The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias

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.