{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T07:18:20Z","timestamp":1788247100909,"version":"build-2803163510"},"reference-count":50,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2024,10,14]],"date-time":"2024-10-14T00:00:00Z","timestamp":1728864000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>The exploration of the cardiac conduction system evolved over a century, marked by groundbreaking discoveries in atrioventricular (AV) nodal physiology. Atrioventricular nodal re-entrant tachycardia (AVNRT), the most prevalent regular tachycardia in humans, remains enigmatic despite extensive research. Detailed examinations of AV nodal anatomy and histology reveal variations in location and shape, influencing electrophysiological properties. Variability in AV nodal extensions and their embryological origins contribute to the complexity of the conduction system. Physiologically, the AV node plays a crucial role in modulating AV conduction, introducing delays for ventricular filling and filtering atrial impulses. Dual-pathway physiology involving fast and slow pathways further complicates AVNRT circuitry. Integrated approaches combining pre-procedural imaging with electroanatomical mapping enhance our understanding of AV nodal structures and high-definition mapping improves precision in identifying ablation targets. Electrophysiological\u2013anatomical correlations may unveil the specific roles of conduction axis components, aiding in the optimization of ablation strategies. This review traces the historical journey from Tawara\u2019s pioneering work to recent integrated approaches aimed at unraveling the intricacies of AV nodal structures while emphasizing the importance of a multidimensional approach, incorporating technological advancements, anatomical understanding, and clinical validation in human mapping studies.<\/jats:p>","DOI":"10.3390\/jcdd11100323","type":"journal-article","created":{"date-parts":[[2024,10,14]],"date-time":"2024-10-14T06:46:33Z","timestamp":1728888393000},"page":"323","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Relevance of Anatomical Significance of AV Nodal Structures within Koch\u2019s Triangle and Pyramid"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8831-6178","authenticated-orcid":false,"given":"Andrea","family":"Matteucci","sequence":"first","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"},{"name":"Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudio","family":"Pandozi","sequence":"additional","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurizio","family":"Russo","sequence":"additional","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Galeazzi","sequence":"additional","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giammarco","family":"Schiaffini","sequence":"additional","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9480-1209","authenticated-orcid":false,"given":"Marco Valerio","family":"Mariani","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, \u201cSapienza\u201d University of Rome, 00166 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0794-4296","authenticated-orcid":false,"given":"Carlo","family":"Lavalle","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, \u201cSapienza\u201d University of Rome, 00166 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7187-2234","authenticated-orcid":false,"given":"Furio","family":"Colivicchi","sequence":"additional","affiliation":[{"name":"Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,10,14]]},"reference":[{"key":"ref_1","unstructured":"Tawara, S. (1906). Das Reizleitungssystem des Saugetierherzens, Gustav Fisher."},{"key":"ref_2","first-page":"208","article-title":"Uber Das Ultimum Moriens Des Menschlichen Herzens","volume":"42","author":"Koch","year":"1907","journal-title":"Ein Beitrag Zur Frage Des Sinusgebietes. Beitr Pathol Anat"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1093\/europace\/euab285","article-title":"Miniseries 1-Part III: \u2018Behind the scenes\u2019 in the triangle of Koch","volume":"24","author":"Tretter","year":"2022","journal-title":"Europace"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1093\/europace\/euab292","article-title":"Miniseries 2-Septal and paraseptal accessory pathways-Part I: The anatomic basis for the understanding of para-Hisian accessory atrioventricular pathways","volume":"24","author":"Anderson","year":"2022","journal-title":"Europace"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1093\/europace\/euab291","article-title":"Miniseries 1-Part II: The comparative anatomy of the atrioventricular conduction axis","volume":"24","author":"Tretter","year":"2022","journal-title":"Europace"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.aanat.2010.11.002","article-title":"Gross anatomy of the human cardiac conduction system with comparative morphological and developmental implications for human application","volume":"193","author":"Tomokazu","year":"2011","journal-title":"Ann. Anat."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1002\/ar.20631","article-title":"Connexin 43 expression delineates two discrete pathways in the human atrioventricular junction","volume":"291","author":"Hucker","year":"2008","journal-title":"Anat. Rec."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1161\/01.CIR.97.2.188","article-title":"Posterior extensions of the human compact atrioventricular node: A neglected anatomic feature of potential clinical significance","volume":"97","author":"Inoue","year":"1998","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"179","DOI":"10.15420\/aer.2017.30.1","article-title":"At the atrioventricular crossroads: Dual pathway electrophysiology in the atrioventricular node and its underlying heterogeneities","volume":"6","author":"George","year":"2017","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1016\/j.hrthm.2009.01.021","article-title":"The extent of the specialized atrioventricular ring tissues","volume":"6","author":"Yanni","year":"2009","journal-title":"Heart Rhythm."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1093\/europace\/euaa031","article-title":"Re-evaluation of the structure of the atrioventricular node and its connections with the atrium","volume":"22","author":"Anderson","year":"2020","journal-title":"Europace"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1152\/physrev.1988.68.2.608","article-title":"Morphology and electrophysiology of the mammalian atrioventricular node","volume":"68","author":"Meijler","year":"1988","journal-title":"Physiol. Rev."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Rivaud, M., Blok, M., Jongbloed, M., and Boukens, B. (2021). How cardiac embryology translates into clinical arrhythmias. J. Cardiovasc. Dev. Dis., 8.","DOI":"10.3390\/jcdd8060070"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Anderson, R., Mori, S., Spicer, D., Sanchez-Quintana, D., and Jensen, B. (2018). The anatomy, development, and evolution of the atrioventricular conduction axis. J. Cardiovasc. Dev. Dis., 5.","DOI":"10.3390\/jcdd5030044"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1016\/j.hrthm.2022.08.025","article-title":"New Insights Into the Mechanisms of Fast and Slow Conduction in the Atrioventricular Node","volume":"20","author":"Katritsis","year":"2022","journal-title":"Heart Rhythm."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1016\/j.yjmcc.2010.12.017","article-title":"Molecular architecture of the human specialized atrioventricular conduction axis","volume":"50","author":"Greener","year":"2011","journal-title":"J. Mol. Cell. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1016\/j.hrthm.2012.10.020","article-title":"Connexins and the atrioventricular node","volume":"10","author":"Temple","year":"2013","journal-title":"Heart Rhythm."},{"key":"ref_18","first-page":"449","article-title":"Voltage-gated sodium channels in the mammalian heart","volume":"14","author":"Zimmer","year":"2014","journal-title":"Glob. Cardiol. Sci. Pract."},{"key":"ref_19","first-page":"164","article-title":"Molecular investigation into the human atrioventricular node in heart failure","volume":"5","author":"Dobrzynski","year":"2015","journal-title":"Anat. Physiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1113\/jphysiol.2006.126714","article-title":"Regional and tissue-specific transcript signature of ion channel genes in the non-diseased human heart","volume":"582","author":"Gaborit","year":"2007","journal-title":"J. Physiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.hrthm.2004.11.018","article-title":"Atrioventricular conduction in mammalian species: Hemodynamic and electrical scaling","volume":"2","author":"Meijler","year":"2005","journal-title":"Heart Rhythm."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1152\/physrev.00025.2003","article-title":"Basic mechanisms of cardiac impulse propagation and associated arrhythmias","volume":"84","author":"Rudy","year":"2004","journal-title":"Physiol. Rev."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1161\/01.RES.7.1.11","article-title":"Electrical activity of single fibers of the atrioventricular node","volume":"7","author":"Hoffman","year":"1959","journal-title":"Circ. Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1152\/ajplegacy.1958.194.3.491","article-title":"Mechanism of the Wenckebach-Luciani cycles","volume":"194","author":"Rosenblueth","year":"1958","journal-title":"Am. J. Physiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1111\/j.1540-8167.1993.tb01239.x","article-title":"Morphology of the cardiac conduction system in patients with electrophysiologically proven dual atrioventricular nodal pathways","volume":"4","author":"Ho","year":"1993","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1111\/j.1540-8167.1998.tb00927.x","article-title":"Evidence for multiple atrio-AV nodal inputs in the normal dog heart","volume":"9","author":"Antz","year":"1998","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_27","first-page":"H2333","article-title":"Evidence for functionally distinct dual atrial inputs to the human AV node","volume":"267","author":"Stein","year":"1994","journal-title":"Am. J. Physiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1152\/ajpheart.00115.2007","article-title":"Atrioventricular conduction with and without AV nodal delay: Two pathways to the His in the rabbit heart","volume":"293","author":"Hucker","year":"2007","journal-title":"Am. J. Physiol.-Heart Circ. Physiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1007\/s10840-015-0079-0","article-title":"His electrogram alternans (Zhang\u2019s phenomenon) and a new model of dual pathway atrioventricular node conduction","volume":"45","author":"Zhang","year":"2016","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1093\/europace\/euy099","article-title":"Cardiac connexion genotyping for the identification of the circuit of atrioventricular nodal re-entrant tachycardia","volume":"21","author":"Katritsis","year":"2019","journal-title":"Europace"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1596","DOI":"10.1093\/europace\/euab130","article-title":"Spatial characterization of the tachycardia circuit of atrioventricular nodal re-entrant tachycardia","volume":"23","author":"Katritsis","year":"2021","journal-title":"Europace"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e022811","DOI":"10.1161\/JAHA.121.022811","article-title":"The specialized atrioventricular ring tissues participate in the circuit of atrioventricular nodal re-entrant tachycardia","volume":"10","author":"Katritsis","year":"2021","journal-title":"J. Am. Heart Assoc."},{"key":"ref_33","first-page":"101276","article-title":"Multi-modal characterization of the left atrium by a fully automated integration of pre-procedural cardiac imaging and electro-anatomical mapping","volume":"49","author":"Hermans","year":"2023","journal-title":"Int. J. Cardiol. Heart Vasc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1116","DOI":"10.1016\/j.neuroimage.2006.01.015","article-title":"User-guided 3D active contour segmentation of anatomical structures: Significantly improved efficiency and reliability","volume":"31","author":"Yushkevich","year":"2006","journal-title":"Neuroimage"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1111\/jce.16168","article-title":"High-density mapping of Koch\u2019s triangle during sinus rhythm and typical atrioventricular nodal re-entrant tachycardia, integrated with direct recording of atrio-ventricular node structure potential","volume":"35","author":"Pandozi","year":"2024","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1016\/j.hrthm.2023.01.004","article-title":"New insights into atrioventricular nodal anatomy, physiology, and immunochemistry: A comprehensive review and a proposed model of the slow-fast atrioventricular nodal reentrant tachycardia circuit in agreement with direct potential recordings in the Koch\u2019s triangle area","volume":"20","author":"Pandozi","year":"2023","journal-title":"Heart Rhythm."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1093\/europace\/euab292","article-title":"Miniseries 2-Septal and paraseptal accessory pathways-Part III: Mid-paraseptal accessory pathways-revisiting bypass tracts crossing the pyramidal space","volume":"24","author":"Anderson","year":"2022","journal-title":"Europace"},{"key":"ref_38","first-page":"705","article-title":"Clinical structural anatomy of the inferior pyramidal space reconstructed within the cardiac contour using multidetector-row computed tomography","volume":"26","author":"Mori","year":"2015","journal-title":"JCE"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1093\/europace\/euab292","article-title":"Miniseries 2-Septal and paraseptal accessory pathways-Part II: Para-Hisian accessory pathways-so-called anteroseptal pathways revisited","volume":"24","author":"Anderson","year":"2022","journal-title":"Europace"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1344","DOI":"10.1016\/j.hrthm.2017.04.036","article-title":"Focal atrial tachycardias from the parahisian region: Strategies for mapping and catheter ablation","volume":"14","author":"Yang","year":"2017","journal-title":"Heart Rhythm."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1016\/j.jacep.2015.11.003","article-title":"What Is the Optimal Approach to Ablation of Para-Hisian Atrial Tachycardias?","volume":"2","author":"Markowitz","year":"2016","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1016\/j.jacc.2010.03.069","article-title":"Atrial tachycardia arising adjacent to noncoronary aortic sinus: Distinctive atrial activation patterns and anatomic insights","volume":"31","author":"Liu","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1268","DOI":"10.1016\/j.hrthm.2018.02.028","article-title":"How to map and ablate parahisian ventricular arrhythmias","volume":"15","author":"Enriquez","year":"2018","journal-title":"Heart Rhythm."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1136\/hrt.43.3.332","article-title":"Classification of ventricular septal defects","volume":"43","author":"Soto","year":"1980","journal-title":"Br. Heart J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.1016\/j.hrthm.2018.04.029","article-title":"Endocardial ablation of ventricular ectopic beats arising from the basal inferoseptal process of the left ventricle","volume":"15","author":"Li","year":"2018","journal-title":"Heart Rhythm."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e004048","DOI":"10.1161\/CIRCEP.116.004048","article-title":"Right atrial approach for ablation of ventricular arrhythmias arising from the left posterior-superior process of the left ventricle","volume":"9","author":"Santangeli","year":"2016","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Brunet, J., Cook, A.C., Walsh, C.L., Cranley, J., Tafforeau, P., Engel, K., Berruyer, C., O\u2019Leary, E.B., Bellier, A., and Torii, R. (2023). Multidimensional Analysis of the Adult Human Heart in Health and Disease using Hierarchical Phase-Contrast Tomography (HiP-CT). bioRxiv.","DOI":"10.1101\/2023.10.09.561474"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1002\/ca.23793","article-title":"The atrioventricular conduction axis and the aortic root-Inferences for transcatheter replacement of the aortic valve","volume":"35","author":"Tretter","year":"2022","journal-title":"Clin. Anat."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e000972","DOI":"10.1136\/openhrt-2018-000972","article-title":"Anatomical predictors of conduction damage after transcatheter implantation of the aortic valve","volume":"6","author":"Tretter","year":"2019","journal-title":"Open Heart."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1016\/j.hrthm.2017.10.030","article-title":"High-resolution mapping of the triangle of Koch: Spatial heterogeneity of fast pathway atrionodal connections","volume":"15","author":"Chua","year":"2018","journal-title":"Heart Rhythm."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/11\/10\/323\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:12:58Z","timestamp":1760112778000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/11\/10\/323"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,10,14]]},"references-count":50,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2024,10]]}},"alternative-id":["jcdd11100323"],"URL":"https:\/\/doi.org\/10.3390\/jcdd11100323","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,10,14]]}}}