Ultrastructure of the human atrioventricular node

AV-node isolation as an alternative to AV-node ablation in patients undergoing pace & ablate strategy

INTRODUCTION

Atrioventricular (AV)-node ablation (AVNA) is a common therapy option for rate control strategy of permanent atrial fibrillation (AF). We hypothesized that isolation of the AV nodal isolation (AVNI) is associated with a more frequent preservation of an adequate escape rhythm compared to AVNA.

METHODS

This retrospective study included 20 patients with therapy-refractory AF being treated with AVNI and 40 historical AVNA-controls. In AVNI the AV-node region was mapped using a 3D mapping system. Ablation was performed around the previously mapped HIS-cloud regions isolating the atrium from the AV-node. In the AVNI group, ablation was performed with irrigated tip ablation catheter in all cases. The two approaches were compared regarding rate of escape rhythm, delta QRS, and procedural data.

RESULTS

The number of patients with adequate escape rhythm in AVNI was significantly superior to AVNA immediately postoperative (90% vs. 40%, p < 0.01) and during follow-up (77% vs. 36%, p < 0.05). The median change in QRS width was 0 ms in AVNI versus +26 ms in AVNA (p < 0.01). Thirty percent new bundle branch blocks in AVNA were observed compared to 0% in AVNI (p < 0.01). In the AVNI group, fluoroscopy time and total dose area product were significantly lower (p < 0.01).

CONCLUSION

The present study suggests that AV-node isolation using 3D navigation mapping system is a feasible and effective alternative to conventional AVNA. The precise application of radiofrequency lesions preserves a stable AV-junctional rhythm.

Optical Electrophysiology in the Developing Heart

The heart is the first organ system to form in the embryo. Over the course of development, cardiomyocytes with differing morphogenetic, molecular, and physiological characteristics are specified and differentiate and integrate with one another to assemble a coordinated electromechanical pumping system that can function independently of any external stimulus. As congenital malformation of the heart presents the leading class of birth defects seen in humans, the molecular genetics of heart development have garnered much attention over the last half century. However, understanding how genetic perturbations manifest at the level of the individual cell function remains challenging to investigate. Some of the barriers that have limited our capacity to construct high-resolution, comprehensive models of cardiac physiological maturation are rapidly being removed by advancements in the reagents and instrumentation available for high-speed live imaging. In this review, we briefly introduce the history of imaging approaches for assessing cardiac development, describe some of the reagents and tools required to perform live imaging in the developing heart, and discuss how the combination of modern imaging modalities and physiological probes can be used to scale from subcellular to whole-organ analysis. Through these types of imaging approaches, critical insights into the processes of cardiac physiological development can be directly examined in real-time. Moving forward, the synthesis of modern molecular biology and imaging approaches will open novel avenues to investigate the mechanisms of cardiomyocyte maturation, providing insight into the etiology of congenital heart defects, as well as serving to direct approaches for designing stem-cell or regenerative medicine protocols for clinical application.

Evidence of specialized tissue in human interatrial septum: histological, immunohistochemical and ultrastructural findings

Background

There is a paucity of information on structural organization of muscular bundles in the interatrial septum (IAS). The aim was to investigate histologic and ultrastructural organization of muscular bundles in human IAS, including fossa ovalis (FO) and flap valve.

Methods

Macroscopic and light microscopy evaluations of IAS were performed from postmortem studies of 40 patients. Twenty three IAS specimens underwent serial transverse sectioning, and 17 - longitudinal sectioning. The transverse sections from 10 patients were immunolabeled for HCN4, Caveolin3 and Connexin43. IAS specimens from 6 other patients underwent electron microscopy.

Results

In all IAS specimens sections the FO, its rims and the flap valve had muscle fibers consisting of working cardiac myocytes. Besides the typical cardiomyocytes there were unusual cells: tortuous and horseshoe-shaped intertangled myocytes, small and large rounded myocytes with pale cytoplasm. The cells were aggregated in a definite structure in 38 (95%) cases, which was surrounded by fibro-fatty tissue. The height of the structure on transverse sections positively correlated with age (P = 0.03) and AF history (P = 0.045). Immunohistochemistry showed positive staining of the cells for HCN4 and Caveolin3. Electron microscopy identified cells with characteristics similar to electrical conduction cells.

Conclusions

Specialized conduction cells in human IAS have been identified, specifically in the FO and its flap valve. The cells are aggregated in a structure, which is surrounded by fibrous and fatty tissue. Further investigations are warranted to explore electrophysiological characteristics of this structure.

An image-based model of the whole human heart with detailed anatomical structure and fiber orientation

Many heart anatomy models have been developed to study the electrophysiological properties of the human heart. However, none of them includes the geometry of the whole human heart. In this study, an anatomically detailed mathematical model of the human heart was firstly reconstructed from the computed tomography images. In the reconstructed model, the atria consisted of atrial muscles, sinoatrial node, crista terminalis, pectinate muscles, Bachmann's bundle, intercaval bundles, and limbus of the fossa ovalis. The atrioventricular junction included the atrioventricular node and atrioventricular ring, and the ventricles had ventricular muscles, His bundle, bundle branches, and Purkinje network. The epicardial and endocardial myofiber orientations of the ventricles and one layer of atrial myofiber orientation were then measured. They were calculated using linear interpolation technique and minimum distance algorithm, respectively. To the best of our knowledge, this is the first anatomically-detailed human heart model with corresponding experimentally measured fibers orientation. In addition, the whole heart excitation propagation was simulated using a monodomain model. The simulated normal activation sequence agreed well with the published experimental findings.

Interstitial Cajal-like cells (ICLC) in atrial myocardium: ultrastructural and immunohistochemical characterization

We have previously reported (Hinescu & Popescu, 2005) the existence of interstitial Cajal-like cells (ICLC), by transmission electron microscopy, in human atrial myocardium. In the present study, ICLC were identified with non-conventional light microscopy (NCLM) on semi-thin sections stained with toluidine blue and immunohistochemistry (IHC) for CD117/c-kit, CD34, vimentin and other additional antigens for differential diagnosis. Quantitatively, on semi-thin sections, ICLC represent about 1-1.5% of the atrial myocardial volume (vs. approximately 45% working myocytes, approximately 2% endothelial cells, 3-4% for other interstitial cells, and the remaining percentage: extracellular matrix). Roughly, there is one ICLC for 8-10 working atrial myocytes in the intercellular space, beneath the epicardium, with a characteristic (pyriform, spindle or triangular) shape. These ICLC usually have 2-3 definitory processes, emerging from cell body, which usually embrace atrial myocytes (260 nm average distance plasmalemma/sarcolemma) or establish close contact with nerve fibers or capillaries (approximately 420 nm average distance to endothelial cells). Cell prolongations are characteristic: very thin (mean thickness = 0.15+/-0.1 microm), very long for a non-nervous cell (several tens of microm) and moniliform (uneven caliber). Stromal synapses between ICLC and other interstitial cells (macrophages) were found (e.g. in a multicontact type synapse, the average synaptic cleft was approximately 65 nm). Naturally, the usual cell organelles (mitochondria, smooth and rough endoplasmic reticulum, intermediate filaments) are relatively well developed. Caveolae were also visible on cell prolongations. No thick filaments were detected. IHC showed that ICLC were slightly and inconsistently positive for CD117/c-kit, variously co-expressed CD34 and EGF receptor, but appeared strongly positive for vimentin, along their prolongations. Some ICLC seemed positive for a-smooth muscle actin and tau protein, but were negative for nestin, desmin, CD13 and S-100. In conclusion, we provide further evidence of the existence of ICLC in human atrial myocardium, supporting the possible ICLC role in pacemaking, secretion (juxta- and/or paracrine), intercellular signaling (neurons and myocytes). For pathology, ICLC might as well be 'players' in arrhythmogenesis and atrial remodeling.

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.

Electrophysiological properties of morphologically distinct cells isolated from the rabbit atrioventricular node

1. Experiments were conducted using the whole-cell patch clamp technique to determine the electrophysiological properties and ionic currents of ovoid and rod-shaped single isolated calcium-tolerant rabbit atrioventricular (AV) nodal cells. 2. Action potential morphologies observed in these cells were similar to those obtained previously from intracellular recordings of intact atrioventricular nodal preparations: ovoid cells had N- or NH-like action potential configurations (see below), whereas rod-shaped cells had AN-like configurations. 3. Action potential restitution in AV nodal cells was characterized by a progressive increase in overshoot potential, maximal upstroke velocity (Vmax) and action potential duration, as well as a decrease in latency from stimulus to Vmax. In rod-shaped cells, premature stimuli could induce regenerative membrane responses before full action potential repolarization, whereas ovoid cells showed only post-repolarization refractoriness. In ovoid cells stimulated at the low stimulus intensities there was no shortening of the action potential duration and the most premature action potentials were often prolonged. 4. The quasi-steady-state current-voltage relationship of ovoid cells was significantly steeper, at both depolarized and hyperpolarized potentials, than that of either the rod-shaped AV nodal cells or atrial cells. The rod-shaped AV nodal cells and the atrial cells had similar current-voltage (I-V) relationships in the positive potential range, but the I-V curves crossed over at potentials of about-90 mV. 5. A hyperpolarization-activated inward current (I(f)) was apparent in the range between -60 and -90 mV in 95% of the ovoid cells (n = 75), whereas in 88% of rod-shaped cells (n = 16) I(f) was activated at more negative potentials. The magnitude of I(f) in ovoid cells, measured at -100 mV, was approximately 25 times that in rod-shaped cells. 6. A rapid inward current (INa) greater than 1 nA was found in all rod-shaped cells (n = 16) but in only 30% of ovoid cells (n = 75). A transient outward current (I(to)) was found in 93% of rod-shaped cells (n = 14) and in 42% of ovoid cells (n = 54). The combination of I(to) and INa was found in 93% of rod-shaped cells but in only 24% of ovoid cells. 7. These results suggest that there are at least two populations of isolated AV nodal cells with distinct action potentials and ionic current profiles that may contribute to the complex electrophysiological properties observed in the intact AV node.

Impulse formation and conduction of excitation in the atrioventricular node

Meijler et al. have recently challenged the classical concept of AV nodal conduction (the conduction hypothesis) and suggest that the AV node might be controlling ventricular rhythmicity through its automaticity electrotonically modulated by atrial excitation (the modulated pacemaker hypothesis). This article critically evaluates the three major arguments of Meijler: (1) the absence of convincing evidence for conduction of excitation in the AV node; (2) the prevalence of disproportionately short AV intervals in larger animals; and (3) elimination of RR intervals shorter than the cycle length of ventricular pacing during atrial fibrillation, to judge which of these two hypotheses would more satisfactorily explain various experimental and clinical findings accumulated in the past. Previous observations including microelectrode mapping of the rabbit AV junction during regular sinus rhythm as well as second-degree AV block, clinical and experimental studies on concealed conduction, and studies on the ventricular response to atrial fibrillation appear to be compatible with the conduction hypothesis, whereas clearcut evidence for automatic impulse formation in the AV node has not been presented, except in a small number of hearts showing spontaneous AV junctional rhythms. In view of these observations and theoretical considerations based on comparative anatomy of the AV node-His-Purkinje system and on the latest experimental study on the equine AV node, the authors conclude that the conduction hypothesis appears to better explain all the available data, except perhaps in a few cases with second-degree intra-AV nodal block.

Evidence of quadruple anterograde atrioventricular nodal pathways in a patient with atrioventricular node reentry

Functional longitudinal dissociation of the atrioventricular (AV) node exhibiting two discrete discontinuities in AV nodal conduction curves suggestive of triple AV nodal pathways has been described. The authors report here unusual electrophysiologic properties of the AV node in a patient with documented episodes of paroxysmal supraventricular tachycardia. Programmed atrial extrastimuli introduced at A1-A2 coupling intervals of 390 ms with a driven cycle length of 500 ms produced a sudden marked increase of 75 ms at the A2-H2 intervals suggesting failure of the fast pathway with conduction proceeding through a slower pathway with a shorter refractory period. With further decreasing coupling intervals, a second sudden jump of 70 ms and a third one of 150 ms occurred at A1-A2 coupling intervals of 330 and 290 ms, respectively. Beyond the first sudden jump, atrial echoes occurred when sufficiently slow pathway delay permitted recovery of the fast pathway for retrograde conduction. The atrial echo zone was 170 ms. These electrophysiologic demonstrations of reentry within the AV node in a patient with clinically documented supraventricular tachycardia and the existence of four ranges of AH conduction times and refractory periods strongly suggest the presence of quadruple anterograde AV nodal pathways and a variety of potential loops available for the development of sustained AV nodal reentrant tachycardia.

Atrioventricular nodal reentry: evidence supporting an intranodal location

The exact site of the reentrant circuit in AV nodal reentry remains controversial. While recent ablative techniques have yielded information, the interpretation of which suggests that the atrium is required, other explanations for these interpretations are available. Prior pathophysiological studies with three-dimensional reconstruction of the node suggest that it is a highly anisotropic structure and extends through Koch's Triangle. Data from humans suggesting the atria are not necessary include the presence of AV dissociation during supraventricular tachycardia (SVT), depolarization of atrial tissue surrounding the node without affecting SVT, pacing induced AH intervals exceeding those during SVT, and site dependency of a critical AH interval (exceeding atrial refractoriness) that is required for initiation of AV nodal reentry.

Ultrastructural alterations of the conduction system in mice exhibiting sinus arrest or heart block during Coxsackievirus B3 acute myocarditis

By light and electron microscopy we studied the sinus nodes and atrioventricular (AV) conducting tissue of six C3H/He mice having coxsackievirus B3 acute myocarditis. Sinus arrest was documented in all six mice, and second- or third-degree AV block was documented in three of the six mice. Although myocarditic changes in the conduction system, especially in the sinus node, were less than those in atrial and ventricular working myocardium, there were distinct abnormalities within both the sinus node and AV conducting tissue in all six hearts. Important ultrastructural alterations were inflammatory cell infiltrates and significant injury of specialized cells and of neural tissue. Specialized cells showed various features of degeneration and necrosis. Neural tissue damage included degeneration of axons and Schwann cells and disorganization of the neuromuscular junctions. Inflammatory cells, particularly macrophages, were often in intimate contact with injured specialized cells and neural tissue. Interstitial edema and bleeding and lymphatic vessel dilatation were also observed. These pathologic changes are considered to play an important role in the development of the documented disturbances of rhythm and conduction.

Ultrastructural effects induced by global ischaemia on the AV node compared with the working myocardium. A qualitative and morphometric investigation on the canine heart

The cardiac conduction system is considered to be particularly resistant to ischaemia. Nevertheless, following open heart surgery with short periods of ischaemia disturbances in AV conduction or ventricular arrhythmia have been reported. We compared the ultrastructure of AV node and working myocardium following 30 min global ischaemia at 25 degrees C, during pure ischaemia and with HTK cardioplegia qualitatively and morphometrically. After 30 min of pure ischaemia, interstitial and intracellular oedema together with considerable changes in organelles in AV nodes predominate over mainly cellular oedema in working myocardium. Sometimes irregular overcontractions of sarcomeres occur in the AV node, though very seldom in working myocardium. In pure ischaemia, mitochondrial swelling is comparable in both types of tissue. Following HTK cardioplegia and 30 min ischaemia, cellular oedema and mitochondrial swelling are significantly reduced in AV nodal cells and working myocardium, but remain more extensive in the AV nodes. Irregularities in the contractile state of sarcomeres are not observed. The extent of the ultrastructural alterations corresponds to the degree of metabolic change in the working myocardium. Thus, despite considerable differences during pure ischaemia and HTK cardioplegia, ultrastructurally the AV nodal cells do not display a greater resistance to ischaemia than working myocardium.

Polarity and length of actin filaments at the fascia adherens of the cardiac intercalated disk

Digestion of canine and bovine intercalated disks with a calcium-activated protease (CAF) removes the electron-dense material similar to that found at the Z-line and presumably consisting primarily of alpha-actinin. The major filaments exposed by CAF are actin, and the polarity is away from the intercalated disk, as was confirmed by decoration with heavy meromyosin. The length of actin filaments associated with the fascia adherens region at the concave region is 1.2- to 2.2-fold that of actin filaments (I-filaments) in the sarcomere and varies depending on the interdigitation of the membrane at the cell junction. Actin filaments at the intercalated disk seem to be attached (or very close) to the membrane in a direct, rather than looping, manner.

Differential effects of sympathetic activity on AV junctional automaticity and AV conduction

Rapid ventricular response during episodes of supraventricular tachycardia are often followed, on abrupt cessation of the tachycardia, by prolonged pauses terminated by a sluggish and sometimes erratic escape of a supraventricular pacemaker. Such chronotropic-dromotropic paradoxes are readily reproduced in the animal laboratory following elimination of the sinus node and bilateral decentralization of the stellate ganglia and vagi. This study examined whether left stellate stimulation (0.5, 1, 2, 4, 8 and 16 Hz) or lack thereof differentially affected AV junctional automaticity and AV conduction. In the absence of any sympathetic neural activity (maximal sympathetic deficit), the AV junctional rate averaged a mere 22 +/- 2 percent of its peak performance, whereas under the same conditions, anterograde AV conduction averaged 73 +/- 5 percent and retrograde VA conduction 56 +/- 13 percent of their respective peak performances. On comparing the response curve (normalized responses) for AV junctional automaticity with that obtained for anterograde AV conduction the differences were significant at all frequencies between 0 and 4 Hz. Retrograde VA conduction (as assessed by the fastest ventricular pacing rate still conducted 1:1 to the atria) was always significantly less than anterograde AV conduction (as assessed by the fastest atrial pacing still conducted 1:1 to the ventricles). These results indicate that AV junctional automaticity is considerably more affected by sympathetic deficit than are either anterograde or retrograde AV conduction. In other words, AV junctional automaticity is far more dependent upon sympathetic input than AV conduction. While sympathetic influence is critical to the escape and maintenance of AV junctional automaticity both anterograde and retrograde AV conduction are remarkably resilient even under conditions of severe sympathetic deficit.

Effects of calcium, calcium entry blockers and calmodulin inhibitors on atrioventricular conduction disturbances induced by hypoxia

Effects of hypoxia on atrioventricular conduction were investigated in the Langendorff-perfused isolated heart of the rabbit with various extracellular calcium concentrations ([Ca2+]) as well as in the presence of verapamil, nifedipine, N-(6-aminohexyl)-5-chloro-1-naphthalenesulphonamide (W-7) and chlorpromazine. The prolongation of the atrio-His (AH) interval by hypoxia for 7 min was greater with increasing [Ca2+]o ranging from 1.2 to 5.2 mM. At [Ca2+]o of over 3.2 mM under hypoxic conditions, AH block of the Wenckebach type was observed in some cases. Verapamil (5 X 10(-8) M) and nifedipine (5 X 10(-8) M) caused a significant prolongation of AH intervals before hypoxia. However, the intensity of AH prolongation due to hypoxia was significantly attenuated in the presence of the calcium entry blocker, and AH block was not induced even at 3.2 mM [Ca2+]o. W-7 (5 X 10(-6) M) and chlorpromazine (10(-6) M) did not affect the AH intervals before hypoxia. The hypoxia-induced prolongation of the AH interval or AH block was prevented in the presence of these drugs. W-5, a chlorine-deficient derivative of W-7, showed no protection against hypoxia-induced AV nodal conduction disturbances. These findings suggest that hypoxia-induced AV nodal conduction disturbance is explained, at least in part, by the electrical uncoupling of nodal cells, probably due to the calcium overload. This conduction disturbance is protected by calcium entry blockers or by calmodulin inhibitors, but the mode of protective action is not the same for these different categories of drugs.

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.

Multiple atrioventricular nodal pathways--a new electrophysiological phenomenon in children

Multiple atrioventricular (A-V) nodal pathways are described in five dysrhythmia-free children with congenital heart defects. The five were some (2.9%) of 175 children who underwent diagnostic cardiac catheterization and electrophysiological evaluation over a three year period. Supraventricular tachycardia was not induced during the electrophysiological evaluation. Medical follow-up is recommended since multiple A-V nodal pathways have been demonstrated in adults with A-V nodal reentrant tachycardia.

A scanning electron microscopic study of the ferret atrioventricular node

The atrioventricular (AV) node and surrounding transitional zone in the ferret heart were examined with scanning electron microscopy. This permitted the direct visualization of the three-dimensional cell shape, as well as intercellular relationships. Transitional cells were roughly cylindrical with extensively branching end processes. These cells were apposed to many adjacent transitional cells. The superficial AV nodal cells were smaller than transitional cells and were fusiform in shape. Most of the cell contacts between superficial AV nodal cells were between overlapping end processes, and there was very little branching of these cells. The deep AV nodal cells were similar to the superficial AV nodal cells, but were slightly larger and also had more cell contacts with adjacent cells. The possible significance of cell sizes and shape and intercellular relationships as they relate to atrioventricular impulse propagation and AV nodal delay are discussed.

Junctional resistance and action potential delay between embryonic heart cell aggregates

Spheroidal aggregates of embryonic chick ventricle cells were brought into contact and allowed to synchronize their spontaneous beats. Action potentials were recorded with both intracellular and extracellular electrodes. The degree of electrical interaction between the newly apposed aggregates was assessed by measuring the delay or latency (L) between the entrained action potentials, and by determining directly interaggregate coupling resistance (Rc) with injected current pulses. Aggregate size, contact area between the aggregates, and extracellular potassium concentration (Ko+) were important variables regulating the time-course of coupling. When these variables were controlled, L and Rc were found to be linearly related after beat synchrony was achieved. In 4.8 mM Ko+ L/Rc = 3.7 ms/M omega; in 1.3 mM Ko+ L/Rc = 10.1 ms/M omega. We conclude that action potential delay between heart cell aggregates can be related quantitatively to Rc.

Triple AV nodal pathways in man?

A 41 year old woman underwent electrophysiological studies for the evaluation of paroxysmal supraventricular tachycardia. AV nodal conduction time and refractory period plots (atrial extra-stimulus technique) suggested the presence of triple AV nodal pathways.

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

The fine structure of the normal internodal pathways was studied in 1 human and 2 canine hearts and correlated with histologic observations on more than 100 human and 10 canine hearts. From the electron microscopic studies six different kinds of myocardial cells were classified from two locations: the Eustachian ridge (posterior internodal pathway) and the Bachmann bundle (anterior internodal pathway). Five of the six kinds of cells (working myocardial cells, Purkinje-like cells, either broad or slender transitional cells and P cells, all previously described) were present in both locations. A sixth cell, pleomorphic and dark in appearance, with a special intertwined relation to P cells, is newly designated as an ameboid cell. It was found solely in the Eustachian ridge. In the same area a rare direct contact between a nerve and a myocardial cell was observed. The importance of these different kinds of cells, their respective cell connections, and their topographic locations inside the internodal pathways are discussed relative to certain functions such as rapid conduction and subsidiary pacemaking. The possible influence of these factors on clinical electrocardiographic changes is considered.

The atrioventricular node and bundle in the ferret heart: a light and quantitative electron microscopic study

The cells of the atrioventricular (AV) junction in the ferret heart were examined using light microscopy, a wax-model reconstruction and quantitative electron microscopy to determine their organization and characteristics. A series of subdivisions of the specialized tissues of the AV junction was apparent at both the light and electron microscopic levels. A transitional zone was observed interposed between the atrial muscle cells and the AV node. The AV node consisted of a coronary sinus portion, a superficial portion and a deep portion. The AV bundle had a segment above the anulus fibrosus, a segment which penetrated the right fibrous trigone, a non-branching segment below the anulus fibrosus and a branched segment. At the ultrastructural level the AV junctional conduction tissues had fewer irregularly oriented myofibrils than did working atrial myocardial cells. T-tubules, present in atrial muscle cells, were not observed in the modified muscle cells of the AV node and bundle. Conventional intercalated discs also were not observed between the cells of the AV node or the AV bundle. Atrial myocardial cells had the highest percentage of the plasma membrane occupied by desmosomes, fasciae adherentes and gap junctions. The AV bundle cells had the highest percentage of appositional surface membrane and a relatively large fraction of plasma membrane occupied by gap junctions. Cells of the superficial portion of the AV node had the smallest percentage of the plasma membrane composed of gap junctions, desmosomes or fasciae adherentes, as well as the smallest fraction of the cell membrane apposed to adjacent cells. The stereological data indicate that the most useful distinguishing characteristic between atrial muscle cells and conduction cells was that a smaller percentage of the conduction cell sarcoplasm was occupied by mitochondria and myofibrils. The most useful characteristics that could be used to differentiate between the regions of the AV junctional conduction tissues were the amounts and types of surface membrane specializations in the respective cell types.

Transvascular endomyocardial biopsy in infants and small children. Myocardial findings in 10 cases of cardiomyopathy

Transvascular endomyocardial biopsy specimens from nine children with congestive cardiomyopathy and one with hypertrophic cardiomyopathy were studied by light microscopy using sections 1 mu thick cut from Epon embedded tissue and by electron microscopy. There was a disparity between the severity of the physiologic impairment and the morphologic abnormalities. Interstitial fibrosis was present only in the one case in which significant viral antibody titers were obtained. The sizes of the cardiac muscle cells varied abnormally in all specimens. Cardiac muscle cells in two patients contained abnormal mitochondria, and a leptomeric fibril was found in one patient. Virologic cultures of the tissues were negative and no viral particles were identified by electron microscopy. An attempt was made to correlate the clinical and pathologic findings.

Passive electrical properties of the atrio-ventricular node

The passive electrical properties of the atrioventricular node and of the atrial muscle of the rabbit heart were determined. To polarize the cells, a small suction electrode was used. The space constant of the atrio-ventricular node was found to be small (430 micron) compared to other cardiac fibers. The small value of gamma in nodal cells is due to a high intracellular resistance (ra, 40.9 +/- 9 M omega/cm) which is higher than in atrial muscle (9.6 +/- 2.2 M omega/cm). The input resistance of cells of the N layer was found equals to 880 K omega while in the right atrium was 320 K omega. The time constant of nodal cells in the AN layer was 3.4 ms, in the N layer 9 ms and in the atrium 5 ms. Assuming a specific membrane capacity (Cm) of nodal and atrial fibers of 1 micron F/cm2, Rm was found equals to 9.000 omega cm2 in N layer. 3.400 omega cm2 in AN layer and 3.800 omega cm2 in the right atrium. Acetylcholine (5 microgram/ml) reduced the space constant of the atrio-ventricular node by 38% and the time constant of nodal cells by 33%. The delay of impulse conduction in the A-V node semms then related to a high intracellular resistance along the pathway of conduction.

Intercellular coupling in the atrioventricular node and other tissues of the rabbit heart

1. A fluorescent tracer dye, sodium fluorescein (mol.wt. 332), was used to assess the relative degree of intercellular coupling in various tissues of the rabbit heart. 2. Dye was injected intracellularly by micro-iontophoresis. Subsequent movement into contiguous cells was monitored by video microscopy. From these data the permeability of the intercellular boundaries was computed. 3. The values of boundary permeability were consistent with those expected from previous studies with tracers whose molecular weights bracketed that of fluorescein. 4. In the atrium, ventricle, Purkinje strands and His bundle, the relative magnitude of the boundary permeability correlated reasonably well with the relative profusity of gap junctional area on the intercalated disk, the latter estimated from published data. 5. The rate of passage of dye between N cells of the atrioventricular, AV, node was at least three orders of magnitude lower than between cells of the other tissues studied; this result is consistent with published reports indicating few gap junctions between cells within the region of slow conduction. 6. Quantitative considerations based on these data indicate that N cells may not be sufficiently well coupled to permit impulse propagation through the AV node by intercellular current flow, alone.

Fine structure of the bundle-branches

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Accelerated atrioventricular conduction after myocardial infarction. A study using His bundle electrograms

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Low conduction in cardiac muscle. Biophysical model

Mechanisms of slow conduction in cardiac muscle are categorized and the most likely identified. Propagating action potentials were obtained experimentally from a synthetically grown strand of cardiac muscle (around 50 mum by 30 mm) and theoretically from a one-dimensional cable model that incorporated varying axial resistance and membrane properties along its length. Action potentials propagated at about 0.3 m/s, but in some synthetic strands there were regions (approximately 100 mum in length) where the velocity decreased to 0.002 m/s. The electrophysiological behavior associated with this slow conduction was similar to that associated with slow conduction in naturally occurring cardiac muscle (notches, Wenckebach phenomena, and block). Theoretically, reasonable changes in specific membrane capacitance, membrane activity, and various changes in geometry were insufficient to account for the observed slow conduction velocities. Conduction velocities as low as 0.009 m/s, however, could be obtained by increasing the resistance (r(i)) of connections between the cells in the cable; velocities as low as 0.0005 m/s could be obtained by a further increase in r(i) made possible by a reduction in membrane activity by one-fourth, which in itself decreased conduction velocity by only a factor of 1/1.4. As a result of these findings, several of the mechanisms that have been postulated, previously, are shown to be incapable of accounting for delays such as those which occur in the synthetic strand as well as in the atrioventricular (VA) node.