Conduction system of the

heart
Dr. Ashok Kumar.J
Cardiology Resident
Institute of Cardiology
RGGGH/MMC
• The main components of the cardiac conduction system include the
sinus (sinoatrial, SA) node, and the atrioventricular (AV) conduction
axis.
• The AV conduction axis comprises of the compact AV node, His
bundle, right and left bundle branches, and the Purkinje network.
• Accessory pathways
Sinus Node
• a crescent shaped sub-epicardial structure located at the junction of
the right atrium and superior vena cava along the terminal crest.
• measures 10–20mm in length and upto 5mm in width.
• comprised of specialized nodal cells (P cells), At the periphery, these
nodal cells intermingle with transitional cells
• The SA node has the highest rate of spontaneous depolarization
(automaticity) Sinus nodal cells have a low resting membrane
potential of −50 to −60mV.
• The SAN may be divided into the head (anterosuperior portion close
to the SVC), body (main portion) and tail (posteroinferior portion)
regions
• the sinus nodal artery which originates from the right coronary artery
in half of the patients and left circumflex artery in remaining half of
the patients
• SA node also receives rich sympathetic and parasympathetic inputs
that regulate the heart rate.
Atrial Activation
• begins in the sinoatrial (SA)node .
• It spreads in a radial fashion to depolarize the right atrium, the
interatrial septum, and then the left atrium.
• The last region of the left atrium to be activated is the tip of the left
atrial appendage, or the posteroinferior left atrium
• Three specialized pathways that contain Purkinje fibers have been
identified as connecting the SA node to the (AV) node
• the anterior, middle, and posteriorinternodal pathways.
• An interatrial pathway, the Bachmann bundle, connects the right and
left atria.
Atrioventricular node
• a sub-endocardial structure situated within the triangle of Koch and
measuring 5–7mm in length and 2–5mm in width
• Rightward and leftward posterior extensions of the AV node were
described by Inoue and Becker.
• These extensions have clinical implications for defining re-entrant
circuits that act as a substrate of AV nodal re-entrant tachycardia
• abundant blood supply from the large AV nodal artery, a branch of the
right coronary artery, in 90% of patients, and from the left circumflex
artery in 10%
• Triangle of Koch (ToK). The boundaries of ToK include the septal
leaflet of the tricuspid valve anteriorly and tendon of Todaro
posteriorly. The membranous septum forms the apex and the
coronary sinus os forms the base of the triangle.
• The distal one-third of the AV node has a dual blood supply from the
left anterior descending (LAD) artery and the AV nodal artery
• AV nodal conduction is mediated via “slow” calcium-mediated action
potential and demonstrates decremental conduction due to post
repolarization refractoriness as a result of delayed recovery of the
slow inward currents
His–Purkinje system
• the His bundle, a narrow tubular structure that runs through the
membranous septum to the crest of the muscular septum, where it
divides into the bundle branches
• The His bundle has relatively sparse autonomic innervation,
• The blood supply is quite ample, emanating from both the AV nodal
artery and the septal branches of the left anterior descending artery
• The His bundle can be divided anatomically into 3 portions:
• 1) penetrating bundle of His, which penetrates the fibrous
membranous septum or CFB(central fibrous body) close to the mitral
ring and runs anteriorly and inferiorly,
• 2) non-branching portion, which runs a variable course on the crest of
the muscular ventricular septum, and
• 3) branching portion closely related to the aortic ring, branches off to
give left and right bundle branches.
• The bundle branch system is a complex network of interlaced Purkinje
fibers that varies greatly among individuals.
• It generally starts as one or more large fiber bands that split and fan
out across the ventricles until they finally terminate in a Purkinje
network
• The right bundle is usually a single, discrete structure that extends
down the right side of the interventricular septum to the base of the
anterior papillary muscle, where it divides into three or more
branches
• The left bundle more commonly originates as a very broad band of
interlaced fibers that spread out over the left ventricle, sometimes in
two or three distinct fiber tracts.
• subendocardial course on the left side of the septum and typically
branches out in a trifascicular pattern into a septal, anterior and
posterior fascicles
• There is relatively little autonomic innervation of the bundle branch
system, but the blood supply is extensive, with most areas receiving
branches from both the right and left coronary systems.
• The left anterior fascicle is a thin and long structure that traverses
towards the antero-lateral papillary muscle.
• The left posterior fascicle is a thick, broad and short structure that
traverses towards the postero-medial papillary muscle.
Ventricular activation
• the middle-left side of the interventricular septum.
• the apex, anterior left ventricular wall, right ventricular septal surface
near the attachment of the anterior papillary muscle, and part of the
right ventricular free wall.
• Thus the two excitatory waves in the septum propagate in opposite
directions: one from the low middle-left side to the right, and the
other, which starts slightly later, from the lower right septal surface
propagating to the left.
• The opposing septal forces in the apical portion of the septum have
met and have disappeared, and the basal portion of the septum is
activated slowly toward both outflow tracts. ,
• The basal region of the left ventricular diaphragmatic wall.
• The right ventricular and the septal forces are directed toward the
base; the left ventricular forces have a more posterior direction.
Regions Blood supply

Sinus Node Proximal RCA 55% pts, Proximal LCX 45% pts.

AV Node Distal RCA 90% pts, Distal LCX 10% pts.

His bundle AV nodal artery and the first septal perforator branch of the LAD

Right Bundle Branch Septal perforators of LAD

Left Anterior Fascicle Septal perforators of LAD

Main Left Bundle Branch Dual- Distal RCA and Proximal circumflex vessels

Left Posterior Fascicle PDA, LCX

• Action potentials in the Purkinje fibers are of the fast-response type,
i.e., rapid depolarization rates that, in part, are due to their large
diameters.
• Conduction velocity of 1.5 to 4.0 m/sec, a velocity about six times that
in the usual ventricular muscle and 150 times that in some of the A-V
nodal fibers.
Accessory pathways
• Atrioventricular (AV), atrio-His, atriofascicular, nodoventricular,
nodofascicular and fasciculoventricular.
• AV accessory pathways are the most common form.
• Right atriofascicular accessory pathways are involved in most cases of
Mahaim-type tachycardias.
Mahaim fibres
• Accessory pathways with
decremental conduction
properties that connected the
Right atrium( or AV Node) to the
right bundle branch (RBB) (or
RV).
• mapped mainly at the lateral
aspect of the tricuspid annulus,
and thus the term atriofascicular
Conduction System Pacing
• CSP corrects BBB either by pacing beyond the site of block in distal
His bundle or by penetrating beyond the site of block when paced at
higher output
• HBP( His Bundle Pacing) results in simultaneous, physiological
activation of both the ventricles and prevents the untoward effects of
non-physiological, chronic RV pacing.
• LBBAP( Left Bundle Branch Area Pacing) results in direct capture of
the LBB and preserves or restores physiologic activation of the LV.
Thank you