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Anatomy of Cardiac Conduction System
曹玄明 醫師陽明大學附設醫院
Normal Sinus Rhythm
Click heart to view
animation
*Animation
Impulse Formation In SA Node
Atrial Depolarization
Delay At AV Node
Conduction Through Bundle Branches
Conduction Through Purkinje Fibers
Ventricular Depolarization
Discovery of anatomic substrates for conduction
1852. Stanius: impulses were conducted across the atrioventricular junction through the myocardium in amphibian hearts
1893. His: the presence of a solitary muscle bundle crossing the fibrous plane of AV insulation
1893. Kent: found multiple muscular strands crossing the insulated AV planes
1906. Tawara: clarification of the existence of a specialized axis: atrioventricular node, continued as the bundle of His and terminated in the ventricular Purkinje cells
1907. Keith and Flack: confirm the existence of AV node and also discover the location of cardiac pacemaker: sinus node
Criterions for the histological definition
of cardiac conduction system
Histological discrete from the adjacent working myocardium
Serially traceable from section to section Insulated from the adjacent working
myocardium by a sheath of fibrous tissue
Sinus node
The sinus node is located at the junction of superior caval vein with the right atrium, spindle shape structure 10-20mm long, 2-3mm wide and thick
90% cases: it is positioned just inferior to the crest of the right atrial appendage
10% cases: it extended as a horseshoe across the crest, reaching into the interatrial groove
In human heart, an extensive area within the terminal crest adjacent to the node where nodal cells intermingled with working atrial myocytes
The paranodal area was separated by short zone of atrial myocardium from true node
This specialized myocytes is very likely to generate abnormal rhythm
Cells from the SA node region exhibit a wide variety of morphologies.
Only spindle and spider shaped cells exhibit a typical electrophysiological characteristics of pacemaker cell
Presence of hyperpolarization-activated current, If; and absence of inwardly rectifying K current, Ik1; and spontaneous beating under physiological conditions
Function of SA node
Sinus node cells function as electrically coupled oscillators that discharge synchronously because of mutual entrainment.
Faster discharging cells area slowed by the cells firing more slowly
The interaction depends on the degree of coupling and the EP characteristics of each sinus nodal cells.
Blood supply of SA node
55-60% from RCA40-45% from LCX
Internodal and intraatrial conduction
Three intraatrial pathways
1. anterior internodal pathway: SA nodeanterior interatrial band (Backmann bundle)
2. Middle internodal pathway: SA node crest of IAS AVN
3. posterior internodal tract: SA node crista terminalis eustachian ridge IAS above coronary sinus
Interatrial bundles
Septum primum
Foramen secundum
Foramen ovale
Septum secundum
1. True septal wall: flap valve of OF (1.5-2.4
cm2)2 . Limbus: pronounced
superiorly & laterally Fusion of septum primum
and secundum3. Folds, interposed between
the chamber: no the true septal wall
Europace 2007
The atrioventricular axis
The normal junction area:
(1) Transitional cell zone
(2) Atrioventricular node (compact node): located at the apex of koch triangle
(3) Bundle of His: distal part of compact AV node ,perforates central fibrous body and through the annulus fibrosis
AV conduction axis can be segregated into two connecting compartments based on immunohistological analyses
(1) Connexin45: compact node and transitional cell
(2) Coexpressing of connexin43 and connexin45: His bundle, lower nodal cells and posterior nodal extension
Ho Clin Anat 2009
KOCH Triangle
The mean distance from nodal artery to endocardium 3.5± 1.5mm
18% patients had compact node close to the hinge of TV
Sanchez Quintata JCE 2001
Blood supply and Risk of Nodal Artery and AV Conduction Tissue Injury
Dual AVN and AVNRT
Anderson JCE 1999 Ho Circulation 2008
Pre-excitation and AP mediated tachycardia
Bundle branches
These structures begin at the superior margin of interventricular septum
Left bundle branch onto the septum beneath the non-coronary cusp fascicular system (anterior and posterior)
Right bundle branch unbranched AV bundle down the right interventricular septum RV apex
Trifascicular bundle branch system
Terminal Purkinje fibers
These fibers connect with the ends of the bundle branches to form networks on the endocardial surface of both ventricles.
Less concentrated at the base of ventricles and at the papillary muscle
In human, they penetrate the inner 1/3 of the endocardium.
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