Fine structure of cells and their histologic organization within internodal pathways of the heart: clinical and electrocardiographic implications

P-wave Indices as Predictors of Atrial Fibrillation: The Lion from a Claw

The P wave, representing the electrical fingerprint of atrial depolarization, contains information regarding spatial and temporal aspects of atrial electrical-and potentially structural-properties. However, technical and biological reasons, including-but not limited to-the low amplitude of the P wave and large interindividual variations in normal or pathologic atrial electrical activity, make gathering and utilizing this information for clinical purposes a rather cumbersome task. However, even crude ECG descriptors, such as P-wave dispersion, have been shown to be of predictive value for assessing the probability that a patient already has or will shortly present with AF. More sophisticated methods of analyzing the ECG signal, on a single- or multi- beat basis, along with novel approaches to data handling, namely machine learning, seem to be leading up to more accurate and robust ways to obtain clinically useful information from the humble P wave.

Alternative atrial pacing site to improve cardiac function: focus on Bachmann's bundle pacing

Pacing from the right atrial appendage (RAA) prolongs the P wave duration and can induce interatrial and especially left-sided atrio-ventricular dyssynchrony. Pacing from Bachmann's bundle closely reproduces normal physiology and has the potential to avoid the electromechanical dysfunction associated with conventional RAA pacing. Interatrial conduction delay is associated with an increased risk of stroke, heart failure, and death. In addition to a reduction in atrial fibrillation, Bachmann's bundle pacing has emerging applications as a hemodynamic pacing modality. This review outlines the pathophysiology of atrial conduction disturbances and their potential remedies and provides the reader with a practical guide to implementing Bachmann's bundle pacing with an emphasis on the recapitulation of normal electrical and mechanical function.

Dependence of the Atrioventricular Conduction Time on the Conduction through the Atrioventricular Node and His-Purkinje System

The electrical depolarization of the heart passes through various structures of the cardiac conduction system, which modify its conduction to different extents. In this study, we investigated the relationship between the atrioventricular conduction time (AV interval) and its contributors, the atrioventricular node (AVN) and the His-Purkinje system (HPS), as represented by the AH and HV intervals, respectively. We also compared sex differences in these intervals and their relations. Resting intracardiac tracings lasting 5 min were obtained from 64 patients (33 women) during an invasive electrophysiological study. The aforementioned intervals were measured for all consecutive beats. The mean AH interval was 85.9 ms, HV 43.7 ms, and AV 129.6 ms. Men had longer AH (80.0 vs. 65.9 ms), HV (38.4 vs. 35.3 ms), and AV intervals (124.7 vs. 108.5 ms) than women. The AV intervals were linearly correlated with AH intervals in all patients (r² = 0.65). No significant correlation was found between AV and HV intervals in all patients (r² = 0.05). There were no sex differences in these associations. Our results suggest that the atrioventricular conduction time depends mainly on the conduction through the AVN and less on the HPS. These relations are similar in both sexes, although men had longer conduction times through the AVN, HPS, and total atrioventricular conduction time.

Atrioventricular junctional ablation: The good, the bad, the better

Background

The management of patients with atrial fibrillation and an abnormally fast ventricular response has been through the use of pharmacologic agents. In those cases where rate control cannot be achieved pharmacologically, a standard approach has been atrioventricular (AV) junctional ablation and ventricular pacemaker implantation to achieve a stable ventricular rate. Long-term ventricular pacing has been shown to result in diminished ventricular function that can lead to heart failure.

Objective

To describe an experimental and clinical study demonstrating a modified form of AV junction ablation.

Methods

Ablation of the slow and fast AV nodal input does not produce AV block. Ablation of the connection between the two induces AV block, leaving the AV node and His bundle intact.

Results

Subsequently the escape heart rate is close to normal and responds well to exercise.

Conclusion

In a clinical study with a 42 month follow-up, the modified procedure resulted in significantly reduced pacemaker dependence and mortality compared to the standard AV ablation procedure.

Triggers and anatomical substrates in the genesis and perpetuation of atrial fibrillation

The definition of atrial fibrillation (AF) as a functional electrical disorder does not reflect the significant underlying structural abnormalities. Atrial and Pulmonary Vein (PV) muscle sleeve microstructural remodeling is present, and establishes a vulnerable substrate for AF maintenance. In spite of an incomplete understanding of the anatomo-functional basis for AF, current evidence demonstrates that this arrhythmia usually requires a trigger for initiation and a vulnerable electrophysiological and/or anatomical substrate for maintenance. It is still unclear whether the trigger mechanisms include focal enhanced automaticity, triggered activity and/or micro re-entry from myocardial tissue. Initiation of AF can be favored by both parasympathetic and sympathetic stimulation, which also seem to play a role in maintaining AF. Finally, evolving clinical evidence demonstrates that inflammation is associated with new-onset and recurrent AF through a mechanism that possibly involves cellular degeneration, apoptosis, and subsequent atrial fibrosis.

Bachmann's Bundle: Does It Play a Role in Atrial Fibrillation?

BACKGROUND

Cardiac anatomists have known the presence of a group of specialized fibers connecting the right and left atrium for years. However, only recently have clinical cardiologists come to recognize the potential importance of this specialized conduction system. Anatomical and microscopic studies have shown that the Bachmann's bundle (BB) represents a distinct structure similar to the atrio-ventricular node and the His-Purkinje conduction system but without any insulating tissue.

RESULTS

BB cells have specialized electrophysiological properties like supernormal excitability and faster longitudinal conduction that can facilitate more rapid impulse transmission compared to the normal atrial tissue. Experimental blockage of this pathway causes prolongation and widening of the P wave, which is associated with an increased incidence of atrial fibrillation. Atrial pacing is effective in reducing the incidence of atrial fibrillation by preventing bradycardia, synchronizing the atria, limiting anisotropy and reducing the dispersion of refractoriness. Various animal and human studies have shown pacing near the right atrial insertion of BB to have a beneficial effect in patients with interatrial conduction delay and atrial tachyarrhythmias. This mode of atrial septal pacing is convenient, safe, reliable, and clinically as effective as multisite pacing.

CONCLUSION

This article is an effort to define the special properties of BB and its possible role in prevention of atrial fibrillation by permanent pacemakers.

Atrial activation mapping in sinus rhythm in the clinical electrophysiology laboratory: observations during Bachmann's bundle block

INTRODUCTION

The high posterolateral right atrium (RA) is considered the "sinus node area," but we lack information on endocardial atrial activation in sinus rhythm. We studied RA and left atrial (LA) endocardial activation in the electrophysiology laboratory.

METHODS AND RESULTS

Thirty-five patients (21 men) aged 47 +/- 16.4 years (mean +/- SD) underwent RA mapping (22.2 +/- 3.8 points). In 21 patients, LA activation was mapped (11.1 +/- 3.9 points) through the coronary sinus (CS), right pulmonary artery, and/or a patent oval foramen. Fourteen patients had atrial arrhythmias, and 3 an ECG pattern of Bachmann's bundle block. Endocardial RA activation preceded P wave in 5 (-14 +/- 4.2 ms), coincided in 11, and followed P onset in 18 (16.7 +/- 6.6 ms). Location of the zero point varied from the superior vena cava to the low RA and from lateral to paraseptal RA. In 19 patients, activation started simultaneously in 2 to 5 points located >or=1 cm apart. RA activation was descending in most, but in 3 with low onset there was collision in the anterior and septal walls. In 15 of 21 patients, descending LA activation dominated, ending in the mid CS in 12, proximal CS in 1, and simultaneously throughout the CS in 2. In 3 with Bachmann's bundle block, CS activation was ascending and in 2 double potentials were recorded from the LA roof.

CONCLUSION

During stable sinus rhythm, RA activation can start in different areas or simultaneously over large areas resulting in different activation patterns, both in the RA and the LA. LA activation is predominantly descending, but in Bachmann's bundle block it becomes ascending, and double potentials suggest a location of block in the LA roof.

Embryonic Conduction Tissue:

INTRODUCTION

The occurrence of arrhythmias in adult patients may arise preferentially in anatomic regions derived from the specialized cardiac conduction system. To examine this hypothesis, we performed a detailed analysis of the developing cardiac conduction system using the recently described CCS-lacZ transgenic mouse strain.

METHODS AND RESULTS

Transgenic embryos (E9.5-15.5) were stained for beta-galactosidase activity and co-stained with the myocardial marker HHF35. Results were reconstructed three dimensionally. CCS-lacZ expression was observed in the sinoatrial node, left and right venous valves, septum spurium, right and left atrioventricular ring, His bundle, bundle branches, and right ventricular moderator band. Furthermore, lacZ-positive cells could be demonstrated for the first time in the left atrium, in the posterior wall surrounding the pulmonary venous orifice. and, in later stages, surrounding the pulmonary venous wall. These cells were continuous with the left venous valve in the right atrium. LacZ-positive tissue also could be identified in Bachmann's bundle, running retro-aortically between the right atrium and left atrium.

CONCLUSION

Known arrhythmogenic areas including Bachmann's bundle, the pulmonary veins, and sinus venosus derived internodal structures, demonstrate lacZ expression. These data support the hypothesis that areas derived from the developing cardiac conduction system may contribute to the arrhythmogenic substrate in adult hearts.

Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation

Specialized Conducting Cells in Human PV.

INTRODUCTION

Depolarizations similar to those from the sinus node have been documented from the pulmonary veins after isolation procedures. We assessed the hypothesis that sinus node-like tissue is present in the pulmonary veins of humans.

METHODS AND RESULTS

Pulmonary vein tissue was obtained from five autopsies (four individuals with a history of atrial fibrillation and one without a history of atrial arrhythmias) and five transplant heart donors. Autopsy veins were fixed in formaldehyde and processed for light microscopy to identify areas having possible conductive-like tissue. Areas requiring additional study were extracted from paraffin blocks and reprocessed for electron microscopy. Donor specimens were fixed in formaldehyde for histologic sections and glutaraldehyde for electron microscopy. Myocardial cells with pale cytoplasm were identified by light microscopy in 4 of the 5 autopsy subjects. Electron microscopy confirmed the presence of P cells, transitional cells, and Purkinje cells in the pulmonary veins of these cases.

CONCLUSION

Our report is the first to show the presence of P cells, transitional cells, and Purkinje cells in human pulmonary veins. Whether these cells are relevant in the genesis of atrial fibrillation requires further study.

Spatial distribution and frequency dependence of arrhythmogenic vagal effects in canine atria

INTRODUCTION

Prior studies in isolated canine atria demonstrated that acetylcholine-induced reentrant atrial fibrillation (AF) was triggered by multifocal activity in the area of normal impulse origin (sinus node-crista terminalis). The aim of this study was to investigate the activation sequence in AF induced by vagal stimulation (VS) in intact dog hearts.

METHODS AND RESULTS

VS (10 to 50 Hz, 1 msec, 15 V, 5-sec trains) induced single or multiple atrial premature depolarizations (APDs), and/or AF in 8 of 10 open chest dogs. Occurrence of APDs and AF increased with increasing VS intensity. Epicardial mapping (254 unipolar electrodes) of both atria showed that APDs as a rule emerged from ectopic sites, often from the right atrial appendage. Activation mapping of the first 10 cycles of AF showed that only a small number (<3 to 4) of unstable reentrant circuits were possible at the same moment. Moreover, most sustained VS-induced AFs were accounted for by a single leading stable reentrant circuit that activated the remainder of the atria.

CONCLUSION

(1) Occurrence of vagally induced APDs and AF increases with increasing frequency of VS. (2) VS-induced focal ectopic APDs are widely distributed over the atria. (3) A single APD can be sufficient for initiation of reentrant AF. (4) Despite its high rate of sustained AF, it may be maintained by single stable reentrant circuit. (5) The atrial septum can play an important role in both the initiation and the maintenance of VS-induced AF.

Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity

BACKGROUND

Abnormal atrial automaticity in young patients with structurally normal hearts is often located around the pulmonary veins and in sinus venosus-related parts of the right atrium. We hypothesize that these ectopic pacemaker sites correspond to areas of embryonic myocardium with an early phenotypic differentiation, as indicated by differences in antigen expression during normal cardiac development.

METHODS AND RESULTS

In human embryos ranging in age from 42 to 54 days of gestation, the development of the cardiac conduction system was studied with the use of HNK-1 immunohistochemistry. HNK-1 stains the developing atrioventricular conduction system, ie, the bundle branches, His bundle, right atrioventricular ring, and retroaortic ring. In addition, the myocardium around the common pulmonary vein showed transient HNK-1 antigen expression. In the right atrium, 3 HNK-1-positive connections were demonstrated between the sinoatrial node and the right atrioventricular ring. An anterior tract through the septum spurium connects the sinoatrial node with the anterior right atrioventricular ring, and 2 posterior tracts connect the sinoatrial node with the posterior right atrioventricular ring through the right venous valve (future crista terminalis) and sinus septum, encircling the coronary sinus. The medioposterior part of the right atrioventricular ring connected to the His bundle and the medioanterior part form 2 node-like structures.

CONCLUSIONS

In patients with abnormal atrial automaticity, the distribution of left and right atrial pacemaker foci correspond to areas of the embryonic myocardium that temporarily express the HNK-1 antigen.

Are interatrial band myocytes maximally hypertrophied in normal canine hearts?

In canine right atrial hypertrophy, the cross-sectional area (Axs) of right atrial myocytes increases, whereas the Axs of the broader interatrial band myocytes does not. In the current study, myocyte reconstructions showed that right atrial myocyte length increased in proportion to Axs in right atrial hypertrophy. On the other hand, mean interatrial band myocyte length in both normal and right atrial hypertrophy dogs was roughly inversely proportional to mean Axs, as expected if interatrial band myocyte volume was constant. Plotting mean Axs vs. myocyte length for individual interatrial band myocytes revealed a distribution whose border defined a maximal volume curve; many myocytes were well beneath that curve. Mononuclear myocytes (generally diploid) were limited by a 65,000-micrometer 3 curve, which many binuclear myocytes (generally tetraploid) surpassed; myocyte ploidy thus constrained myocyte volume. However, because many mononuclear and binuclear myocytes had lower volumes, their failure to hypertrophy cannot be attributed to attainment of the maximal volume possible for their ploidy.

Normal and abnormal consequences of apoptosis in the human heart

Knowledge about apoptosis has become essential for understanding many aspects of cardiac structure and function. In the human heart there are major periods of morphogenesis that begin only after birth, and some of these processes recur intermittently for many years. Although the exact mechanisms by which these events are initiated or terminated remain poorly understood, it is clear that their benefits may be mirrored in destructive effects. In this review, selected examples include normal morphogenesis of the cardiac conduction system and the normal postnatal involution of the right ventricle, both of which are mediated by apoptosis. Destructive counterparts include familial heart block ending in fatal arrhythmias, similar results in the long QT syndrome, and the pathogenesis of both Uhl's anomaly and arrhythmogenic right ventricular dysplasia; in each apoptosis is an important factor.

Structural changes of atrial myocardium due to sustained atrial fibrillation in the goat

BACKGROUND

After cardioversion of sustained atrial fibrillation (AF), the electrical and contractile functions of the atria are impaired, and recurrences of AF frequently occur. Whether remodeling of the structure of atrial myocardium is the basis for this problem is not known.

METHODS AND RESULTS

Sustained AF was induced by electrical pacing in 13 goats instrumented long-term. The goats were killed after 9 to 23 weeks, and the atrial myocardium was examined by light and electron microscopy. The changes were quantified in left and right atrial free walls, appendages, trabeculae, the interatrial septum, and the bundle of Bachmann. A substantial proportion of the atrial myocytes (up to 92%) revealed marked changes in their cellular substructures, such as loss of myofibrils, accumulation of glycogen, changes in mitochondrial shape and size, fragmentation of sarcoplasmic reticulum, and dispersion of nuclear chromatin. These changes were accompanied by an increase in size of the myocytes (up to 195%). There were virtually no signs of cellular degeneration, and the interstitial space remained unaltered. The duration of sustained AF did not significantly affect the degree of myolytic cell changes.

CONCLUSIONS

Sustained AF in goats leads to predominantly structural changes in the atrial myocytes similar to those seen in ventricular myocytes from chronic hibernating myocardium. These structural changes may explain the depressed contractile function of atrial myocardium after cardioversion. This goat model of AF offers a new approach to study the cascade of events leading to sustained AF and its maintenance.

Apoptosis as a possible cause of gradual development of complete heart block and fatal arrhythmias associated with absence of the AV node, sinus node, and internodal pathways

BACKGROUND

Gradually progressive development of complete heart block in young people often is associated with cardiac arrhythmia and sudden death, but the pathogenesis remains unexplained.

METHODS AND RESULTS

A young woman with complete heart block died suddenly. Her mother had serological but no clinical evidence of antiphospholipid syndrome. Five brothers of another family had arrhythmia and heart block. Three died suddenly; the other two have automatic defibrillators and are alive. The hearts from the young woman and two of the three brothers who died were available for our histological examination of their cardiac conduction systems. In two of the three hearts, the AV node was absent; in the third heart, only fragments of the AV node remained. In all three hearts, the sinus node was nearly destroyed by a noninflammatory degeneration with no abnormal fibrosis or infiltrate. In each heart, the interatrial and internodal pathways were similarly involved, and in the young woman, there were no myocardial cells in which these pathways normally exist.

CONCLUSIONS

In these three subjects with progressive development of complete heart block and various arrhythmias, all of whom died suddenly, the histological abnormalities of their cardiac conduction systems are best interpreted as resulting from apoptosis. Programmed cell death is a logical explanation for the pathogenesis of this puzzling clinical picture.

Assessment of anthracycline cardiomyopathy by endomyocardial biopsy

Ultrastructural evaluation of endomyocardial biopsy specimens is a sensitive and effective method with which to detect and quantitate cardiotoxicity produced by anthracylines. The procedure and grading system used at the M.D. Anderson Cancer Center are described, and some of the pitfalls that may be encountered by the electron microscopist are reviewed.

Electron microscopic demonstration of intercellular junctions between subendocardial smooth muscle and myocardium in the sheep heart

The eustachian ridge of 11 sheep hearts was examined by light and electron microscopy to elucidate the morphologic relationship between cardiac smooth muscle cells and myocardial cells. Smooth muscle cells were commonly observed in the subendocardial connective tissue and they were usually arranged in strands. When mixed with myocardial cells at the margin of these strands, smooth muscle cells exhibited numerous direct connections with the myocardial cells. These intercellular junctions were composed primarily of simple appositions (undifferentiated regions), but occasional desmosomes and fasciae adherents (intermediate junctions) were seen. We found no nexus (gap junctions) at these sites. The existence of direct intercellular junctions between smooth muscle and myocardium suggests several possible electrical and mechanical interactions.

An update of the stereology of the myocyte of the baboon's heart: analysis of the crista terminalis, interatrial and interventricular septa, and atrioventricular bundle

We used light microscopy to compare the stereology of the myocytes from the following regions of the baboon's heart: a) cardiac walls (crista terminalis, interatrial and interventricular septa) and b) cardiac conduction tissue (atrioventricular bundle). Six hearts were perfused and several pieces of tissue were taken from these regions. A staggered test lattice consisting of cycloids was superimposed on twelve random pairs of photomicrographs in order to make disectors, and on twelve other random fields for each cardiac region in order to estimate certain stereological parameters. Statistically significant differences were found when comparing the number of myocytes from the crista terminalis (highest value) with either the interatrial or interventricular septum. There is also a significant difference between the number of myocytes in the interventricular septum and the atrioventricular bundle (highest value). For the mean profile area of the myocytes, significant differences were found between the myocytes of both the crista terminalis and the interatrial septum, and those of the interventricular septum (highest value). Under the light microscope, myocytes from the two regions of the atrial wall studied were indistinguishable in size, since they constitute a single cell population. It was also impossible to distinguish them from the atrioventricular cells. The myocytes from the interventricular septum differed in both size and number from those of the right atrium, but only in number from those of the atrioventricular bundle.

Properties of the pacemaker current (If) in latent pacemaker cells isolated from cat right atrium

1. Single latent pacemaker cells were isolated from the Eustachian ridge of cat right atrium using Langendorff perfusion and enzyme dispersion techniques. Whole-cell patch-clamp techniques were used to study the hyperpolarization-activated inward current (I(f)). 2. All cells studied beat rhythmically. Pacemaker activity was recorded in the voltage range -68 +/- 1 to -54 +/- 2 mV and its cycle length was 901 +/- 67 ms (72 +/- 5 beats min-1) at 34-36 degrees C. Cells were elongated with tapered ends, and appeared bent or crinkled without obvious striations. Mean cell diameter and length were 7.4 +/- 0.5 microns and 93.1 +/- 5.9 microns, respectively (n = 15). Input resistance and total membrane capacitance were 2.2 +/- 0.2 G omega and 27.8 +/- 3.1 pF, respectively. 3. Hyperpolarizing clamp steps more negative than -50 mV elicited a time-dependent increasing inward current that was maximally activated at -120 mV. Activation of I(f) was well within the pacemaker voltage range. Half-maximal activation voltage and slope factor were calculated, using a Boltzmann function, to be -80.5 mV and 8.4, respectively. 4. The fully activated current-voltage (I-V) relationship was approximately linear at voltages more negative than -30 mV and showed outward rectification at more positive voltages. The reversal potential of I(f) was -26 mV and the fully activated conductance was 1.75 +/- 0.14 nS (n = 21). Caesium (2 mM) blocked I(f) at voltages more negative than the reversal potential. Reducing extracellular Na+ or K+ shifted the reversal potential more negative, and increasing extracellular K+ exerted the opposite effect. Reducing extracellular Na+ decreased I(f) amplitude and the slope of the fully activated I-V relationship, and elevated extracellular K+ increased I(f) amplitude and the slope of the fully activated I-V relationship. 5. Some pacemaker cells exhibited a short delay in the onset of I(f) activation whereas other pacemaker cells exhibited little, if any, delay in activation. I(f) currents exhibiting no delay in activation were best fitted by a single exponential function with a mean time constant of 3.20 +/- 1.03 s at -70 mV (n = 4). 6. A nystatin-permeabilized patch recording method was used to record spontaneous pacemaker action potentials and I(f) from the same pacemaker cell. Caesium (2 mM) inhibited I(f) by more than 90% (at -70 mV), and decreased the slope of diastolic depolarization, resulting in a 48 +/- 5% decrease in spontaneous rate.(ABSTRACT TRUNCATED AT 400 WORDS)

The cardiac conduction system in the rat expresses the alpha 2 and alpha 3 isoforms of the Na+,K(+)-ATPase

The sodium pump is crucial for the function of the heart and of the cardiac conduction system, which initiates the heartbeat. The alpha (catalytic) subunit of this pump has three isoforms; the alpha 1 isoform is ubiquitous, but the alpha 2 and alpha 3 isoforms are localized to excitable tissue. Because rodent alpha 2 and alpha 3 isoforms are relatively sensitive to ouabain, which also slows cardiac conduction, we studied heart-cell-specific expression of pump isoform genes. Multiple conduction-system structures, including sinoatrial node, bundle branches, and Purkinje strands, had prominent, specific hybridization signal for alpha 2 and alpha 3 isoforms compared with adjacent working myocytes. This gene-expression approach may be useful for labeling conduction tissue and also for localizing specific membrane channels and receptors in this system.

Ionic currents activated during hyperpolarization of single right atrial myocytes from cat heart

Whole-cell recording techniques were used on single right atrial myocytes to study the ionic currents that may be responsible for the diverse diastolic voltage characteristics of atrial tissue. Ionic currents were activated by hyperpolarizing voltage pulses negative to -30 mV. In general, four different types of cells were identified based primarily on the ionic currents elicited during hyperpolarization. The first cell type exhibited an inward current that decayed with time at more negative voltages, reversed near the potassium equilibrium potential, inwardly rectified at more positive voltages, increased in elevated extracellular potassium, and was blocked by 3 mM barium or 10 mM cesium. This current was identified as the potassium current iK1. A second cell type exhibited a time-dependent inward current that increased at more negative voltages, had an activation range between -50 and -110 mV, had a reversal potential of -26 mV, and was blocked by 3 mM cesium. This current was identified as an if current. A third cell type exhibited an inward current that initially decayed and then became more inward with time. Barium (3 mM) abolished the initial inward current and revealed a time-dependent increasing inward current that was blocked by 3 mM cesium. This current was composed of both the iK1 and if currents. A fourth cell type exhibited only small time-independent leak currents in response to hyperpolarization. These results indicate that individual cells within the right atrium are electrophysiologically heterogeneous with respect to the types of ionic channels present in their sarcolemmal membranes. This specialization in ionic currents partially explains the diverse diastolic voltage characteristics and functional properties of atrial tissue.

Distribution of atrial natriuretic peptide in the conduction system and ventricular muscles of the human heart

Atrial natriuretic peptide (ANP), a cardiac hormone, is known to be located in the atrial specific granules, but its presence and localization in the ventricular muscle of the human heart has not been examined fully. Using a specific antibody to human ANP, we studied the conduction system and ventricular muscle with immunohistochemical and ultrastructural methods in 30 hearts obtained at autopsy. These included 12 normal and 18 diseased hearts. In the normal hearts, ANP-positive granules, which were regularly observed in the atrial myocytes, were found in small quantities in the cells of the penetrating and branching bundles in 4 of 12, and in the cells of the ventricular free walls in 2 of the 12 hearts. In the diseased hearts, the positivity increased significantly (P less than 0.05), being found in 13 of 18 (72.2%) conduction systems and 10 of 18 (55.6%) ventricular muscles. The granules were confirmed to be immunoreactive with ANP by ultrastructural examination. Furthermore, the presence of ANP mRNA in the conduction system as well as in the ventricular myocytes was demonstrated by Northern blot hybridization for which we used the complementary DNA of human ANP. Thus, a small quantity of ANP appears to be synthesized and stored in the conduction system and ventricles of some normal hearts. However, ANP was shown to be present in a larger percentage of the diseased hearts.

Morphology of the region of the coronary sinus in respect to coronary sinus rhythm

The arterial supply to the region of the coronary sinus and the interatrial septum was examined in 18 normal canine hearts. In 13 of a further 18 dogs, coronary sinus rhythm was evoked by the ligation of atrial arteries, subsequent to which the arteries were visualized by injection of latex. A stable coronary sinus rhythm is evoked by producing ischaemia in an extensive area of the right atrium, including the sinus node, the interatrial septum and Bachmann's bundle, but preserving from ischaemia the posteroinferior part of the right atrium. Microscopical examination of the hearts with coronary sinus rhythm, and comparison with 9 control hearts, failed to demonstrate any morphological centre, in the form of nodal cells, which might have been responsible for the abnormal rhythm. In the posterior part of the right atrium, the ischaemic changes failed to affect the approaches of the atrioventricular node. The approaches were predominantly composed of cells poor in myofibrils mixed to a variable degree with cells of the working myocardium. We discuss the possibilities of the development of coronary sinus rhythm and "circus movement" with regard to the participation of the approaches to the atrioventricular node.

Interaction of inhomogeneities of repolarization with anisotropic propagation in dog atria. A mechanism for both preventing and initiating reentry

Having found the regional differences in right atrial action potentials shown in an accompanying article, we tested two seemingly paradoxical hypotheses: 1) The spatial pattern of repolarization provides a protective mechanism against reentry, and 2) repolarization inhomogeneities interact with anisotropic discontinuous propagation to produce reentry. Measurement of multidimensional refractory periods demonstrated an anisotropic distribution within large bundles with the longest refractory periods in the medial upper crista terminalis (sinus node area), a distribution similar to that of action potential durations. Also, discontinuities of repolarization were found at muscle bundle junctions. Early premature impulses originating in the sinus node area propagated throughout the right atrial preparations without conduction disturbances or reentry. Conversely, early premature impulses that originated at sites distal to the sinus node area resulted in localized conduction block at multiple sites, which frequently produced complex conduction changes and reentry. The critical nature of the site of origin of a premature impulse in initiating reentry was related to locations where the steepest repolarization gradients occurred: within anisotropic bundles in the direction of highest axial resistance (across fibers) and at muscle bundle junctions that represented localized discontinuities of axial resistance. The multiple conduction abnormalities at localized sites interacted to produce different types of reentry at a larger size scale (25 mm2 to several cm2). In each case, neither repolarization inhomogeneities (leading circle concept) nor anisotropic discontinuous propagation was the only "mechanism" involved. That is, reentry at a macroscopic size scale occurred as a result of a combined repolarization-anisotropic discontinuous propagation mechanism.

Myosin light chain compositions of the interatrial and interventricular septa of sheep heart

The myosin light chain composition of sheep interatrial and interventricular septa were analysed by one- and two-dimensional polyacrylamide gel. The interventricular septum has myosin light chain composition indistinguishable from that of ventricular myosin. Myosin from the interatrial septum contains three light chains, two of which co-migrated with the two atrial light chains (ALC1 and ALC2), while the third co-migrated with ventricular light chain 2 (VLC2). ALC1 are more abundant than ALC2 or VLC2 suggesting a mixed myosin population. Myosin with ALC1 and VLC2 light chain composition may be present, and its possible relationship with cardiac "conducting" cells is discussed.

Function of the atrioventricular node considered on the basis of observed histology and fine structure

From the hearts of 20 young dogs, the region of the atrioventricular (AV) node was studied in vitro utilizing direct perfusion of the AV node artery. Intracellular impalement with microelectrodes provided records of local transmembrane action potentials in all 20 dogs. These were correlated with serial section histologic studies in 7 of the 20 dogs to characterize a smaller region that served as an anatomic guide for electron microscopic examination in 4 other dog hearts. This report describes the variety of specific cells found, including their intracellular content and organization, as well as the nature of their intercellular junctions. On the basis of these findings, AV nodal cells were arbitrarily divided into two types, transitional cells and P cells, although three somewhat different groups of transitional cells were identified. The first group, found principally at the outer margin of the AV node, has long and slender cells that exhibit large profiles of gap junctions or nexuses. The second and third groups of transitional cells, which constitute most of the body of the AV node, are oblong or oval and contain fewer and smaller gap junctions. P cells of the AV node resemble those more abundantly present in the sinus node; they are found principally at the junction of the AV node and His bundle. On the basis of these fine structural features and the histologic organization and transmembrane action potentials observed, clinical and experimental aspects of the local electrophysiologic events are discussed.

Secretory patterns of atrial natriuretic factor (ANF) by cultured cardiocytes of right and left atrium from newborn and adult rats

Atrial cardiocytes from newborn (2-5 day old) and adult rats were cultured and the secretory patterns of atrial natriuretic factor (ANF) from isolated right and left atrial cells were investigated by radioimmunoassay. Newborn atrial cardiocytes from the left atrium consistently secreted larger amounts of ANF than those from the right with a peak on the 6th day and a decrease up to the 12th day. In contrast, adult atrial cardiocytes secreted much less ANF and this decreased to very low levels from the 3rd day up to the 12th day in culture although ANF was present in measurable amounts in these cells.

Ultrastructure of cultured atrial cardiac muscle cells from adult rats

Atrial cardiac muscle cells enzymatically isolated from adult rats were maintained in culture for 0-17 days and examined by transmission electron microscopy (TEM). Cells were stained with conventional TEM stains as well as with osmium ferrocyanide and tannic acid. Our results show that cultured adult atrial cells are capable of in vitro ultrastructural reorganization and possess differentiated ultrastructural characteristics including specific atrial granules, sarcomerically arranged myofilaments, appropriately organized sarcoplasmic reticulum (both junctional and nonjunctional), and intercalated disc components. In addition, the cultured atrial cells also possess rare, but ultrastructurally typical, elements of the transverse tubular system. These can be identified on the basis of size, location, association with internal junctional sarcoplasmic reticulum, and accumulation of extracellular tracer. Atrial muscle cells are capable of reestablishing a myotypic ultrastructure, although they have a considerably less complex and organized in vitro ultrastructure than similarly cultured adult ventricular myocytes. This lessened in vitro ultrastructural specialization is in accord with the in vivo comparative ultrastructure of atrial vs. ventricular myocytes.

Sir Thomas Lewis redivivus: from pebbles in a quiet pond to autonomic storms

Images

Myosin types in the human heart. An immunofluorescence study of normal and hypertrophied atrial and ventricular myocardium

Two distinct myosin heavy chain isoforms, referred to as alpha and beta, were identified in the human heart with specific antimyosin antibodies. By indirect immunofluorescence, myosin heavy chain alpha was found to be a major component of atrial myosin and a minor component of ventricular myosin, while heavy chain beta was found to be a major component of ventricular myosin and a minor component of atrial myosin. In the normal heart, there was marked individual variability in the proportion of ventricular myocytes reactive for heavy chain alpha. Atrial myocytes staining for heavy chain beta were rare in the left atrium and more numerous in the right atrium, especially in the crista terminalis and in the interatrial septum. Surgical and autoptic specimens from hypertrophied left ventricles of patients with mitral regurgitation showed a myosin immunoreactivity pattern similar to that of normal specimens. Very rare muscle cells reactive for heavy chain alpha were seen in the hypertrophied left ventricles of subjects with hypertension and in the hypertrophied right ventricles of subjects with tetralogy of Fallot. A dramatic transformation of myosin heavy chain composition was observed in hypertrophied left atria of patients with mitral stenosis, with a shift to heavy chain beta in a large proportion of atrial myocytes. The findings indicate that chronic exposure to hemodynamic overload can induce marked changes in the myosin heavy chain composition of human atria, whereas it affects only slightly that of the ventricles.

Mechanisms for atrial arrhythmias associated with cardiomyopathy: a study of feline hearts with primary myocardial disease

The cellular electrophysiologic and structural characteristics of arrhythmic and non-arrhythmic atria isolated from feline hearts with spontaneously occurring cardiomyopathy were studied. The animals were divided into three groups according to the degree of left atrial enlargement: mild (group I), moderate (group II), and severe (group III). The right atria were of relatively normal size. Microelectrode recordings showed that inexcitable cells were present in both left and right atria of all groups but were most numerous in the left atria of group III animals. Most inexcitable cells had low resting membrane potentials. There was also a significant reduction in resting membrane potentials, maximum rate of phase 0 depolarization, and action potential amplitude of excitable cells in left atria of animals in groups II and III, whereas action potentials of excitable cells in the right atria were normal. Acetylcholine or norepinephrine often restored excitability to cells that originally did not generate action potentials. Norepinephrine also caused slow-response action potentials as well as abnormal automaticity and triggered activity due to delayed afterpotentials. The diseased atria showed marked structural abnormalities, which were most pronounced in group III cats, including large amounts of interstitial fibrosis, cellular hypertrophy and degeneration, and thickened basement membranes. Therefore electrophysiologic abnormalities and concurrent changes in cell structure may be involved in the genesis of atrial tachyarrhythmias caused by cardiomyopathy.

The ultrastructure of the cardiac Purkinje strand in the dog: a morphometric analysis

Purkinje strands from both ventricles of adult mongrel dogs were excised, and electrical properties were studied by the voltage-clamp technique. The strands were then examined with light and electron microscopy and structural properties were analysed by morphometric techniques. The canine Purkinje strand contains (by volume) about 28% myocyte and 55% dense outer connective tissue. The remainder of the volume is taken up by the inner shell of loosely packed connective tissue within 10 microns of a myocyte membrane. These volume fractions vary considerably from one strand to another. Clefts less than 10 microns wide occupy 18% of the myocyte volume and clefts less than 1 micron wide occupy 1%. The membrane surface area of the myocytes can be divided into three categories by reference to the size of the adjacent cleft. About 47.8% of the membrane surface area faces clefts wider than 1 micron, another 22.2% faces clefts between 0.1 and 1 micron wide, and the final 30% faces clefts less than 0.1 micron wide. The surface area facing the narrowest clefts (less than 0.1 micron wide) is divided between nexuses 3%, desmosomes 10%, and unspecialized membrane 17% (each figure is expressed as a percentage of the total surface area of myocyte membrane). The canine Purkinje strand has a more favourable anatomy than the sheep Purkinje strand for most physiological experiments. We expect that the complicating effects of series resistance and change in the concentration of extracellular ions will be much smaller than in sheep strands, but still not negligible.

Myosin types and fiber types in cardiac muscle. II. Atrial myocardium

Antibodies were produced against myosins isolated from the left atrial myocardium (anti-bAm) and the left ventricular myocardium (anti-bVm) of the bovine heart. Cross-reactive antibodies were removed by cross-absorption. Absorbed anti-bAm and anti-bVm were specific for the myosin heavy chains when tested by enzyme immunoassay combined with SDS gel electrophoresis. Indirect immunofluorescence was used to determine the reactivity of atrial muscle fibers to the two antibodies. Three populations of atrial muscle fibers were distinguished in the bovine heart: (a) fibers reactive with anti-bAm and unreactive with anti-bVm, like most fibers in the left atrium; (b) fibers reactive with both antibodies, especially numerous in the right atrium; (c) fibers reactive with anti-bVm and unreactive with anti-bAm, present only in the interatrial septum and in specific regions of the right atrium, such as the crista terminalis. These findings can be accounted for by postulating the existence of two distinct types of atrial myosin heavy chains, one of which is antigenically related to ventricular myosin. The tendency for fibers labeled by anti-bVm to occur frequently in bundles and their preferential distribution in the crista terminalis, namely along one of the main conduction pathways between the sinus node and the atrioventricular node, and in the interatrial septum, where different internodal tracts are known to converge, suggests that these fibers may be specialized for faster conduction.

Ouabain sensitivity of Rb+ uptake in canine Purkinje fibre and ventricular muscle

Ouabain inhibitable active Rb+ uptake was compared in canine Purkinje fibre and the left ventricular muscle to define the possible difference in electrophysiological sensitivity to ouabain in the two tissues. Ouabain inhibitable, active uptake of Rb+ was calculated from the difference between total Rb+ uptake assayed in the absence of ouabain and nonspecific Rb+ accumulation assayed in the presence of 10(-4) mol/l ouabain. A similar degree of active Rb+ uptake was inhibited by ouabain in both Purkinje fibre and the left ventricular muscle from the same animal, even though the Purkinje fibre took up more 86Rb+ than the ventricle. The specific tissue binding of ouabain in vitro was also not significantly different in the functionally different two tissues. It is concluded that there is no differential ouabain sensitivity of Rb+ uptake in canine Purkinje fibre and ventricular muscle.

Autonomic interactions among subsidiary atrial foci

Although the existence of a specific pacemaker hierarchy outside of the sinus node but within the atrium has been documented, little evidence regarding mechanisms controlling activity of these sites has been gathered. This investigation utilized an autologous perfusion of the sinus nodal artery, by way of the femoral artery, in order to suppress the sinus node cholinergically while unmasking latent atrial sites. Electrograms were recorded from the region of the sinus node and several atrial sites. Perfusion with small doses of acetylcholine and physostigmine unmasked pacemakers outside of the sinus and atrioventricular nodes, but within the atrium. Either vagal stimulation or topical acetylcholine on the area of the presumed pacemaker returned dominance gradually toward the sinus node. Stimulation of the right stellate ganglion accelerated the latent pacemaker but did not shift activation toward the sinus node. These results are consistent with the existence of subsidiary atrial pacemakers that appear to be highly sensitive to the effects of acetylcholine. This may represent one mechanism, in addition to overdrive suppression, that maintains pacemaker hierarchy within the right atrium.

The internodal atrial myocardium

The anatomical substrates of internodal conduction have long been a contentious topic. Debated first by the German Pathological Society in 1910, the consensus of established opinion for over half a century was that conduction between sinus and atrioventricular nodes occurred through plain myocardium. This was a conclusion supported by Truex in 1961. Despite his restatement of this fact in 1976, it has become fashionable to describe internodal conduction as being mediated by specialized internodal pathways. To reinvestigate this problem we studied 22 human fetal and 32 human infant hearts. In each case it was possible to cut the atrial tissues as a single block of tissue and to examine serial sections through the internodal myocardium. The sinus node, atrioventricular node, and segments of atrioventricular ring specialized tissue were recognized as specialized tissue using the light microscope in each heart. In contrast, there was nothing "special" about the myocardium between the nodes, nor was it possible to recognize tracts on the basis of either histological appearance or cellular architecture. It is concluded that, from the standpoint of light microscopy, there is no evidence whatsoever to support the purported concept of specialized anatomical substrates for internodal conduction.