate the close relation of the RVOT to
the proximal coronary arteries and distal coronary veins.17
The LAA is easily reached and the first atrial structure
to be encountered when a catheter is advanced laterally and
cranially, being identifiable by the characteristic change in
electrograms.18 Understanding its fluoroscopic anatomy is
important for electrophysiologists because of its close prox-
imity to the RVOT and the proximal coronary arterial sys-
tem. It should be noted that the left ventricular outflow tract
(LVOT) cannot be reached using this approach because it is
covered by the RVOT anteriorly and the mitral valve or the
left atrium posteriorly (Fig. 2).7
The blind-ending oblique sinus can be reached by passing
the catheter superiorly behind the heart, its opening being
bounded by the two inferior pulmonary veins. Its importance
in contemporary ablation practice of atrial arrhythmias is
related to its unique anatomic location behind the pulmonary
venous atrium and the posterior left atrial wall. Within it
rests the vein of Marshall, which can itself be a source of
arrhythmia amenable to ablation.19 The esophagus is directly
behind and subject to thermal injury.20
The transverse sinus lies superior to the oblique sinus and
can be reached by passing the catheter around the lateral
wall of the left ventricle and left atrium, and then under the
pulmonary arteries. It is of functional importance because
a catheter placed at this site may ablate the roof of the left
atrium or Bachmann’s bundle and important sites for certain
atrial arrhythmias.21 It is intimately related to the aorta, which
arches around it, the pulmonary arteries, and left atrium. The
floor of the transverse sinus is formed by the pericardial re-
flection between the right and left superior pulmonary veins,
which separates it from the oblique sinus and the roof of the
left atrium, which is the location of Bachmann’s bundle. It
allows access to the anterior LVOT as it communicates with
the epicardial aspect of the noncoronary and right coronary
aortic cusps via the inferior aortic recess. It also communi-
cates with the venae cavae by way of the aortocaval sinus,
a small virtual space between the SVC and the ascending
aorta that in some individuals is large enough to bypass with
a catheter and reach the right heart border.19 In the vicin-
ity are 3 parasympathetic ganglia that can be found within
epicardial fat pads.
1424 Journal of Cardiovascular Electrophysiology Vol. 21, No. 12, December 2010
Electrophysiology Correlation
Although the invasive electrophysiologist needs to be
aware of the epicardial space regional anatomy in general,
there are some specific locations that require detailed atten-
tion, either because of the complexity of the region or the
frequency that these sites are targeted (Fig. 3).
The Oblique Sinus
Anatomy
The oblique sinus is not an actual passage but rather a
cul-de-sac that may be explored by accessing the area behind
the left atrium and left ventricle. From within the oblique
sinus the posterior wall of the left atrium with its retroatrial
fat housing the retroatrial ganglionated plexuses can be ac-
cessed anteriorly. The oblique sinus is devoid of a floor as it
communicates with the main pericardial space inferiorly. To
the left, the fold of Marshall may be seen, as well as the left-
sided pulmonary veins located lateral to the fold of Marshall
in the superior half of the oblique sinus, with the inferior
pulmonary vein in closer proximity to the lateral limit of the
oblique sinus. To the right, the sinus is related to regional
specific epicardial fat ganglionated plexuses and the right
pulmonary veins. Immediately behind the oblique sinus, the
esophagus and the plexal branches of the vagus nerve may
be accessed.19,20
Electrophysiology Correlation
Posterior left atrial ablation
Since the oblique sinus (along with a variable amount of
fibrous tissue, fat, and occasional lymph nodes) separates
the posterior wall of the left atrium from the esophagus,
monitoring the oblique sinus for evidence of thermal injury
Figure 3. Cartoon showing the pericar-
dial sinuses and recesses that result from
the entering of the great arteries and veins
into the heart. The oblique sinus lies pos-
terior to the left atrium, and the transverse
sinus above the roof of the left atrium be-
hind the posterior wall of the ascending
aorta (see text for details). PCR = poste-
rior caval recess; RPVR = right posterior
venous recess; LPVR = left posterior ve-
nous recess; IAR = inferior atrial recess.
can help prevent esophageal trauma. Esophageal perforation
may breach the integrity of the oblique sinus, giving rise to
pericardial inflammation and pneumopericardium.20
Autonomic ganglia ablation
Epicardial access to the oblique sinus may be required
for mapping and targeting for modulation of the epicardial
retroatrial cardiac ganglia.
The Transverse Sinus
Anatomy
For the electrophysiologist, an understanding of the re-
lations of surrounding anatomical structures provides an ef-
fective way of appreciating the anatomy of the transverse
sinus. It is important to note that the ascending aorta and pul-
monary trunk are enclosed by a common pericardial sleeve.
The posterior reflection off the aorta and pulmonary trunk in
a posterior and downward direction to line a portion of the
pericardial cavity into which a probe may be passed. This
anatomical space, referred to as the transverse pericardial si-
nus, is simply a passage from the left side to the right side of
the pericardial cavity, which lies behind the great arteries.22
Superiorly within the roof of the transverse sinus lies the right
pulmonary artery as it passes to the right beneath the aortic
arch. Inferiorly, the floor of the transverse sinus is formed by
the roof of the left atrium, specifically the transverse fibers
that constitute Bachmann’s bundle, which crosses the floor
of the transverse sinus from the roof of the right to the roof
of the LAA. The posterior wall of the ascending aorta at the
level of the superior margin of the aortic cusps or sinotubu-
lar junction lies anteriorly. To the left and in front lies the
main pulmonary artery with the SVC and its small continuing
recess called the aorto-caval sinus to the right (Fig. 4).23-25
 Lachman et al.
Figure 4. Regional anatomy of the trans-
verse sinus. Panel A: (courtesy Dr.
William D. Edwards, MD, Mayo Clinic
Rochester) shows a red probe placed in
the transverse sinus. Note anterior to the
probe is the ascending aorta and the
common pulmonary trunk. Panel B: tho-
racic discussion with overlaid figure of
the transverse sinus showing the route of
the sheath and mapping catheter from the
subxiphoid, around the natural border of
the heart, and into the posteriorly located
transverse sinus above the left atrial roof.
Electrophysiology Correlation
Specific navigation of the mapping/ablation catheter into
the transverse sinus may be required to treat certain arrhyth-
mias. Bachmann’s bundle (the floor of the transverse sinus)
may require targeted ablation to treat interatrial flutters often
seen following the surgical maze procedure.
The transverse sinus may also be the only significant
method of epicardially accessing the LVOT and proximal
aorta. Anteriorly, the RVOT nearly entirely overlies the
LVOT. However, the posterior proximal wall of the ascending
aorta in the region of the noncoronary cusp may be accessed
via the transverse sinus since the ascending aorta is the ante-
rior boundary of this sinus.26
Pericardial Fat
Anatomy
In demarcating the distribution of adipose tissue around
the heart, studies have shown epicardial fat to aggregate
around specific anatomic sites that include the free wall of
the right ventricle and the left ventricular apex, around the
atria and atrial appendages, and along the adventitia sur-
rounding the coronary artery branches.27,28 While epicardial
fat presents in this typical pattern, studies have shown adi-
pose tissue to infiltrate myocardium in a close functional
and anatomic relationship between these two tissues with no
difference in the absolute amount of fat located within each
ventricle.28-30
Electrophysiology Correlation
A common method of identifying the target sites for ab-
lation with reentrant ventricular tachyarrhythmia, as seen in
ischemic heart disease, is to perform a substrate map and
identify and target areas of low amplitude electrograms and
fragmented signals for ablation. This “scar”-based approach,
when performed epicardially, needs to take into account the
typical anatomic distribution of the epicardial fat.31-33 Thus,
low amplitude signals, especially when relatively far-field
in nature, obtained near the atrial ventricular grooves or on
the anterior and posterior intraventricular grooves, need to
The Pericardial Space, Oblique Sinus, Transverse Sinus 1425
be interpreted with caution, given the abundance of adipose
tissue that may prevent catheter contact with the underlying
myocardium in these locations.
The anatomic distribution of the epicardial fat is also im-
portant since the coronary vasculature and the pericardiac
ganglia are frequently intertwined and distributed through
this fat. (See Part II regarding detailed anatomy and correla-
tion for the cardiac ganglia.)
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