Specialized Conduction System Research Articles

Genetic variation at the human connexin 43 locus but not at the connexin 40 locus is associated with left bundle branch block

BackgroundBundle branch block (BBB) has been regarded as a disease of the conduction system, but occurs in mice lacking connexin 40 (expressed in atria, proximal conduction system) or connexin 43...

Image-Based Structural Modeling of the Cardiac Purkinje Network.

The Purkinje network is a specialized conduction system within the heart that ensures the proper activation of the ventricles to produce effective contraction. Its role during ventricular arrhythmias is less clear, but some experimental studies have suggested that the Purkinje network may significantly affect the genesis and maintenance of ventricular arrhythmias. Despite its importance, few structural models of the Purkinje network have been developed, primarily because current physical limitations prevent examination of the intact Purkinje network. In previous modeling efforts Purkinje-like structures have been developed through either automated or hand-drawn procedures, but these networks have been created according to general principles rather than based on real networks. To allow for greater realism in Purkinje structural models, we present a method for creating three-dimensional Purkinje networks based directly on imaging data. Our approach uses Purkinje network structures extracted from photographs of dissected ventricles and projects these flat networks onto realistic endocardial surfaces. Using this method, we create models for the combined ventricle-Purkinje system that can fully activate the ventricles through a stimulus delivered to the Purkinje network and can produce simulated activation sequences that match experimental observations. The combined models have the potential to help elucidate Purkinje network contributions during ventricular arrhythmias.

Jesús Alanís and the first recording of the his bundle: the scientist and the man.

The anatomy and physiology of the specialized conduction system has intrigued investigators since the 19th century and is still not fully understood. Dr. Wilhelm His Jr. is well known because he discovered the A-V bundle, and Dr. Sunao Tawara is rightly credited with the discovery of the atrioventricular (AV) node, but who was the first to record the electrical activity of the His bundle? This paper reviews the historical background and scientific contributions made by Dr. Jesús Alanís in the middle of the 20th century working at the National Institute of Cardiology in Mexico City. Collaborating with outstanding investigators such as Arturo Rosenblueth, Dr. Alanís recorded for the first time the electrical activity of the His bundle in the isolate canine heart. That the recorded electrogram was indeed the His bundle and not the AV node was confirmed by detailed studies that set the basis for modern clinical electrophysiology. The life and research contributions of this extraordinary man are reviewed in the context of a unique group of investigators who made significant advances in cardiac electrophysiology.

His bundle activates faster than ventricular myocardium during prolonged ventricular fibrillation.

BackgroundThe Purkinje fiber system has recently been implicated as an important driver of the rapid activation rate during long duration ventricular fibrillation (VF>2 minutes). The goal of this study is to determine whether this activity propagates to or occurs in the proximal specialized conduction system during VF as well.Methods and ResultsAn 8×8 array with 300 µm spaced electrodes was placed over the His bundles of isolated, perfused rabbit hearts (n = 12). Ventricular myocardial (VM) and His activations were differentiated by calculating Laplacian recordings from unipolar signals. Activation rates of the VM and His bundle were compared and the His bundle conduction velocity was measured during perfused VF followed by 8 minutes of unperfused VF. During perfused VF the average VM activation rate of 11.04 activations/sec was significantly higher than the His bundle activation rate of 6.88 activations/sec (p<0.05). However from 3–8 minutes of unperfused VF the His system activation rate (6.16, 5.53, 5.14, 5.22, 6.00, and 4.62 activations/sec significantly faster than the rate of the VM (4.67, 3.63, 2.94, 2.24, 3.45, and 2.31 activations/sec) (p<0.05). The conduction velocity of the His system immediately decreased to 94% of the sinus rate during perfused VF then gradually decreased to 67% of sinus rhythm conduction at 8 minutes of unperfused VF.ConclusionDuring prolonged VF the activation rate of the His bundle is faster than that of the VM. This suggests that the proximal conduction system, like the distal Purkinje system, may be an important driver during long duration VF and may be a target for interventional therapy.

Simplified 2D Bidomain Model of Whole Heart Electrical Activity and ECG Generation

Abstract The aim of this study was the development of a geometrically simple and highly computationally-efficient two dimensional (2D) biophysical model of whole heart electrical activity, incorporating spontaneous activation of the sinoatrial node (SAN), the specialized conduction system, and realistic surface ECG morphology computed on the torso. The FitzHugh-Nagumo (FHN) equations were incorporated into a bidomain finite element model of cardiac electrical activity, which was comprised of a simplified geometry of the whole heart with the blood cavities, the lungs and the torso as an extracellular volume conductor. To model the ECG, we placed four electrodes on the surface of the torso to simulate three Einthoven leads VI, VII and VIII from the standard 12-lead system. The 2D model was able to reconstruct ECG morphology on the torso from action potentials generated at various regions of the heart, including the sinoatrial node, atria, atrioventricular node, His bundle, bundle branches, Purkinje fibers, and ventricles. Our 2D cardiac model offers a good compromise between computational load and model complexity, and can be used as a first step towards three dimensional (3D) ECG models with more complex, precise and accurate geometry of anatomical structures, to investigate the effect of various cardiac electrophysiological parameters on ECG morphology.

Effect of NRG-1/ErbB Signaling Intervention on the Differentiation of Bone Marrow Stromal Cells Into Sinus Node–like Cells

The neuregulin-1 (NRG-1)/ErbB signaling pathway is a crucial regulator of cardiac development and plays an important role in the formation of the cardiac special conduction system. To establish a rat bone marrow stromal cell (BMSC) cardiomyocyte (CM)-like differentiation model, BMSCs were treated with 5-azacytidine and fibroblast growth factor basic (FGF-basic) for 24 hours and then cocultured with neonatal rat CMs in a Transwell culture system. The feasibility of regulating the differentiation of BMSCs into sinoatrial node cells by manipulating the NRG-1/ErbB pathway was investigated. Three weeks after induction, reverse transcription-polymerase chain reaction analysis revealed that inhibition of NRG-1/ErbB signaling (using AG1478) greatly enhanced the expression of HCN4, Tbx3, and Tbx2. Additionally, Tbx3 protein levels were higher than in the control group and even produced distinct nodal-type action potentials. The expression of Nkx2.5 in the NRG-1 group (treated with exogenous NRG-1) was higher than the other 2 groups. The expression of phospho-Akt was also increased in the NRG-1 group but decreased in the AG1478 group. Together, these data demonstrate that inhibiting the endogenous NRG-1/ErbB signaling pathway when rat BMSCs differentiate into CMs can greatly enhance the pacemaker phenotype. Akt signaling may be one of the underlying molecular mechanisms responsible for these results.

Cell Junctions in the Specialized Conduction System of the Heart

Anchoring cell junctions are integral in maintaining electro-mechanical coupling of ventricular working cardiomyocytes; however, their role in cardiomyocytes of the cardiac conduction system (CCS) remains less clear. Recent studies in genetic mouse models and humans highlight the appearance of these cell junctions alongside gap junctions in the CCS and also show that defects in these structures and their components are associated with conduction impairments in the CCS. Here we outline current evidence supporting an integral relationship between anchoring and gap junctions in the CCS. Specifically we focus on (1) molecular and ultrastructural evidence for cell-cell junctions in specialized cardiomyocytes of the CCS, (2) genetic mouse models specifically targeting cell-cell junction components in the heart which exhibit CCS conduction defects and (3) human clinical studies from patients with cell-cell junction-based diseases that exhibit CCS electrophysiological defects.

Revisiting heart activation-conduction physiology, part I: atria

This discussion paper re-examines the conduction-activation of the atria, based on observations, with respect to the complexity of the heart as an organ with a brain, and its evolution from a peristaltic tube. The atria do not require a specialized conduction system because they use the subendocardial layer to produce centripetal transmural activation fronts, regardless of the anatomical and histological organization of the transmural atrial wall. This has been described as "two-layer" physiology which provides robust transmission of activation from the sinus to the AV node via a centripetal transmural activation front. New productive insights can come from re-examining the physiology, not only during sinus rhythm but also during atrial tachycardias, in particular atrial flutter and atrial fibrillation (AF). During common flutter, the areas of slow conduction, in the isthmus and following trabeculations, particularly the subendocardial layer confines conduction through the trabeculations which supports re-entry. During experimental or postoperative flutter, the circular 2D activation around the obstacle follows the physiological transmural activation. Understanding this physiology offers insights into AF. During acute or protracted AF, the presence of stationary or drifting rotors is characteristic and consistent with normal physiological 2D atrial activation, suggesting that suppressing physiological transmural activation of AF will permanently restore normal sinus node atrial activation. In contrast, during permanent AF, normal 2D activation is abolished; the presence of transmural, serpentine, and chaotic atrial activation suggests that the normal physiological activation pattern has been replaced by a new, irreversible variety of atrial conduction that is a new physiology, which is consistent with evolution of complex systems.

Successful ablation of an incessant ventricular tachycardia in a 3.5 kg infant

We report a 3.5 kg female infant without structural heart disease having rapid, repetitive, monomorphic ventricular tachycardia (VT). The surface electrocardiogram showed a relatively narrow QRS pattern, and suggesting a focal automatic VT originating from the infra-Hissian specific conduction system …

Bachmann’s Bundle

Bachmann’s bundle (BB), also known as the interatrial bundle, is well recognized as a muscular bundle comprising of parallel aligned myocardial strands connecting the right and left atrial walls and is considered to be the main pathway of interatrial conduction.1 Disruption of the bundle’s structure causes interatrial conduction block (IAB),2 which is associated with development of various atrial tachyarrhythmias3,4 and with electromechanical dysfunction of the left atrium.5 Technological progress providing sophisticated mapping and imaging techniques in the past decade has increased our knowledge of specific anatomic structures and their role in development of both atrial brady- and tachyarrhythmias. This review outlines the current knowledge of the relation between anatomic and electrophysiological properties of BB and its possible role in initiation and perpetuation of atrial fibrillation (AF). In 1963, Thomas N. James described 3 pathways connecting the sinus node to the atrioventricular node (AVN), namely the anterior, medial, and posterior internodal pathways.6 Whether these conduction pathways were because of the presence of specialized conduction tissue or because of the anisotropic orientation of the muscle fibers remains controversial. Nevertheless, James described the anterior pathway as leaving the sinus node in anterior direction and giving off a secondary branch at the level of the superior vena cava to form BB.1 BB stretches subepicardially across the interatrial groove (septal raphe). It is at the interatrial groove that the BB can be identified as a discrete bundle (Figures 1 and 2) separated by fatty tissues from the infolded right atrial wall that is the limbus of the oval fossa. Notably, the bundle is not surrounded by a fibrous tissue sheath. Instead, the bundle is comprised of strands of atrial myocardium that are similarly aligned in parallel fashion. Its rightward and leftward extensions bifurcate to pass to either …

The funny and not-so-funny effects of dronedarone

The funny and not-so-funny effects of dronedarone

Genetic variation at the human connexin 43 locus but not connexin 40 locus is associated with left bundle branch block

Purpose: Bundle branch block has previously been regarded as a disease of the conduction system. Evolving evidence, including data from knock-out mice, suggest that Bundle Branch Block (BBB) also can be the result of impaired conduction distal to the conduction system. Connexin 40 is expressed in atria and the proximal conduction system. Connexin 43 is expressed in cardiomyocytes. We wanted to explore if bundle branch block is a heritable trait and if genetic variation at the loci for connexin 40 and 43 are associated with bundle branch block. Methods: To assess heritability of bundle branch block we screened descendants from men with bundle branch blocks participating in Study of Men Born 1913. To assess genetic variation at the connexin 40 and 43 loci DNA samples from twenty 80 year old men (representing extreme phenotypes regarding long/short QRS) and two sons with BBB were used as a screening panel. The coding exons and 5' and 3-UTR part of the genes for connexin 40 and connexin 43 were sequenced in search for polymorphisms. Association between the identified polymorphisms and bundle branch block were then evaluated in an independent cohort sampled from INTERGENE with 108 BBB (70 RBBB, 38 LBBB) and 266 controls without BBB. Results: Seventyseven men from Study of Men Born 1913 with BBB and families had 116 offspring, of these 76 (66%) were willing to participate. Offspring had a mean age of 53 years on examination. Seventeen of all men (41%) had a QRS >95 ms, which is longer than expected at that age, and two sons had BBB. 6 Single Nucleotide Polymorphisms (SNPs) were identified in Connexin 40 and one insertion/deletion polymorphism in connexin 43. The INTERGENE cohort was genotyped for identified polymorphisms and an association between the Cx43 insertion/deletion polymorphism and Left Bundle Branch Block was observed, (chi-square 8.6, p=0.02) but no association to RBBB or overall BBB. None of the connexin 40 SNPs or haplotypes were associated with LBBB nor RBBB. Conclusions: In conclusion, we identified an insertion/deletion polymorphism in connexin 43 associated with left bundle branch block. No association was seen between genetic variation in Connexin 40 and LBBB nor RBBB. These findings suggest that conduction within the ventricular muscle distal to the specialised conduction system can be of importance for bundle branch block development.

HCN4 Dynamically Marks the First Heart Field and Conduction System Precursors

To date, there has been no specific marker of the first heart field to facilitate understanding of contributions of the first heart field to cardiac lineages. Cardiac arrhythmia is a leading cause of death, often resulting from abnormalities in the cardiac conduction system (CCS). Understanding origins and identifying markers of CCS lineages are essential steps toward modeling diseases of the CCS and for development of biological pacemakers. To investigate HCN4 as a marker for the first heart field and for precursors of distinct components of the CCS, and to gain insight into contributions of first and second heart lineages to the CCS. HCN4CreERT2, -nuclear LacZ, and -H2BGFP mouse lines were generated. HCN4 expression was examined by means of immunostaining with HCN4 antibody and reporter gene expression. Lineage studies were performed using HCN4CreERT2, Isl1Cre, Nkx2.5Cre, and Tbx18Cre, coupled to coimmunostaining with CCS markers. Results demonstrated that, at cardiac crescent stages, HCN4 marks the first heart field, with HCN4CreERT2 allowing assessment of cell fates adopted by first heart field myocytes. Throughout embryonic development, HCN4 expression marked distinct CCS precursors at distinct stages, marking the entire CCS by late fetal stages. We also noted expression of HCN4 in distinct subsets of endothelium at specific developmental stages. This study provides insight into contributions of first and second heart lineages to the CCS and highlights the potential use of HCN4 in conjunction with other markers for optimization of protocols for generation and isolation of specific conduction system precursors.

Erratum: Interfering amino terminal peptides and functional implications for heteromeric gap junction formation

Connexin43 (Cx43) is widely expressed in many different tissues of the human body. In cells of some organs, Cx43 is co-expressed with other connexins (Cx), including Cx46 and Cx50 in lens, Cx40 in atrium, Purkinje fibers, and the blood vessel wall, Cx45 in heart, and Cx37 in the ovary. Interactions with the co-expressed connexins may have profound functional implications. The abilities of Cx37, Cx45, Cx46, and Cx50 to function in heteromeric gap junction combinations with Cx43 are well documented. Different studies disagree regarding the ability of Cx43 and Cx40 to produce functional heteromeric gap junctions with each other. We review previous studies regarding the heteromeric interactions of Cx43. The possibility of negative functional interactions between the cytoplasmic pore-forming amino-terminal (NT) domains of these connexins was assessed using pentameric connexin sequence-specific NT domain [interfering NT (iNT)] peptides applied to cells expressing homomeric Cx40, Cx37, Cx45, Cx46, and Cx50 gap junctions. A Cx43 iNT peptide corresponding to amino acids 9-13 (Ac-KLLDK-NH2) specifically inhibited the electrical coupling of Cx40 gap junctions in a transjunctional voltage (V j)-dependent manner without affecting the function of homologous Cx37, Cx46, Cx50, and Cx45 gap junctions. A Cx40 iNT (Ac-EFLEE-OH) peptide counteracted the V j-dependent block of Cx40 gap junctions, whereas a similarly charged Cx50 iNT (Ac-EEVNE-OH) peptide did not, suggesting that these NT domain interactions are not solely based on electrostatics. These data are consistent with functional Cx43 heteromeric gap junction formation with Cx37, Cx45, Cx46, and Cx50 and suggest that Cx40 uniquely experiences functional suppressive interactions with a Cx43 NT domain sequence. These findings present unique functional implications about the heteromeric interactions between Cx43 and Cx40 that may influence cardiac conduction in atrial myocardium and the specialized conduction system.

Transgenic models of cardiac arrhythmias and sudden death

Transgenic models of cardiac arrhythmias and sudden death

Interfering amino terminal peptides and functional implications for heteromeric gap junction formation

Connexin43 (Cx43) is widely expressed in many different tissues of the human body. In cells of some organs, Cx43 is co-expressed with other connexins (Cx), including Cx46 and Cx50 in lens, Cx40 in atrium, Purkinje fibers, and the blood vessel wall, Cx45 in heart, and Cx37 in the ovary. Interactions with the co-expressed connexins may have profound functional implications. The abilities of Cx37, Cx45, Cx46, and Cx50 to function in heteromeric gap junction combinations with Cx43 are well documented. Different studies disagree regarding the ability of Cx43 and Cx40 to produce functional heteromeric gap junctions with each other. We review previous studies regarding the heteromeric interactions of Cx43. The possibility of negative functional interactions between the cytoplasmic pore-forming amino-terminal (NT) domains of these connexins was assessed using pentameric connexin sequence-specific NT domain [interfering NT (iNT)] peptides applied to cells expressing homomeric Cx40, Cx37, Cx45, Cx46, and Cx50 gap junctions. A Cx43 iNT peptide corresponding to amino acids 9–13 (Ac-KLLDK-NH2) specifically inhibited the electrical coupling of Cx40 gap junctions in a transjunctional voltage (Vj)-dependent manner without affecting the function of homologous Cx37, Cx46, Cx50, and Cx45 gap junctions. A Cx40 iNT (Ac-EFLEE-OH) peptide counteracted the Vj-dependent block of Cx40 gap junctions, whereas a similarly charged Cx50 iNT (Ac-EEVNE-OH) peptide did not, suggesting that these NT domain interactions are not solely based on electrostatics. These data are consistent with functional Cx43 heteromeric gap junction formation with Cx37, Cx45, Cx46, and Cx50 and suggest that Cx40 uniquely experiences functional suppressive interactions with a Cx43 NT domain sequence. These findings present unique functional implications about the heteromeric interactions between Cx43 and Cx40 that may influence cardiac conduction in atrial myocardium and the specialized conduction system.

A Simplified 3D Model of Whole Heart Electrical Activity and 12-Lead ECG Generation

We present a computationally efficient three-dimensional bidomain model of torso-embedded whole heart electrical activity, with spontaneous initiation of activation in the sinoatrial node, incorporating a specialized conduction system with heterogeneous action potential morphologies throughout the heart. The simplified geometry incorporates the whole heart as a volume source, with heart cavities, lungs, and torso as passive volume conductors. We placed four surface electrodes at the limbs of the torso: V R, V L, V F and V GND and six electrodes on the chest to simulate the Einthoven, Goldberger-augmented and precordial leads of a standard 12-lead system. By placing additional seven electrodes at the appropriate torso positions, we were also able to calculate the vectorcardiogram of the Frank lead system. Themodel was able to simulate realistic electrocardiogram (ECG) morphologies for the 12 standard leads, orthogonal X, Y, and Z leads, as well as the vectorcardiogram under normal and pathological heart states. Thus, simplified and easy replicable 3D cardiac bidomain model offers a compromise between computational load and model complexity and can be used as an investigative tool to adjust cell, tissue, and whole heart properties, such as setting ischemic lesions or regions of myocardial infarction, to readily investigate their effects on whole ECG morphology.

Papillary Muscle Ventricular Tachycardia: Another Zigsaw Puzzle to Be Solved

Papillary Muscle Ventricular Tachycardia: Another Zigsaw Puzzle to Be Solved

Cardiomyocyte-specific deletion of survivin causes global cardiac conduction defects

Survivin (Surv) belongs to the inhibitor of apoptosis protein family. Its cardiac-specific deletion results in reduced cardiomyocyte number, increased cardiomyocyte size and ploidy, and development of heart failure. Its impact on cardiac electrophysiology is unknown. In vivo transvenous electrophysiological studies were carried out in adult male mice with a cardiac-specific deletion of survivin (Surv(-/-); n = 12) and wild-type controls (Surv(+/+); n = 12). Epicardial activation mapping (EAM) was performed in Langendorff-perfused hearts of 16 Surv(-/-) and 6 Surv(+/+) mice. Surface-ECG showed lower heart rates in Surv(-/-) mice (326 ± 66 bpm vs. 440.6 ± 39 ms; P = 0.0001), accompanied by significantly prolonged P waves (20.3 ± 5.8 vs. 14.6 ± 2.0 ms; P = 0.009), PQ-(47.4 ± 8.6 vs. 41.1 ± 3.7 ms; P = 0.043), QRS- (19.5 ± 4.8 vs. 14.0 ± 1.0 ms; P = 0.002) and QT-intervals (41.6 ± 4.4 vs. 36.2 ± 3.4 ms; P = 0.003). The HV-interval was prolonged in Surv(-/-) mice (12.1 ± 2.4 vs. 9.3 ± 1.4 ms; P = 0.0045). We found impaired sinus-nodal function (sinus node recovery times: 310.2 ± 76.6 vs. 207.8 ± 68.6 ms; P = 0.003) and AV-nodal conduction (Wenckebach-periodicity: 105.9 ± 15.9 vs. 79.6 ± 8.1 ms; P = 0.0002). EAM showed significant slowing and heterogeneity of conduction in the myocardium of Surv(-/-) mice. All Surv(-/-) mice showed spontaneous supraventricular and ventricular ectopic beats (P < 0.0001 vs. wildtype). Quantitative immunofluorescence staining for connexin43 (Cx43) revealed a decrease in both per cardiomyocyte and single gap junction. Surv(-/-) mice exhibit severe global conduction attenuations in atrial and ventricular myocardium as well as the specific conduction system, accompanied by lower connexin43 levels. Lack of susceptibility to AF and VT suggests that reduced cardiomyocyte number and increased size constitute determinants of electrical stableness in the heart and counteract potentially proarrhythmogenic connexin43 loss in Surv(-/-).

Phenotype, genotype, and cellular physiology: Need for clarity in characterization

The voltage-dependent sodium channel α-subunit is encoded by the SCN5A gene and carries INa, which is the current predominantly responsible for the rapid upstroke of the action potential in the heart. 1,2 INa is central to the control of excitability and conduction in atrial and ventricular myocardial tissue and the specialized conduction system Purkinje fibers. Mutations in SCN5A have been associated with several inherited cardiac conditions, including long QT syndrome type 3 (LQT3), Brugada syndrome (BrS), familial atrial fibrillation, sudden infant death syndrome, mixed conduction disease, and dilated cardiomyopathy.