11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants

News&Perspective
Drugs&Diseases
CME&Education
Specialty:
Edition:ENGLISH
DEUTSCH
ESPAOL
FRANAIS
PORTUGUS
MyAccount:TIskandar
LogOut
Edition:ENGLISHDEUTSCHESPAOLFRANAISPORTUGUS
TIskandar

MyAccountLogOut

http://emedicine.medscape.com/article/1922987overview 1/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants

http://emedicine.medscape.com/article/1922987overview 2/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants

http://emedicine.medscape.com/article/1922987overview 3/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants

Search
NoResults

Search
NoResults

News&PerspectiveDrugs&DiseasesCME&Education

close
PleaseconfirmthatyouwouldliketologoutofMedscape.Ifyoulogout,youwillberequiredtoenteryourusernameand
passwordthenexttimeyouvisit.LogoutCancel

ConductionSystemoftheHeart
Author:RaminAssadi,MDChiefEditor:RichardALange,MD,MBAmore...

Updated:Jun28,2016

Overview
Theconductingsystemoftheheartconsistsofcardiacmusclecellsandconducting
fibers(notnervoustissue)thatarespecializedforinitiatingimpulsesandconducting
themrapidlythroughtheheart(seetheimagebelow).Theyinitiatethenormal
cardiaccycleandcoordinatethecontractionsofcardiacchambers.Bothatria
contracttogether,asdotheventricles,butatrialcontractionoccursfirst.

Theconductingsystemprovidestheheartitsautomaticrhythmicbeat.Fortheheart
topumpefficientlyandthesystemicandpulmonarycirculationstooperatein
synchrony,theeventsinthecardiaccyclemustbecoordinated. [1,2]

http://emedicine.medscape.com/article/1922987overview 4/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants

Schematicillustrationofthecardiacconductionsystem.

SeealsoHeartAnatomy,AorticValveAnatomy,MitralValveAnatomy,Pulmonic
ValveAnatomy,TricuspidValveAnatomy,AnatomyoftheNervesoftheHeart,and
AnatomyoftheAutonomicNervousSystem.

GrossAnatomy
Sinoatrialnode

Thesinoatrial(SA)nodeisaspindleshapedstructurecomposedofafibroustissue
matrixwithcloselypackedcells.Itis1020mmlong,23mmwide,andthick,
tendingtonarrowcaudallytowardtheinferiorvenacava(IVC).TheSAnodeis
locatedlessthan1mmfromtheepicardialsurface,laterallyintherightatrialsulcus
terminalisatthejunctionoftheanteromedialaspectofthesuperiorvenacava
(SVC)andtherightatrium(RA).

Thearterysupplyingthesinusnodebranchesfromtherightcoronaryarteryin55
60%ofheartsortheleftcircumflexarteryin4045%ofhearts.Theartery
approachesthenodefromaclockwiseorcounterclockwisedirectionaroundthe
SVCRAjunction. [3]

TheSAnodeisdenselyinnervatedwithpostganglionicadrenergicandcholinergic
nerveterminals.NeurotransmittersmodulatetheSAnodedischargerateby
stimulationofbetaadrenergicandmuscarinicreceptors.Bothbeta1andbeta2
adrenoceptorssubtypesarepresentintheSAnode.ThehumanSAnodecontains
amorethan3foldgreaterdensityofbetaadrenergicandmuscariniccholinergic
receptorsthantheadjacentatrialtissue. [4]

Internodalandintraatrialconduction

Anatomicevidencesuggeststhepresenceof3intraatrialpathways:(1)anterior
internodalpathway,(2)middleinternodaltract,and(3)posteriorinternodaltract.

TheanteriorinternodalpathwaybeginsattheanteriormarginoftheSAnodeand
curvesanteriorlyaroundtheSVCtoentertheanteriorinteratrialband,calledthe
Bachmannbundle(seetheimagebelow).Thisbandcontinuestotheleftatrium
(LA),withtheanteriorinternodalpathwayenteringthesuperiormarginoftheAV
node.TheBachmannbundleisalargemusclebundlethatappearstoconductthe
cardiacimpulsepreferentiallyfromtheRAtotheLA.

Schematicillustrationofthecardiacconductionsystem.

http://emedicine.medscape.com/article/1922987overview 5/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants
Themiddleinternodaltractbeginsatthesuperiorandposteriormarginsofthesinus
node,travelsbehindtheSVCtothecrestoftheinteratrialseptum,anddescendsin
theinteratrialseptumtothesuperiormarginoftheAVnode.

Theposteriorinternodaltractstartsattheposteriormarginofthesinusnodeand
travelsposteriorlyaroundtheSVCandalongthecristaterminalistotheeustachian
ridgeandthenintotheinteratrialseptumabovethecoronarysinus,whereitjoins
theposteriorportionoftheAVnode.Thesegroupsofinternodaltissuearebest
referredtoasinternodalatrialmyocardium,nottracts,astheydonotappeartobe
histologicallydiscretespecializedtracts. [3,5]

Atrioventricularnode

Thecompactportionoftheatrioventricular(AV)nodeisasuperficialstructure
locatedjustbeneaththeRAendocardium,anteriortotheostiumofthecoronary
sinus,anddirectlyabovetheinsertionoftheseptalleafletofthetricuspidvalve.It
isattheapexofatriangleformedbythetricuspidannulusandthetendonof
Todaro,whichoriginatesinthecentralfibrousbodyandpassesposteriorlythrough
theatrialseptumtocontinuewiththeeustachianvalve(seetheimagesbelow).

Thestippledareaadjacenttothecentralfibrousbodyistheapproximatesiteofthecompact
atrioventricularnode.(IllustrationbasedonJanseMJ,AndersonRH,McGuireMA,HoSY."AV
nodal"reentry:PartI:"AVnodal"reentryrevisited.JCardiovascElectrophysiol.1993
Oct4(5):56172.)

DrawingofanormalhumanheartshowingtheanatomiclandmarksofthetriangleofKoch.This
triangleisdelimitedbythetendonofTodarosuperiorly,thefibrouscommissureoftheflap
guardingtheopeningsoftheinferiorvenacavaandcoronarysinus,bytheattachmentofthe
septalleafletofthetricuspidvalveinferiorly,andbythemouthofthecoronarysinusatthebase.
(IllustrationbasedonJanseMJ,AndersonRH,McGuireMA,HoSY."AVnodal"reentry:PartI:
"AVnodal"reentryrevisited.JCardiovascElectrophysiol.1993Oct4(5):56172.)

In8590%ofhumanhearts,thearterialsupplytotheAVnodeisabranchfromthe
rightcoronaryarterythatoriginatesattheposteriorintersectionoftheAVand
interventriculargrooves(crux).Intheremaining1015%ofthehearts,abranchof
theleftcircumflexcoronaryarteryprovidestheAVnodalartery.Fibersinthelower
partoftheAVnodemayexhibitautomaticimpulseformation.Themainfunctionof
theAVnodeismodulationoftheatrialimpulsetransmissiontotheventriclesto
coordinateatrialandventricularcontractions. [3,6]

BundleofHis

ThebundleofHisisastructurethatconnectswiththedistalpartofthecompactAV
node,perforatesthecentralfibrousbody,andcontinuesthroughtheannulus
fibrosus,whereitiscalledthenonbranchingportionasitpenetratesthe
membranousseptum.Connectivetissueofthecentralfibrousbodyand

http://emedicine.medscape.com/article/1922987overview 6/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants
membranousseptumenclosesthepenetratingportionoftheAVbundle,whichmay
sendoutextensionsintothecentralfibrousbody.Proximalcellsofthepenetrating
portionareheterogeneousandresemblethoseofthecompactAVnodedistalcells
aresimilartocellsintheproximalbundlebranches.

Branchesfromtheanteriorandposteriordescendingcoronaryarteriessupplythe
uppermuscularinterventricularseptumwithblood,whichmakestheconduction
systematthissitemoreimpervioustotheischemicdamage,unlesstheischemiais
extensive. [7]

Bundlebranches

Thebundlebranchesoriginateatthesuperiormarginofthemuscular
interventricularseptum,immediatelybelowthemembranousseptum,withthecells
oftheleftbundlebranchcascadingdownwardasacontinuoussheetontothe
septumbeneaththenoncoronaryaorticcusp.Therightbundlebranchcontinues
intramyocardiallyasanunbranchedextensionoftheAVbundledowntherightside
oftheinterventricularseptumtotheapexoftherightventricleandbaseofthe
anteriorpapillarymuscle.Theanatomyoftheleftbundlebranchsystemmaybe
variableandmaynotconformtoaconstantbifasciculardivision.However,for
clinicalpurposesandelectrocardiography(ECG),theconceptofatrifascicular
systemremainsuseful(seetheimagesbelow)

Schematicrepresentationofthetrifascicularbundlebranchsystem.A=anteriorfascicleofleft
bundlebranchAVN=atrioventricularnodeHB=bundleofHisLBB=leftbundlebranchRBB
=rightbundlebranchP=posteriorfascicleofleftbundlebranch.

StructuralorganizationoftheHisPurkinjesysteminmouseheart.Expressionofagreen
fluorescentproteinwasspecificallytargetedtocellsoftheHisPurkinjesysteminmice.Green
fluorescentcellnetworksintheleftventricularchamberareshown.Theleftventricularfreewall
(LVW)wasincisedfrombasetoapex,andthenthe2partsoftheLVWwerepulledbackto
exposetheleftflankoftheinterventricularseptum(LF).Thedottedlinedemarcatestheborder
betweentheLFandtheLVW.A=anterosuperiorfascicleoftheleftbundleAVN=
atrioventricularnodeHB=Hisbundle:LBB=leftbundlebranchP=posteroinferiorfascicleof
theleftbundlebranch:RBB=rightbundlebranch:PF=Purkinjefiber.(Illustrationbasedon
MiquerolL,MeysenS,MangoniM,etal.ArchitecturalandfunctionalasymmetryoftheHis
Purkinjesystemofthemurineheart.CardiovascRes.2004Jul163(1):7786.)

TerminalPurkinjefibers

TheterminalPurkinjefibersconnectwiththeendsofthebundlebranchestoform
interweavingnetworksontheendocardialsurfaceofbothventricles,whichtransmit
thecardiacimpulsealmostsimultaneouslytotheentirerightandleftventricular
endocardium.Purkinjefiberstendtobelessconcentratedatthebaseofthe
ventricleandthepapillarymuscletips.Theypenetrateonlytheinnerthirdofthe
endocardium.Purkinjefibersappeartobemoreresistanttoischemiathanordinary
myocardialfibers. [3]

InnervationoftheAVnode,Hisbundle,andventricularmyocardium

http://emedicine.medscape.com/article/1922987overview 7/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants
TheAVnodeandHisbundleareinnervatedbyarichsupplyofcholinergicand
adrenergicfiberswithhigherdensitiesascomparedwiththeventricular
myocardium.ParasympatheticnervestotheAVnoderegionentertheheartatthe
junctionoftheIVCandtheinferioraspectoftheLA,adjacenttothecoronarysinus
ostium.

Theautonomicneuralinputtotheheartdemonstratessomedegreeof"sidedness,"
withtherightsympatheticandvagalnervesaffectingtheSAnodemorethanthe
AVnodeandtheleftsympatheticandvagalnervesaffectingtheAVnodemore
thantheSAnode.ThedistributionoftheneuralinputtotheSAandAVnodesis
complexbecauseofsubstantialoverlappinginnervation.

Stimulationoftherightstellateganglionproducessinustachycardiawithlesseffect
onAVnodalconduction,whereasstimulationoftheleftstellategangliongenerally
producesashiftinthesinuspacemakertoanectopicsiteandconsistentlyshortens
AVnodalconductiontimeandrefractoriness,butitinconsistentlyspeedstheSA
nodedischargerate.However,stimulationoftherightcervicalvagusnerveslows
theSAnodedischargerate,andstimulationoftheleftvagusprimarilyprolongsAV
nodalconductiontimeandrefractorinesswhensidednessispresent.Neither
sympatheticnorvagalstimulationaffectsnormalconductionintheHisbundle. [3,4]

NaturalVariants
Therightvagusnerveprimarilyinnervatesthesinoatrial(SA)node,whereastheleft
vagusinnervatestheatrioventricular(AV)nodehowever,significantoverlapcan
existintheanatomicdistribution.

Effectsofsympatheticstimulation

Stimulationofsympatheticgangliashortenstherefractoryperiodequallyinthe
epicardiumandunderlyingendocardiumoftheleftventricularfreewall,although
dispersionofrecoverypropertiesoccurs(ie,differentdegreesofshorteningof
refractorinessoccur)whenmeasuredatdifferentepicardialsites.Nonuniform
distributionofnorepinephrine(NE)may,inpart,contributetosomeofthe
nonuniformelectrophysiologiceffects,becausetheventricularcontentofNEis
greateratthebasethanattheapexoftheheart,withgreaterdistributiontomuscle
thantoPurkinjefibers.Afferentvagalactivityappearstobehigherintheposterior
ventricularmyocardium,whichmayaccountforthevagomimeticeffectsofinferior
myocardialinfarction. [4,8]

Effectsofvagalstimulation

Thevagusmodulatescardiacsympatheticactivityatprejunctionaland
postjunctionalsitesbyregulatingtheamountofNEreleasedandbyinhibitingcyclic
adenosinemonophosphate(cAMP)inducedphosphorylationofcardiacproteins.
Tonicvagalstimulationresultsinagreaterabsolutereductioninsinusrateinthe
presenceoftonicbackgroundsympatheticstimulation.Incontrast,changesinAV
conductionduringconcomitantsympatheticandvagalstimulationareessentiallythe
algebraicsumoftheindividualAVconductionresponsestotonicvagaland
sympatheticstimulationalone.

Cardiacresponsestobriefvagalburstscommenceafterashortlatencyand
dissipatequicklyconversely,cardiacresponsestosympatheticstimulationbegin
anddissipateslowly.Therapidonsetandoffsetofresponsestovagalstimulation
allowdynamicbeattobeatvagalmodulationofheartrateandAVconduction,
whereastheslowtemporalresponsetosympatheticstimulationprecludesanybeat
tobeatregulationbysympatheticactivity.Becausethepeakvagaleffectsonsinus
rateandAVnodalconductionoccuratdifferenttimesinthecardiaccycle,abrief
vagalburstcanslowthesinusratewithoutaffectingAVnodalconductionorcan
prolongAVnodalconductiontimeandnotslowthesinusrate. [3]

PathophysiologicVariants
Arrhythmias

Thenormalsinusrateof60100beat/minatrestisaffectedbyseveralfactors
includingautonomicnervoussysteminput,medications,metabolicandelectrolyte
status,andpathologicalconditions. [9]

Etiologiesofsinusnodeandatrioventricularnodedysfunctionareasfollows:

Enhancedautomaticity

Fever
Catecholaminerelease
Stimulants
Medications
Hyperthyroidstates
Idiopathic

Decreasedautomaticity

Increasedvagaltone
Medications
Electrolyteabnormalities
Obstructivesleepapnea(OSA)
Myocarditis(inflammatory,infectious,infiltrative)
Endocarditis
Aftercardiacsurgery
Degeneration
Fibrosis
Valvularheartdisease
Rheumatologic
Genetic(channelopathies,neuromusculardisorders)

http://emedicine.medscape.com/article/1922987overview 8/9
11/7/2016 ConductionSystemoftheHeart:Overview,GrossAnatomy,NaturalVariants
Inheritedformsofcardiacconductiondiseasearerare,however,thediscoveryof
causativegeneticmutationshasenhancedourunderstandingoftheprocesses
underlyingimpulsegenerationandpropagation.

Thecircadianpatternofnormalheartrateswidelyvariesenhancedvagaltone
duringsleepcanresultinheartrates<40beats/min,pauses,andWenckebach
conductionblockinnormalindividuals.However,pausesgreaterthan3secare
rarelyseeninnormalindividualsandshouldpromptfurtherevaluation.Exercise
conditioningcanalsoresultinaphysiologicallynormalslowsinusrateatrest. [10]

Alterationsinvagalandsympatheticinnervationcaninfluencethedevelopmentof
arrhythmiasandsuddencardiacdeathduetoventriculartachyarrhythmias.
Cardioneuropathymaydevelopduetodamagetothenervesextrinsictotheheart,
suchasthestellateganglia,aswellastointrinsiccardiacnervesfromdiseasesthat
mayaffectprimarilynerves,suchasviralinfectionsor,secondarily,fromdiseases
thatcausecardiacdamage.Suchneuralchangesmaycreateelectricalinstability
throughvariouselectrophysiologicmechanisms.Forexample,myocardialinfarction
caninterruptafferentandefferentneuraltransmissionandcreateareasof
sympatheticsupersensitivitythatmaybeconducivetothedevelopmentof
arrhythmias. [4]

ContributorInformationandDisclosures
Author
RaminAssadi,MDAssistantProfessorofMedicine,DivisionofInterventionalCardiology,LomaLindaUniversity
MedicalCenter

RaminAssadi,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofCardiology,American
CollegeofPhysicians,AmericanMedicalAssociation,SocietyforCardiovascularAngiographyandInterventions

Disclosure:Nothingtodisclose.

Coauthor(s)
AliMotabar,MDResidentPhysician,DepartmentofInternalMedicine,LomaLindaUniversityMedicalCenter

AliMotabar,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,American
MedicalAssociation

Disclosure:Nothingtodisclose.

ChiefEditor
RichardALange,MD,MBAPresident,TexasTechUniversityHealthSciencesCenter,Dean,PaulLFoster
SchoolofMedicine

RichardALange,MD,MBAisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
CollegeofCardiology,AmericanHeartAssociation,AssociationofSubspecialtyProfessors

Disclosure:Nothingtodisclose.

References

1.AgurAMR,DalleyAF,MooreKL.Thethorax.ClinicallyOrientedAnatomy.5thed.Philadelphia,Pa:
LippincottWilliams&Wilkins2005.

2.KianiJ,AgarwalSK,KamireddyS,AdelsteinE,SabaS.Relationshipofelectromechanicalremodelingto
survivalratesaftercardiacresynchronizationtherapy.TexHeartInstJ.2013.40(3):26873.[Medline].[Full
Text].

3.LibbyP,BonowRO,MannDL,ZipesDP,eds.Braunwald'sHeartDisease:ATextbookofCardiovascular
Medicine.8thed.Philadelphia,Pa:SaundersElsevier2008.Vol1:

4.SchwartzPJ,ZipesDP.Autonomicmodulationofcardiacarrhythmias.ZipesDP,JalifeJ,eds.Cardiac
Electrophysiology:FromCelltoBedside.3rded.Philadelphia,Pa:WBSaunders1999.30014.

5.WuJ,WuJ,OlginJ,MillerJM,ZipesDP.Mechanismsunderlyingthereentrantcircuitofatrioventricular
nodalreentranttachycardiainisolatedcanineatrioventricularnodalpreparationusingopticalmapping.Circ
Res.2001Jun8.88(11):118995.[Medline].

6.EllenbogenKA,WoodMA,eds.CardiacPacingandICDs.5thed.Hoboken,NJ:BlackwellPublishing
2008.

7.WuJ,ZipesDP.Mechanismsunderlyingatrioventricularnodalconductionandthereentrantcircuitof
atrioventricularnodalreentranttachycardiausingopticalmapping.JCardiovascElectrophysiol.2002Aug.
13(8):8314.[Medline].

8.VarmaN.Variegatedleftventricularelectricalactivationinresponsetoanovelquadripolarelectrode:
Visualizationbynoninvasiveelectrocardiographicimaging.JElectrocardiol.2013Oct4.[Medline].

9.ParkDS,FishmanGI.TheCardiacConductionSystem.Circulation.2011Mar01.123(8):90415.
[Medline].[FullText].

10.KristenPatton,MD.Arrythmias.PatrickTO'Gara,MD.AdultClinicallCardiologySelfAssessment
Program(ACCSAP).8.AmericanCollegeofCardiology6:14.5.17.

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1922987overview 9/9