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The ligament of Marshall is an epicardial vestigial fold that marks the location of
the embryologic left superior vena cava. It contains the nerve, vein (vein of Marshall),
and muscle tracts.
On the development of the great anterior veins in man and mammalia: including an account
of certain remnants of foetal structure found in the adult, a comparative view of
these great veins in the different mammalia, and an analysis of their occasional peculiarities
in the human subject.
The proximal portions of the muscle tracts connect directly to the coronary sinus
myocardial sleeves. The distal portions of the muscle tracts extend upward into the
pulmonary vein region. Figure 1 shows a postmortem human heart with the ligament of Marshall located between the
left atrial (LA) appendage and left pulmonary vein.
Histologic study showed that the mid and distal portions of the ligament of Marshall
had large numbers of connecting muscle fibers. These fibers may insert into the epicardium
of the LA and left pulmonary vein. These complex myocardial connections between the
structures can form the substrates for reentry that maintain atrial fibrillation (AF).
Electrical connections between left superior pulmonary vein, left atrium, and ligament
of Marshall: implications for mechanisms of atrial fibrillation.
Am J Physiol Heart Circ Physiol.2006; 290: H312-H322
Figure 1Anatomy of the ligament of Marshall (LOM). A: Location of LOM between left atrial appendage (LAA) and left pulmonary vein (LPV).
B: Immunohistochemical staining for tyrosine hydroxylase showing positive staining in
nerve (brown staining, arrow). M = myocardium. C–E: Serial sections showing the LOM isolated from the left atrial wall (C), with three tracts (arrows) emerging from it (D), and eventually inserting into the atrial wall (E) (hematoxylin and eosin stain magnification ×10). F: Serial section from lower end of LOM showing muscle tracts inserting into the left
atrial wall (arrow) and coronary sinus (CS) (hematoxylin and eosin stain, magnification ×10). (Reproduced
with permission from Kim et al.
On the development of the great anterior veins in man and mammalia: including an account of certain remnants of foetal structure found in the adult, a comparative view of these great veins in the different mammalia, and an analysis of their occasional peculiarities in the human subject.
Electrical connections between left superior pulmonary vein, left atrium, and ligament of Marshall: implications for mechanisms of atrial fibrillation.
Am J Physiol Heart Circ Physiol.2006; 290: H312-H322
Identification and catheter ablation of extracardiac and intracardiac components of ligament of Marshall tissue for treatment of paroxysmal atrial fibrillation.
This study was supported by Grants P01-HL78931, R01s-HL78932, and HL71140 from the National Institutes of Health; a Pauline and Harold Price Endowment; and a Piansky Family Endowment.
