Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
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Unsolved Questions on the Anatomy of the Ventricular Conduction System

  • Oh, Il-Young (Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital) ;
  • Cha, Myung-Jin (Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital) ;
  • Lee, Tae-Hui (Department of Pathology, Mediplex Sejong Hospital) ;
  • Seo, Jeong-Wook (Department of Pathology, Seoul National University College of Medicine) ;
  • Oh, Seil (Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital)
  • Received : 2018.09.30
  • Accepted : 2018.10.22
  • Published : 2018.12.31
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Abstract

We reviewed the anatomical characteristics of the conduction system in the ventricles of human and ungulate hearts and then raised some questions to be answered by clinical and anatomical studies in the future. The ventricular conduction system is a 3-dimensional structure as compared to the 2-dimensional character of the atrial conduction system. The proximal part consisting of the atrioventricular node, the bundle of His and fascicles are groups of conducting cells surrounded by fibrous connective tissue so as to insulate from the underlying myocardium. Their location and morphological characters are well established. The bundle of His is a cord like structure but the left and right fascicles are broad at the proximal and branching at the distal part. The more distal part of fascicles and Purkinje system are linear networks of conducting cells at the immediate subendocardium but the intra-mural network is detected at the inner half of the ventricular wall. The papillary muscle also harbors Purkinje system not in the deeper part. It is hard to recognize histologically in human hearts but conducting cells as well as Purkinje cells are easily recognized in ungulate hearts. Further observation on human and ungulate hearts with myocardial infarct, we could find preserved Purkinje system at the subendocardium in contrast to the damaged system at the deeper myocardium. Further studies are necessary on the anatomical characteristics of this peripheral conduction system so as to correlate the clinical data on hearts with ventricular arrhythmias.

Keywords

Acknowledgement

Supported by : Woochon Cardio-Neuro-Vascular Research Foundation

References

  1. Garcia-Bustos V, Sebastian R, Izquierdo M, Molina P, Chorro FJ, Ruiz-Sauri A. A quantitative structural and morphometric analysis of the Purkinje network and the Purkinje-myocardial junctions in pig hearts. J Anat 2017;230:664-78. https://doi.org/10.1111/joa.12594
  2. Davies MJ. Pathology of conducting tissue of the heart. London: Butterworths; 1971.
  3. Seo JW, Chi JG, Lee SK. Cardiac conduction system-Morphological observations on the autopsy cases. Korean J Pathol 1983;17:127-37.
  4. Ansari A, Ho SY, Anderson RH. Distribution of the Purkinje fibres in the sheep heart. Anat Rec 1999;254:92-7. https://doi.org/10.1002/(SICI)1097-0185(19990101)254:1<92::AID-AR12>3.0.CO;2-3
  5. Saffitz JE, Corradi D. The electrical heart: 25 years of discovery in cardiac electrophysiology, arrhythmias and sudden death. Cardiovasc Pathol 2016;25:149-57. https://doi.org/10.1016/j.carpath.2015.11.005
  6. Silverman ME, Hollman A. Discovery of the sinus node by Keith and Flack: on the centennial of their 1907 publication. Heart 2007;93:1184-7. https://doi.org/10.1136/hrt.2006.105049
  7. Silverman ME, Grove D, Upshaw CB Jr. Why does the heart beat? the discovery of the electrical system of the heart. Circulation 2006;113:2775-81. https://doi.org/10.1161/CIRCULATIONAHA.106.616771
  8. Cho Y, Lee W, Park EA, et al. The anatomical characteristics of three different endocardial lines in the left atrium: evaluation by computed tomography prior to mitral isthmus block attempt. Europace 2012;14:1104-11. https://doi.org/10.1093/europace/eus051
  9. Dong J, Dickfeld T. Image integration in electroanatomic mapping. Herzschrittmacherther Elektrophysiol 2007;18:122-30. https://doi.org/10.1007/s00399-007-0571-z
  10. Dukkipati SR, Koruth JS, Choudry S, Miller MA, Whang W, Reddy VY. Catheter ablation of ventricular tachycardia in structural heart disease: indications, strategies, and outcomes-part II. J Am Coll Cardiol 2017;70:2924-41. https://doi.org/10.1016/j.jacc.2017.10.030
  11. Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol 2017;9:521-30. https://doi.org/10.4330/wjc.v9.i6.521
  12. Tawara S. The conduction system of the Mammalian heart: an anatomico-histological study of the atrioventricular bundle and the Purkinje fibers. London: Imperial College Press; 2000.
  13. De Almeida MC, Lopes F, Fontes P, Barra F, Guimaraes R, Vilhena V. Ungulates heart model: a study of the Purkinje network using India ink injection, transparent specimens and computer tomography. Anat Sci Int 2015;90:240-50. https://doi.org/10.1007/s12565-014-0255-9
  14. Moorman AF, Christoffels VM, Anderson RH. Anatomic substrates for cardiac conduction. Heart Rhythm 2005;2:875-86. https://doi.org/10.1016/j.hrthm.2005.04.025
  15. Bharati S, Scheinman M, Lev M. Histologic findings of the heart and the conduction system in the first patient who underwent catheter ablation. Pacing Clin Electrophysiol 1992;15:1291-9. https://doi.org/10.1111/j.1540-8159.1992.tb03140.x
  16. Jackman WM, Wang XZ, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991;324:1605-11. https://doi.org/10.1056/NEJM199106063242301
  17. Seo JW. Ventricular anatomy for the electrophysiologist (part I). Int J Arrhythm 2010;11:6-11.
  18. Seo JW, Kim MY. Ventricular anatomy for the electrophysiologist (part II). Int J Arrhythm 2010;11:6-12.
  19. Assomull RG, Prasad SK, Lyne J, et al. Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy. J Am Coll Cardiol 2006;48:1977-85. https://doi.org/10.1016/j.jacc.2006.07.049
  20. Massing GK, James TN. Anatomical configuration of the His bundle and bundle branches in the human heart. Circulation 1976;53:609-21. https://doi.org/10.1161/01.CIR.53.4.609
  21. Na CY, Hong JS, Park JJ, Kim WK, Kang MC, Seo JW. Establishment of the heart failure model by coronary artery ligation in sheep. Korean J Thorac Cardiovasc Surg 2002;35:1-10.
  22. Deo M, Boyle PM, Kim AM, Vigmond EJ. Arrhythmogenesis by single ectopic beats originating in the Purkinje system. Am J Physiol Heart Circ Physiol 2010;299:H1002-11. https://doi.org/10.1152/ajpheart.01237.2009

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