Lecture 9- Cardiac conducting system in health and disease 1.

Introduction - Cardiac muscle is a functional syncytium[confluent of adjacent cell] - Action potentials are propagated from one cell to the next adjacent cell - Gap junctions facilitate the propagation of action potential After depolarisation the cell membrane cant be depolarised for a defined period of time to ensure one-way propagation of action potentials across myocardial tissue

The heart contains a specialised conduction system that directs and facilitates spreading of original action potential from the SA node to the entire heart

2. Sequence of cardiac excitation

Action potential initiated at the SA node spread throughout the myocardium, passing from cell to cell by way of gap junctions. Depolarisation first spread through the muscle of cells of the atria, with conduction rapid enough that the right and left atria contract at essentially the same time.

The action potential spreading through muscle cells of the right atrium causes depolarisation of the AV node. Autonomic nervous system regulates the AV conduction(sympathetic and parasympathetic) Autorhytmic cells in the AV node can function as pacemakers at a rate of 25-40 beats/min The propagation of action potential through the AV node is relatively slow in order to allow atrial contraction to be completed before ventricular excitation occur. However, most of ventricular filling is completed during early diastole that is long before cardiac excitation starts in the SA node) After leaving the AV node, action potential propagated down the wall [interventricular septum] between the two ventricles. This pathway has conducting-system fibers called the Bundle of His Within the interventricular septum, the bundle of His divides into right and left bundle branches- which eventually leave the septum to enter the walls of both ventricles. These fibres in turn make contact with Purkinje fibres, large conducting cells that rapidly distribute the impulse throughout much of the ventricles Purkinje fibers have the highest conduction velocity of all cardiac cells. This allows for a rapid spread of the excitation throughout the ventricles Purkinje fibers make contact with ventricular myocardial cells, which spread the impulse through the rest of ventricles Early contraction of the papillary muscles prevents eversion of the AV valves into the atria during systole Purkinje fibers have a long refractory period which can block conduction of premature excitation of atria. Purkinje fibers have a potential for automacity and rhythm generation

Autorhythmic cells become the back-up system. AV node has the capacity of depolarising but dont depolarise as fast as the SAN. Just enough to maintain the pumping action.

3. AV conduction defects can be diagnosed using the ECG

Partial atrioventricular block : disease of the electrical conduction system of the heart. It refers to a conduction block between the atria and ventricles. The presence of second-degree AV block is diagnosed when one or more (but not all) of the atrial impulses fail to conduct to the ventricles due to impaired conduction. is characterized on a surface ECG by intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening. Total atrioventricular block: medical condition in which the impulse generated in the SA node in the atrium does not propagate to the ventricles. two independent rhythms can be noted on the electrocardiogram (ECG). The P waves with a regular P to P interval represents the first rhythm. The QRS complexes with a regular R to R interval represent the second rhythm. The PR interval will be variable Cardiac arrhythmia Tissue damage can cause changes in local ion concentrations and in ion channel function leading to arrhythmia Changes in extracellular K+ levels can induce arrhythmia through effects on resting membrane potential An arrhythmia is a disturbed heart rhythm. Some arrhythmias don't affect your overall health, while others are more serious and life-threatening. Palpitations

are a sensation or awareness of your heart beating. Palpitations may feel like your heart is 'racing', thumping or skipping beats. They can be triggered by exercise, emotional stress, caffeine and nicotine. Palpitations are usually associated with an abnormal heart rhythm (arrhythmia). http://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=arrhyt A cardiac impulse may re excite some myocardial region through which it had passed previously and which is no longer refractory. This phenomenon is called re entry and can cause cardiac arrhythmia The Wolff-Parkinson-White syndrome is a disease where a small amount extra electrical conductive tissue is present between atria and ventricles which may lead to dangerous tachycardias and arrhythmias.

4. Pacemaker therapy of AV conduction defects - is a medical device that uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart - The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's native pacemaker is not fast enough, or there is a block in the heart's electrical conduction system - This pacemaker is made to be able to detect the depolarisation of the atrium induced by the SA node, and after an adequate time-delay to deliver an electrical impulse to the apex of heart.