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Li J, Wiesinger A, Fokkert L, Bakker P, de Vries DK, Tijsen AJ, Pinto YM, Verkerk AO, Christoffels VM, Boink GJJ, Devalla HD. Modeling the atrioventricular conduction axis using human pluripotent stem cell-derived cardiac assembloids. Cell Stem Cell 2024:S1934-5909(24)00294-7. [PMID: 39260368 DOI: 10.1016/j.stem.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/19/2024] [Accepted: 08/19/2024] [Indexed: 09/13/2024]
Abstract
The atrioventricular (AV) conduction axis provides electrical continuity between the atrial and ventricular chambers. The "nodal" cardiomyocytes populating this region (AV canal in the embryo, AV node from fetal stages onward) propagate impulses slowly, ensuring sequential contraction of the chambers. Dysfunction of AV nodal tissue causes severe disturbances in rhythm and contraction, and human models that capture its salient features are limited. Here, we report an approach for the reproducible generation of AV canal cardiomyocytes (AVCMs) with in vivo-like gene expression and electrophysiological profiles. We created the so-called "assembloids" composed of atrial, AVCM, and ventricular spheroids, which effectively recapitulated unidirectional conduction and the "fast-slow-fast" activation pattern typical for the vertebrate heart. We utilized these systems to reveal intracellular calcium mishandling as the basis of LMNA-associated AV conduction block. In sum, our study introduces novel cell differentiation and tissue construction strategies to facilitate the study of complex disorders affecting heart rhythm.
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Affiliation(s)
- Jiuru Li
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Alexandra Wiesinger
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Lianne Fokkert
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Priscilla Bakker
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Dylan K de Vries
- Department of Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Anke J Tijsen
- Department of Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Yigal M Pinto
- Department of Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Arie O Verkerk
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Department of Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Vincent M Christoffels
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Gerard J J Boink
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Harsha D Devalla
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands.
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Tchou P, Nemer D, Saliba W, Varma N, Aziz P, Patel A, Nakagawa H, Kanj M, Hussein A, Bhargava M, Wazni O. Junctional Tachycardia. JACC Clin Electrophysiol 2023; 9:425-441. [PMID: 36990601 DOI: 10.1016/j.jacep.2022.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 02/24/2023]
Abstract
Junctional tachycardia (JT) is typically considered to have an automatic mechanism originating from the distal atrioventricular node. When there is 1:1 retrograde conduction via the fast pathway, JT would resemble the typical form of atrioventricular nodal re-entrant tachycardia (AVNRT). Atrial pacing maneuvers have been proposed to exclude AVNRT and suggest a diagnosis of JT. However, after excluding AVNRT, one should consider the possibility of an infra-atrial narrow QRS re-entrant tachycardia, which can exhibit features that resemble AVNRT as well as JT. Pacing maneuvers and mapping techniques should be performed to assess for infra-atrial re-entrant tachycardia before concluding that JT is the mechanism of a narrow QRS tachycardia. Distinguishing JT from typical AVNRT or infra-atrial re-entrant tachycardia has notable implications regarding the approach to ablation of the tachycardia. Ultimately, a contemporary review of the evidence on JT raises some questions as to the mechanism and source of what has traditionally been considered JT.
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Sternick EB, Sanchez-Quintana D, Wellens HJJ, Anderson RH. Mahaim Revisited. Arrhythm Electrophysiol Rev 2022; 11:e14. [PMID: 35990105 PMCID: PMC9376831 DOI: 10.15420/aer.2022.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022] Open
Abstract
The name Ivan Mahaim is well-known to electrophysiologists. However, alternative anatomical substrates can produce the abnormal rhythms initially interpreted on the basis of the pathways he first described. These facts have prompted suggestions that Mahaim should be deprived of his eponym. It is agreed that specificity is required when describing the pathways that produce the disordered cardiac conduction, and that the identified pathways should now be described in an attitudinally appropriate fashion. The authors remain to be convinced that understanding will be enhanced simply by discarding the term ‘Mahaim physiology’ from the lexicon. It is fascinating to look back at the history of accessory atrioventricular junctional conduction pathways outside the normal accessory atrioventricular conduction system, and their possible role in rhythm disturbances. It took both the anatomist and the clinical arrhythmologist quite some time to understand the complex anatomical architecture and the ensuing electrophysiological properties. Over the years, the name Mahaim was often mentioned in those discussions, although these pathways were not the ones that produced the eponym. The reason for this review, therefore, is to present relevant information about the person and what followed thereafter.
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Affiliation(s)
| | | | | | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Higuchi S, Voskoboinik A, Goldberger JJ, Nazer B, Dewland TA, Danon A, Belhassen B, Tchou PJ, Scheinman MM. Arrhythmias Utilizing Concealed Nodoventricular or His-Ventricular Pathways: A Structured Approach to Diagnosis and Management. JACC Clin Electrophysiol 2021; 7:1588-1599. [PMID: 34332874 DOI: 10.1016/j.jacep.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to describe the electrophysiologic characteristics, diagnostic maneuvers, and treatment of a series of arrhythmias using concealed nodoventricular (cNV) or His-ventricular (cHV) pathways. BACKGROUND Confirming the presence and participation of cNV or cHV pathways in tachyarrhythmias is challenging. METHODS We present 4 cases of tachycardias with a participatory cNV or cHV pathway. RESULTS The first patient had a narrow complex tachycardia with ventriculoatrial dissociation. Findings of an entrainment pacing from the right ventricle and fused premature ventricular complexes suggested cNV pathway involvement. The second patient had nonsustained narrow complex tachycardia with more ventricular than atrial complexes. The tachycardia exhibited an anterograde His-right bundle (RB) activation sequence and normal His-ventricular (HV) interval and consistently terminated with fused ventricular extra stimuli, suggesting cNV pathway participation. The third patient had a wide complex tachycardia (WCT) with either a right or left bundle branch block pattern. The WCT showed an eccentric His-RB activation sequence and short HV interval and terminated with fused premature ventricular complexes, suggesting a cHV (or concealed fasciculoventricular) pathway involvement. The fourth patient had a WCT with alternating bundle branch block morphologies with a short HV interval. Entrainment from the basal right ventricle demonstrated fusion and a short postpacing interval, suggesting cHV (or fasciculoventricular) pathway involvement. Ablation at the proximal RB rendered the tachycardia noninducible. CONCLUSIONS A structured approach can help diagnose and treat cNV or cHV pathways. We emphasize the importance of evaluating both the His-RB activation pattern and HV interval during sinus rhythm and tachycardia as well as the ventricular pacing study.
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Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Aleksandr Voskoboinik
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | | | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas A Dewland
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Asaf Danon
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
| | | | - Patrick J Tchou
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melvin M Scheinman
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.
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Labartkava E, Chkholaria G, Chkholaria A. Atypical accessory fibers as a lone or additional substrate for 1:2 response phenomenon? HeartRhythm Case Rep 2020; 6:733-737. [PMID: 33101943 PMCID: PMC7573378 DOI: 10.1016/j.hrcr.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Evgenii Labartkava
- Address reprint requests and correspondence: Dr Evgenii Labartkava, Cardiology Department, Kutaisi Central Hospital, Solomon Pirveli 10, Kutaisi 4600, Georgia.
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Higuchi S, Kumar UN, Badhwar N, Tchou P, Scheinman MM. An Irregular Rhythm. JACC Clin Electrophysiol 2020; 6:1205-1211. [DOI: 10.1016/j.jacep.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
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Soares Correa F, Lokhandwala Y, Sánchez-Quintana D, Mori S, Anderson RH, Wellens HJJ, Back Sternick E. Unusual variants of pre-excitation: From anatomy to ablation: Part III-Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia. J Cardiovasc Electrophysiol 2019; 30:3097-3115. [PMID: 31646696 DOI: 10.1111/jce.14247] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/24/2019] [Accepted: 10/12/2019] [Indexed: 11/30/2022]
Abstract
The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.
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Affiliation(s)
- Frederico Soares Correa
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
| | | | | | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hein J J Wellens
- CARIM-Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Eduardo Back Sternick
- Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.,Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil
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Ekizler FA, Sahin M, Ozeke O, Cay S, Ozcan F, Aras D, Topaloglu S. Atrial pacing‐induced paroxysmal atrioventricular block: Concealed conduction or phase 3 block or intrahisian reentry? Pacing Clin Electrophysiol 2019; 42:1165-1166. [DOI: 10.1111/pace.13757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - Mursel Sahin
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
- Department of CardiologyKaradeniz Technical University Trabzon Turkey
| | - Ozcan Ozeke
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Serkan Cay
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Firat Ozcan
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Dursun Aras
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Serkan Topaloglu
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
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Bonikowske AR, Barout A, Fortin-Gamero S, Lara MIB, Kapa S, Allison TG. Frequency and characteristics of exercise-induced second-degree atrioventricular block in patients undergoing stress testing. J Electrocardiol 2019; 54:54-60. [DOI: 10.1016/j.jelectrocard.2019.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/19/2019] [Accepted: 03/13/2019] [Indexed: 12/25/2022]
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Chung R, Wazni O, Dresing T, Chung M, Saliba W, Lindsay B, Tchou P. Clinical presentation of ventricular-Hisian and ventricular-nodal accessory pathways. Heart Rhythm 2019; 16:369-377. [DOI: 10.1016/j.hrthm.2018.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Indexed: 10/28/2022]
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12
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Ablative care of atrioventricular block: Uncovering new horizons or chasing ghosts. Heart Rhythm 2018; 15:97-98. [DOI: 10.1016/j.hrthm.2017.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Indexed: 11/20/2022]
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