Pharmacology & Therapeutics 139 (2013) 260288

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Pharmacology & Therapeutics

journal homepage: www.elsevier.com/locate/pharmthera

Associate Editor: P. Molenaar

Structure, function and clinical relevance of the cardiac conduction

system, including the atrioventricular ring and outow tract tissues
Halina Dobrzynski a,, Robert H. Anderson a, Andrew Atkinson a, Zoltan Borbas a, Alicia D'Souza a,
John F. Fraser b, c, Shin Inada d, Sunil J.R.J. Logantha a, Oliver Monfredi a, Gwilym M. Morris a,
Anton F.M. Moorman e, Thodora Nikolaidou a, Heiko Schneider a, Viktoria Szuts f, Ian P. Temple a,
Joseph Yanni a, Mark R. Boyett a,
a
University of Manchester, UK
b
Critical Care Research Group, University of Queensland, Australia
c
Prince Charles Hospital, Australia
d
National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
e
University of Amsterdam, Netherlands
f
University of Szeged, Hungary

a r t i c l e i n f o a b s t r a c t

Keywords: It is now over 100 years since the discovery of the cardiac conduction system, consisting of three main parts, the
Cardiac conduction system sinus node, the atrioventricular node and the HisPurkinje system. The system is vital for the initiation and co-
Atrioventricular ring tissue ordination of the heartbeat. Over the last decade, immense strides have been made in our understanding of
Right ventricular outow tract the cardiac conduction system and these recent developments are reviewed here. It has been shown that the sys-
Arrhythmias tem has a unique embryological origin, distinct from that of the working myocardium, and is more extensive
Biopacemaking
than originally thought with additional structures: atrioventricular rings, a third node (so called retroaortic
Channelopathies
node) and pulmonary and aortic sleeves. It has been shown that the expression of ion channels, intracellular
Ca2+-handling proteins and gap junction channels in the system is specialised (different from that in the ordinary
working myocardium), but appropriate to explain the functioning of the system, although there is continued de-
bate concerning the ionic basis of pacemaking. We are beginning to understand the mechanisms (brosis and
remodelling of ion channels and related proteins) responsible for dysfunction of the system (bradycardia, heart
block and bundle branch block) associated with atrial brillation and heart failure and even athletic training.
Equally, we are beginning to appreciate how naturally occurring mutations in ion channels cause congenital car-
diac conduction system dysfunction. Finally, current therapies, the status of a new therapeutic strategy (use of a
specic heart rate lowering drug) and a potential new therapeutic strategy (biopacemaking) are reviewed.
2013 Elsevier Inc. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
2. Embryonic development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
3. Cardiac conduction system: anatomy, function and clinical relevance . . . . . . . . . . . . . . . . . . 261
4. Atrioventricular ring tissue: anatomy, function and clinical relevance . . . . . . . . . . . . . . . . . . 261
277
5. Right ventricular outow tract: anatomy, function and clinical relevance . . . . . . . . . . . . . . . . . 279
261
6. Channelopathies in humans responsible for dysfunction of the cardiac conduction system . . . . . . . . . 280
261
7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
261
Conict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
262
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
282

Corresponding authors at: Institute of Cardiovascular Sciences, CTF Building, 46 Grafton Street, University of Manchester, Manchester M13 9NT, UK. Tel.: +44 161 2751182,
+44 161 2751192; fax: +44 161 2751183.
E-mail addresses: halina.dobrzynski@manchester.ac.uk (H. Dobrzynski), mark.boyett@manchester.ac.uk (M.R. Boyett).

0163-7258/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pharmthera.2013.04.010
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
1. Introduction
The cardiac conduction system consists of the sinus (or sinuatrial or
sinoatrial) node, the atrioventricular (AV) conduction axis (including
the AV node), its right and left bundle branches, and the terminal
Purkinje network. All of these structures, made up of specialised cardiac
myocytes, have unique anatomical, molecular and functional properties
that permit them to work collectively as the electrical system of the
heart. The system has been the subject of extensive studies since its
elucidation in the rst decade of the 20th century. Recent advances in
technologies have aided our further understanding of this specialised
system of the heart. In particular, other myocytes with comparable
properties, such as the AV ring tissue and myocytes in the ventricular
outow tracts, especially the right ventricular outow tract, have
attracted notice because of their arrhythmogenic properties. A common
feature of the different tissues of the cardiac conduction system is the
ability to show pacemaking and Fig. 1 shows the perhaps surprising
widespread distribution of tissues with pacemaking potentiality in the
heart. Our aim in this review is to describe our current understanding
of the expanded concept of the cardiac conduction system, in terms of
anatomy, function and clinical relevance. So-called channelopathies
related to the cardiac conduction system are also discussed.
2. Embryonic development
2.1. Cardiac conduction system in relation to working myocardium
The heart initially forms as a midline tube ventral to the foregut at the
stage of embryonic folding. Its cells are derived from visceral mesoderm,
with the cells forming a linear primary heart tube containing the primor-
dium for little more than the left ventricle, or even less (Cai et al., 2003;
Aanhaanen et al., 2009). Ongoing development depends on the addition
of cells to the primary tube from the heart-forming areas at both the
venous and arterial poles (Fig. 2A). At this early undifferentiated stage,
the walls of the heart tube are made up of so-called primary myocardi-
um (Moorman & Christoffels, 2003). The myocytes of this myocardium
have a phenotype that includes slow growth, slow contraction, slow
conduction and the ability to depolarize spontaneously (Moorman &
Christoffels, 2003). As the new material is added at the venous and
arterial poles (Kelly & Buckingham, 2002), the tube itself undergoes
looping. Subsequent to looping, the primordiums of the eventual atrial
and ventricular chambers balloon from the cavity of the primary tube,
with the right and left atrial appendages ballooning in parallel from the
atrial component of the tube, and the apical ventricular components
ballooning in series from the inlet and outlet parts of the ventricular
loop (Fig. 2B). The myocytes making up these new parts together make
up the chamber myocardium (Moorman & Christoffels, 2003). Chamber
myocardium is distinct from primary myocardium in a number of ways,
including the possession of gap junctions made up of connexin40 (Cx40)
and connexin43 (Cx43), which permit rapid conduction, along with
rapid rates of cell division. There is also formation of pectinate muscles
and trabeculations in the newly forming chamber components of the
atria and the ventricles, respectively. Already at this early stage, however,
while it is still possible to distinguish the areas of primary and chamber
myocardium, and while there is muscular continuity throughout the
developing heart, it is possible to record a relatively normal electrocar-
diogram (ECG). The tracing incorporates a period of AV delay, even
though at this stage it is not possible to recognise any of the components
of the denitive cardiac conduction system. The areas of the tube made
up of primary as opposed to chamber myocardium are also different in
that blocks of cushion mesenchyme are formed within their lumens
that will ultimately form the valves of the heart, and set the scene for
separation of the systemic and pulmonary pathways of the circulation.
It is also within these components of the primary tube that the
remodelling takes place to allow correct alignment of the separating
atrial and ventricular chambers and the systemic and pulmonary outow
261
tracts. Parts of this primary myocardium also retain their initial embry-
onic phenotype so as to form the cardiac nodes and AV conduction axis
(Fig. 2C; Davis et al., 2001; Rentschler et al., 2001; Hoogaars et al.,
2004), with some of the ventricular trabeculations being incorporated
to form the rapidly conducting Purkinje network. These changes are
achieved by so-called patterning, or regional expression of develop-
mental gene programmes (Christoffels et al., 2004), with the other
parts of the initial primary myocardium becoming transformed into
chamber myocardium. Development of the cardiac conduction system
is controlled by transcription factors and for an excellent review of this
fast developing eld see Christoffels et al. (2010).
2.2. Atrioventricular ring tissue
As described above, only a small part of the primary myocardium
eventually develops into nodal tissues, retaining the characteristics of
automaticity, and failing to be converted into working myocardium. It
is now well established that the expression of the transcriptional inhibi-
tor Tbx3 is responsible for this fundamental process (Hoogaars et al.,
2007). Ectopic expression of Tbx3 in the atrial chambers has been
shown to result in the formation of functional ectopic nodes exhibiting
pacemaker activity. The expression of Tbx3, however, marks not only
the normal cardiac conduction system, but also the so-called AV ring
tissues (Anderson et al., 1974a, 1974b; Yanni et al., 2009a). The areas
of the primary heart tube such as the AV canal, the interventricular
ring and the ventricular outow tract can be considered as supportive
of this concept, albeit that the rings do not appear as new entities,
but rather are part of the initial primary heart tube, becoming evident
as rings only subsequent to the formation of the chamber myocardium.
In particular, part of the embryonic AV canal persists in the denitive
heart within the atrial vestibules as the specialised AV rings that
surround the orices of the tricuspid and mitral valves, with the ring
tissues originating from the dorsal aspect of the AV node, and crossing
over the bundle of His to join so as to form a ventral retroaortic node
(Yanni et al., 2009a).
2.3. Right ventricular outow tract
The initial common outow tract is exclusively composed of the
primary myocardium of the linear heart tube, and is entirely supported
by the right ventricle. The distal portion of this common outow tract is
remodelled by further addition of cells from the visceral mesenchyme
to form the intrapericardial arterial trunks. At this stage, the more
proximal parts retain their muscular walls, with the pulmonary and
aortic valves, along with their sinuses, developing within a muscular
sleeve. The most proximal part of the common outow tract will form
the right ventricular outow tract and the aortic vestibule, with the
proximal cushions themselves fusing and muscularising to form the
dorsal part of the infundibulum, this part also fusing with the crest of
the muscular ventricular septum so as to commit the aorta to the left
ventricle. As development progresses, the proximal right ventricular
outow tract largely differentiates into working right ventricular
myocardium (Rana et al., 2007), with the more distal parts that initially
surrounded the developing arterial valves disappearing by apoptosis
(Barbosky et al, 2006). It has been suggested that not all myocytes in
the right ventricular outow tract differentiate into working ventricular
myocytes and some myocytes retain their initial nodal-like phenotype
(Yanni et al., 2009a; Boukens et al., 2009; Monfredi et al., 2010a, 2010b).
3. Cardiac conduction system:
anatomy, function and clinical relevance
3.1. Sinus node
In health, the sinus node is the pacemaker of the mammalian
heart. Even more than 100 years after its rst description by Keith &
262 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

Fig. 1. Pacemaker potentiality in the heart. The schematic diagram of the heart shows different components of the cardiac conduction system. Orange, sinus node; red, AV ring tissue and AV
node; purple, HisPurkinje network. Typical pacemaker action potentials from the sinus node centre (32 C; Tellez et al., 2006), sinus node periphery (32 C; Tellez et al., 2006), subsidiary
atrial pacemaker site (36 C; Rozanski & Lipsius, 1985), Eustachian ridge (warm temperature; Rubenstein et al., 1987), coronary sinus (36 C; Wit & Craneeld, 1977; Wit et al., 1981), right
ring tissue (37 C; S.J.R.J. Logantha, unpublished data), tricuspid valve leaet (37 C; Rozanski & Jalife, 1986; Rozanski, 1987), Purkinje bre (free running; 37 C; S.J.R.J. Logantha, unpublished
data), AV node (3537 C; Cheng et al., 2011), right ventricular outow tract (37 C; S.J.R.J. Logantha, unpublished data), mitral valve (36 C; Wit et al., 1979), left ring tissue (37 C; S.J.R.J.
Logantha, unpublished data), pulmonary vein (37 C; Wongcharoen et al., 2006) and superior vena cava (37 C; Chen et al., 2002) of different species are shown around the schematic
diagram. All records were obtained in tissue preparations (either in isolated preparations or in tissues with sinus node activity supressed) with the exception of the AV node and superior
vena cava recordings, which were obtained from isolated myocytes. In each trace, the vertical scale bar represents 60 mV and its upper limit indicates the zero potential. Unless otherwise
stated, the horizontal scale bar denotes 200 ms.

Flack in, 1907, the molecular mechanisms underlying its pacemaker
potential are hotly disputed (e.g., Monfredi et al., 2010a, 2010b).
3.1.1. Anatomy
In most human hearts, the sinus node is a banana-shaped structure
located in the subepicardial intercaval region of the heart at the junction
of the superior caval vein and the right atrium, with a tail extending
along the terminal crest (Dobrzynski et al., 2007; Wiese et al., 2009;
Chandler et al., 2011). The nodal myocytes are embedded in a network
of connective tissue and surround the sinus node artery (Fig. 3A). The
action potential originates in the centre of the sinus node and here
the myocytes are small when compared to working atrial myocytes
(Fig. 4). In the centre of the sinus node, the nodal myocytes also have
few mitochondria and sparse and poorly organised myolaments
(Boyett et al., 2000; Christoffels et al., 2010). From the centre to the pe-
riphery of the sinus node, there is a gradual transition from true (central)
nodal myocytes to peripheral nodal myocytes, which share some charac-
teristics with the surrounding atrial myocytes (Boyett et al., 2000). For
example, peripheral nodal myocytes are larger with more and better
organised myolaments (Boyett et al., 2000). Throughout the periphery
of the sinus node, the sinus node can be seen to interdigitate with the
surrounding atrial muscle at many sites (Sanchez-Quintana et al., 2005;
Liu et al., 2007). The interdigitations have been suggested to assist the
exit of the action potential from the sinus node into the atrial muscle
(Boyett et al., 2006). Perhaps in contrast, Bromberg et al. (1995) and
Fedorov et al. (2009, 2010) have argued that exit of the action potential
from the sinus node occurs at specic superior and inferior exit sites and
exit of the action potential at all other points is blocked by brous tissue
and blood vessels. For a review of the possibility of exit sites see Fedorov
et al. (2012). Although it is well established that there is a block zone be-
tween the sinus node and the interatrial septum in the human and other
species (Fedorov et al., 2010; Boyett et al., 2000), we have observed no
evidence of an anatomical block zone between the sinus node and the
terminal crest in the human and other species (Sanchez-Quintana et
al., 2005; Chandler et al., 2011). We suggest that there are no discrete
exit sites; the preferential supero-inferior action potential propagation
within the sinus node as a result of the preferential supero-inferior
myocyte orientation (Boyett et al., 2000; Chandler et al., 2011) may
give the appearance of discrete superior and inferior exit sites. In the
human, a further histologically specialised area has now been noted
at the periphery of the sinus node (Fig. 3A; Chandler et al., 2009).
This paranodal area is distinct from both the sinus node and atrial
muscle for example, the myocytes of the paranodal area are loose-
ly packed in fatty tissue, whereas atrial myocytes are densely packed
and the myocytes of the sinus node are packed in connective tissue
(Fig. 4A; Chandler et al., 2009). The paranodal area has a myocardial
phenotype in between that of the working myocardium and the sinus
node, for example in terms of myocyte size (Fig. 4; Chandler et al.,
2009) and connexin expression (Fig. 4BD; Chandler et al., 2009). It
also contains a mixture of atrial and nodal myocytes (Chandler et al.,
2009). The paranodal area of the human is similar to the periphery of
the sinus node in the rabbit compare Chandler et al. (2009) and
Dobrzynski et al. (2005). In terms of location, the paranodal area is ex-
tensive, and runs parallel to the sinus node along the terminal crest
(Fig. 5A; Chandler et al., 2009). Fig. 5B shows the position of the leading
pacemaker site in the right atrium of the human heart and Fig. 5C shows
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 263

Fig. 2. Cartoons showing the changes involved in forming the denitive conduction tissues. A, lateral view of the developing heart tube subsequent to the beginning of addition of new ma-
terial from the heart-forming areas at both the arterial and venous poles. The central component, the initial linear heart tube, eventually forms only part of the left ventricle. The
intrapericardial components, shown in grey, are all formed of primary myocardium at this stage. The extrapericardial parts are shown in yellow. B, cartoon showing how the chamber com-
ponents balloon from the primary tube, with the atrial appendages (AA) ballooning from the newly formed atrial component of the heart tube, and the left and right ventricles (LV and RV)
ballooning from the inlet and outlet parts of the ventricular loop. Note that, during this intermediate stage, the persisting primary myocardium forms the atrioventricular canal, and an atrial
channel labelled in the cartoon as dorsal since it eventually forms the dorsal atrial wall, albeit being developed from the initially ventral wall of the primary heart tube. Note also that the
developing outow tract is formed at this stage by primary myocardium. C, cartoon showing that the primary myocardium persists only as the sinus node and the atrioventricular conduction
axis in the fully formed heart, albeit that further remnants can be identied, e.g. as the AV ring tissues (not shown).
From R.H. Anderson and A.F. Moorman.

the position of the sinus node (and the neighbouring paranodal area) in
the human heart; the two correspond. The function of the paranodal area
is not known, but it is possible that it may be responsible for the cristal
tachycardias observed by Kalman et al. (1998) or can take over as subsid-
iary pacemaker.
3.1.2. Function
The electrical activity of the sinus node differs from that of the
working myocardium (Irisawa et al., 1993; Boyett et al., 2000;
Dobrzynski et al., 2007; Mangoni & Nargeot, 2008). The sinus node
action potential has a slow upstroke (phase 0; Fig. 6B), because the

A
Terminal crest
Pectinate
RA Paranodal area
muscle

Sinus node

Aatrioventricular conduction axis

B
Compact
node
Penetrating
INE bundle

Fig. 3. Low magnication images of tissue sections through human cardiac conduction system stained with Masson's trichrome. A, histology of the sinus node, paranodal area and atrial
muscle. B, histology of the AV junction (the inferior nodal extension, compact node and penetrating bundle). CFB, central brous body; INE, inferior nodal extension; TA transitional area.
From Chandler et al. (2009) and Greener et al. (2011).
264 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

Fig. 4. High magnication images of human sinus node, paranodal area and right atrial muscle stained with Masson's trichrome (A) and immunolabelled for Cx43 (B, C) and Cx40
and caveolin3 (D). The combination of the markers (Cx40, Cx43 and caveolin3) distinguished the three tissues. Cx40 and Cx43 are absent in the sinus node, but present in the atrial
muscle. In the atrial muscle, Cx40 and Cx43 are present at gap junctions. In the paranodal region, there is a mixture of Cx40 and Cx43 positive and negative myocytes (white arrows
highlight myocytes that express Cx40 and Cx43; red arrows highlight myocytes that do not express Cx40 and Cx43). Caveolin3 is present in the cell membrane of all myocytes and
shows that atrial myocytes are large, nodal myocytes are small and paranodal myocytes are intermediate in size.
From Chandler et al. (2011).

upstroke is not generated by the Na+ current, INa, as in the working
myocardium instead it is largely generated by smaller and slower T-
and L-type Ca2+ currents, ICa,T and ICa,L (Irisawa et al., 1993; Mangoni &
Nargeot, 2008). The sinus node action potential usually lacks an early
phase of repolarization (phase 1), but it has a prominent plateau
(phase 2; Fig. 6B) and, as a result, the sinus node action potential is
longer than the action potential of the surrounding atrial muscle
(Boyett et al., 1999). The downward gradient in action potential duration
from the sinus node has been argued to prevent sinus node reentry
(Boyett et al., 1999). Repolarization of the sinus node, as in the rest of
the heart, is the result of the inactivation of ICa,L and the activation of a va-
riety of K+ currents: transient outward K+ current (Ito) and ultra-rapid
(possibly), rapid and slow delayed rectier K+ currents (IK,ur, IK,r and IK,
s, respectively). During diastole (i.e. phase 4), the sinus node lacks the
stable resting potential characteristic of the working myocardium
(Fig. 6B). This is because the sinus node has little or no background
inward rectier K+ current, IK,1. In the sinus node, the maximum diastol-
ic potential (peak negative potential immediately following the action
potential) is less negative than the resting potential in the working myo-
cardium and, furthermore, throughout diastole there is a slow diastolic
depolarization or pacemaker potential (Fig. 6B). On reaching threshold,
the diastolic depolarization triggers the next action potential (Fig. 6B).
A variety of ionic currents (such as the hyperpolarization-activated or
funny current, If) and mechanisms (such as the Ca2+ clock) are known
to be responsible for diastolic depolarization and they are the subject of
Section 3.1.2.1. The different ionic currents etc. involved in the sinus
node action potential are shown in Fig. 6A. In parallel with the histolog-
ical transition from the centre to the periphery of the sinus node
(Section 3.1.1), there are changes in the electrical properties of the
sinus node: the maximum diastolic potential becomes more negative,
the action potential upstroke becomes faster, the action potential
becomes shorter, and paradoxically the intrinsic pacemaker activity
becomes faster (Boyett et al., 1999). In the rabbit, we have suggested
that these changes are in part at least the result of an increase in the
density of If, INa and IK,r (Boyett et al., 2000). The specialisations in electri-
cal activity in the periphery of the sinus node are likely to be further
adaptations to enable the sinus node to drive the surrounding right atrial
muscle (Honjo et al., 1996; Boyett et al., 2009). It is possible that the func-
tion of the paranodal area in the human is similar computer modelling
suggests that the paranodal area aids propagation of the action potential
from the sinus node to the atrial muscle (Aslanidi et al., 2011).
Electrical coupling between myocytes is well known to be poor in
the centre of the sinus node as compared to the surrounding atrial
muscle (Boyett et al., 2000, 2006). This is one reason why the conduc-
tion velocity of the action potential is lower in the centre of the sinus
node (several cm/s in the rabbit) than in the atrial muscle (~70 cm/s
in the rabbit; Sano & Yamagishi, 1965; Boyett et al., 2000). The poor
electrical coupling in the centre of the sinus node is thought to insulate
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 265

Fig. 5. Three-dimensional reconstruction of the human sinus node and paranodal area and comparison of the activation sequence of the sinus node in a patient and in the
three-dimensional anatomical model. A, three-dimensional reconstruction. Green, atrial muscle; red, sinus node; yellow, paranodal area; blue, adipose tissue. Most of the sinus
node tissue (red) is located on the epicardial side and is a banana-shaped structure. The paranodal area is located on the endocardial side. From Chandler et al. (2011). B, dorsal
view of the atria of a patient during open heart surgery showing the leading pacemaker site (red) and the activation sequence of the atria; the activation sequence is shown as
a colour scale and by the isochrones in ms. From Boineau et al. (1988). C, model of the sinus node (red) and paranodal area (yellow) superimposed on a schematic diagram of
the heart (dorsal view). The activation sequence is shown by the isochrones in ms; the leading pacemaker site is shown by the white spot. Simulated action potentials from the
sinus node, paranodal area and atrial muscle are shown. From Chandler et al. (2009). Ao, aorta; IVC, inferior vena cava; LAA, left atrial appendage; PA, pulmonary artery; PV,
pulmonary vein; RA, right atrium; RAA, right atrial appendage; RV, right ventricle; SVC, superior vena cava.

the centre from the hyperpolarizing inuence of the surrounding atrial
muscle, which acts to slow pacemaker activity (Joyner & van Capelle,
1986; Boyett et al., 2006). It has been postulated that there is a gradual
increase of electrical coupling from the centre to the periphery of the
sinus node as yet another adaptation to enable the sinus node to drive
the surrounding right atrial muscle (Joyner & van Capelle, 1986;
Boyett et al., 2006). In the periphery of the sinus node, the conduction
velocity is intermediate between that in the centre of the sinus node
and atrial muscle (Sano & Yamagishi, 1965) and this is consistent with
a gradient in electrical coupling from the centre to the periphery of
the sinus node.
3.1.2.1. Clock mechanisms in sinus node pacemaking. Pacemaker auto-
maticity is governed by spontaneous diastolic depolarization during
phase 4. Although the events that underlie diastolic depolarization
are not fully understood, diastolic depolarization and sinus node
pacemaking are currently thought to be the result of the synergistic
interaction between two oscillators: the membrane voltage clock
and the Ca 2+ clock (Fig. 6A) (Lakatta & DiFrancesco, 2009; Joung
et al., 2009). The membrane voltage clock comprises an ensemble
of voltage-dependent ion channels (in the surface membrane or
sarcolemma) and the corresponding ionic currents. Following the
action potential, the net ionic current through these channels switches
from outward to inward to drive diastolic depolarization: there is a
voltage-dependent deactivation of outward K+ currents (IK,r and IK,s),
as well as a voltage-dependent activation of inward currents: If,
hyperpolarization-activated Cl current, sustained inward current (Ist),
ICa,T and ICa,L (Fig. 6A; Mangoni & Nargeot, 2008; Huang et al., 2009;
Chen et al., 2010; Park & Fishman, 2011). The importance of If in pace-
making has been shown by conditional knockout of HCN4 in the adult
mouse it causes deep bradycardia (Baruscotti et al., 2011). The impor-
tance of If in pacemaking in the human has been highlighted by pharma-
cological intervention (such as ivabradine) targeting If (Section 3.1.3.2)
and also reports describing a slower heart rate in response to mutations
in the If channel, HCN4 (Section 6). Activation of inward INa is also impor-
tant: in the rabbit, although INa is absent from the centre of the sinus
node (Section 3.1.2), INa is present and plays a role in pacemaking in
the periphery of the sinus node (Kodama et al., 1997a, 1997b); INa has
been recorded in human sinus node myocytes (Verkerk et al., 2009);
and, nally, in the human, mutations in the Na+ channel, Nav1.5, cause
bradycardia (Section 6). In the mouse, INa may be particularly important
(Lei et al., 2004); knock-out of the Na+ channel, Nav1.5, causes bradycar-
dia (Lei et al., 2005). In addition to the inward currents above, a
background inward Na+ current (Ib,Na) owing throughout diastole is
266 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

Fig. 6. Sinus node pacemaking mechanisms. A, the multiple ion channels, ionic currents and Ca2+-handling proteins comprising the membrane and Ca2+ clocks involved in pacemaking.
During the pacemaker potential, there is a voltagedependent decay of outward currents, IK,r and IK,s (carried by ERG and KvLQT1), and a voltagedependent activation of inward currents:
If (carried by HCN1 and HCN4), Cl current (carried by ClC-2), ICa,L (carried by Cav1.2 and Cav1.3) and ICa,T (carried by Cav3.1 and Cav3.2). The Ca2+ clock is also involved in pacemaking:
during the nal phase of the pacemaker potential, there is an activation of inward INaCa (generated by the electrogenic Na+Ca2+ exchanger, NCX1) in response to a spontaneous release of
Ca2+ from the SR via the ryanodine receptor (RYR2). Ca2+ release from the SR also occurs as a result of Ca2+induced Ca2+ release in response to Ca2+ entry into the cell via ICa,L and ICa,T.
The SR is replenished with Ca2+ by reuptake of Ca2+ via SERCA2 (Sarco/Endoplasmic Reticulum Ca2+ ATPase). Storeoperated Ca2+ channels at the cell surface membrane also help to
replenish the sarcoplasmic reticulum with Ca2+. Modied from Monfredi et al. (2010a, 2010b). B, summary of the expression of the main ion channels contributing to the different phases
of the nodal action potential. Rabbit sinus node myocyte action potentials shown.
From O. Monfredi (unpublished data).

often invoked in models of the sinus node action potential (e.g., Zhang et
al., 2000). The Ca2+ clock contributes to sinus node diastolic depolariza-
tion through localised Ca2+ release from the sarcoplasmic reticulum (SR)
via the type 2 ryanodine receptor (RYR2; Huser et al., 2000; Bogdanov et
al., 2001). Whether the Ca2+ release is spontaneous (Vinogradova et al.,
2005) or occurs in response to Ca2+-induced Ca2+ release activated by
ICa,T (Huser et al., 2000) is controversial. Oscillatory spikes in intracellular
Ca2+ occur in voltage clamped and chemically skinned sinus node
myocytes and this suggests that the Ca2+ release is spontaneous
(Vinogradova et al., 2005). The localised Ca2+ releases are thought to
activate the electrogenic operation of the sarcolemmal Na +Ca2+ ex-
changer (NCX1). This generates an inward current (INaCa) that imparts
a steep, exponential increase to the late phase of diastolic depolarization
(Fig. 6; Maltsev & Lakatta, 2010; Lakatta et al., 2010). Li+-induced INaCa
blockade has been demonstrated to abolish sinus node pacemaking
(Bogdanov et al., 2001). Mutations in genes encoding components
of the Ca2+ clock have a detrimental effect on sinus node function
(Section 6). While recent years have seen controversy over the relative
importance of the membrane voltage and Ca2+ clocks, mutual entrain-
ment of the clock mechanisms is likely to underlie normal sinus node
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 267

Table 1
Ion channel expression in the human at the mRNA level in the sinus node, paranodal area, transitional area, inferior nodal extension, compact node, penetrating bundle, Purkinje
bres and ventricular muscle as compared to that in the atrial muscle. *, signicantly upregulated; *, signicantly downregulated; , trend to upregulation; , trend to
downregulation; =, no difference. Based on Chandler et al. (2009), Greener et al. (2011) and Gaborit et al. (2007).

function (Lakatta & DiFrancesco, 2009; Maltsev & Lakatta, 2009; Maltsev
and Lakatta, 2010; Himeno et al., 2011; DiFrancesco & Noble, 2012).
3.1.2.2. Ion channels. There is ample evidence to show that the special-
isations of electrical activity in the centre and periphery of the sinus
node are the result of specialisations in the expression of ion channels
(responsible for ionic currents), gap junction proteins (responsible
for electrical coupling between myocytes) and Ca2+-handling proteins
(involved in the Ca2+ clock mechanism of pacemaking). Table 1
shows the expression levels of a few key players (at the mRNA level)
in different regions of the human heart including the sinus node and
paranodal area. Kir2.1 is primarily responsible for IK,1 and this is more
poorly expressed in the sinus node than in the atrial muscle and this
explains why the sinus node lacks a stable resting potential (Table 1;
Irisawa et al., 1993; Chandler et al., 2009). HCN4 is primarily responsible
for If, an important pacemaker current as described above, and it is high-
ly expressed in the sinus node as expected, but not in the working myo-
cardium (Table 1; Dobrzynski et al., 2007; Mangoni & Nargeot, 2008;
Yanni et al., 2009a, 2009b). HCN1 also plays an important role in If
and it too is highly expressed in the sinus node as expected, but not in
the working myocardium (Table 1; e.g. Chandler et al., 2009). The
inward hyperpolarization-activated Cl current is biophysically similar
to If and the underlying channel, ClC-2, is preferentially expressed in the
sinus node (Huang et al., 2009; Yanni et al., 2011a, 2011b). The cardiac
Na+ channel, Nav1.5, is poorly expressed or not expressed in the sinus
node, whereas it is highly expressed in the working myocardium in
the human and other species (Table 1; Tellez et al., 2006; Hoogaars et
al., 2007; Chandler et al., 2009; Greener et al., 2011). This is why INa is
small or absent in the centre of the sinus node. However, another Na+
channel, Nav1.1, although much less abundant than Nav1.5, is preferen-
tially expressed in the sinus node (Tellez et al., 2006) and is responsible
for part of INa (at least in the mouse; Lei et al., 2004). Specialised Ca 2+
channels, Cav1.3 and Cav3.1, more appropriate for pacemaking, are
more highly expressed in the sinus node than in the atrial muscle
(Table 1; e.g. Chandler et al., 2009). In the human, some K + channels
are more poorly expressed (e.g. ERG responsible for IK,r; Table 1;
Chandler et al., 2009) and this may result in the action potential being
longer in the sinus node than in the atrial muscle (Boyett et al., 1999).
It is curious that, despite the importance of the Ca2+ clock in sinus
node pacemaking, two key components of the Ca2+ clock (SERCA2
and RYR2) are downregulated in the sinus node (Table 1; Chandler et
al., 2009). Electrical coupling between cardiac myocytes is provided
by gap junctions connecting neighbouring myocytes. Gap junction
channels are comprised of connexins: in the heart, Cx40 forms large
conductance (200 pS) channels, Cx43 forms intermediate conductance
(60100 pS) channels and Cx45 forms small conductance (2040 pS)
channels (Boyett et al., 2006). The two higher conductance connexins,
Cx40 and Cx43, are more poorly expressed in the sinus node than in
268 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
the atrial muscle (Fig. 4C and D; Table 1; e.g. Coppen et al., 1999a,
1999b; Chandler et al., 2009) and this explains why electrical coupling
is poor in the centre of the sinus node. In the centre of the sinus node,
Cx45 is expressed (Table 1; e.g. Coppen et al., 1999a, 1999b) and this
is a low conductance connexin (expected to provide poor electrical cou-
pling). In the periphery of the sinus node, including the paranodal area
in the human, expression of ion channels etc. can be transitional. For ex-
ample, in the rabbit and human, there is evidence of little expression of
Nav1.5, Kir2.1 and Cx43 in the centre of the sinus node, intermediate ex-
pression in the periphery of the sinus node/paranodal area and high ex-
pression in the atrial muscle (Coppen et al., 1999a, 1999b; Tellez et al.,
2006; Chandler et al., 2009). We suggest that a gradient in ion channel
expression is an important adaptation to enable to the sinus node to
drive the surrounding atrial muscle (Boyett et al., 2000).
It is clear from the above discussion that there is not just one
pacemaker mechanism there is a multiplicity of mechanisms in-
volved in pacemaking: Ib,Na, If, hyperpolarization-activated Cl cur-
rent, INa, ICa,L, ICa,T, INaCa and the Ca 2+ clock (Fig. 6). There are also
possible new mechanisms emerging: a TRP channel, TRPM4, is expressed
in mouse sinus node myocytes and is possibly responsible for a
Ca2+-activated non-specic current (Demion et al., 2007). Its role is
not known, but evidence suggests that at least in Purkinje bres it is
functionally important (Section 3.3.2). Two-pore-domain K+ channels
are responsible for K+ leak or background current. ORK1 is a two-
pore-domain K+ channel in Drosophila and has been shown to control
the rate of diastolic depolarization and, therefore, the heart rate in
Drosophila: downregulation of ORK1 increases the heart rate and
upregulation decreases it (Lalevee et al., 2006). Various two-pore-
domain K+ channels are known to be expressed in the mammalian
sinus node (TASK1, TREK1, TWIK1 and TWIK2; Tellez et al., 2011).
There is some evidence that one of these channels, TREK1, is functionally
important in mouse sinus node pacemaking (Froese et al., 2012).
3.1.3. Clinical relevance
3.1.3.1. Sinus node dysfunction. Sinus node dysfunction, sometimes used
interchangeably with the term sick sinus syndrome, is a congenital or
acquired malfunction of the sinus node. Clinically, tachy-brady syn-
drome is used to refer to sinus node dysfunction in the setting of atrial
brillation (see below) and the term will be avoided here. Sinus node
dysfunction presents as inappropriate sinus bradycardia, sinus arrest/
sinus pause and sinus node exit block (Rubenstein et al., 1972). There
can be a decrease of the intrinsic heart rate (heart rate in the absence
of autonomic inuences) and increases of the sinus node recovery time
(time taken for pacemaking to resume after rapid pacing) and sinus
node conduction time (time taken for the action potential once initiat-
ed in the sinus node to conduct into the surrounding atrial muscle;
Benditt et al., 1995; Lau et al., 2011). Sinus node dysfunction can be
congenital (hereditary) and in some families it has been linked to
mutations in ion channels (Section 6). However, sinus node dysfunc-
tion is primarily a disease of ageing and its incidence increases in an
exponential-like manner with age (Benditt et al., 1995). In the
human and all other mammals studied, there is a decline in the intrin-
sic heart rate with age (e.g., Benditt et al., 1995). Sick sinus syndrome is
the second commonest indication for bradyarrhythmia pacing world-
wide (after atrioventricular block) and pacemakers are primarily
implanted in the elderly (Mond & Proclemer, 2011).
In the human and/or animal models, sinus node dysfunction is
also associated with heart disease: with atrial brillation (see earli-
er comment; e.g., Elvan et al., 1996; Yeh et al., 2009), heart failure
(e.g., Opthof et al., 2000; Sanders et al., 2004; Zicha et al., 2005),
myocardial infarction (Yanni et al., 2011a, 2011b), pulmonary hyper-
tension (Yanni et al., 2009b), diabetes (Howarth et al., 2005, 2006)
and possibly obesity (Yanni et al., 2010). Bradyarrhythmias account
for a signicant number of deaths of heart failure patients, particularly
of patients with advanced heart failure (Stevenson et al., 1993;
Faggiano et al., 2001). It is well known that there is a resting bradycardia
in athletes the heart rate of race t Tour de France cyclists can be as
low as 30 beats/min. Although this is assumed to be a physiological
adaptation in athletes, there are indications that it can become
pathological there is a higher incidence of the implantation of elec-
tronic pacemakers in endurance athletes (Baldesberger et al., 2008).
Histopathological approaches to studying the underlying aetiology of
sinus node dysfunction suggest a central role for degenerative brosis
in the abnormal sinus node automaticity and conduction (DeMelo et
al., 2002; Adan & Crown, 2003). Recently, in a mouse model of heart
failure triggered by angiotensin II infusion, Swaminathan et al. (2011)
observed sinus node dysfunction together with sinus node myocyte
apoptosis caused by activation of NADPH oxidase and increased levels
of oxidised calmodulin kinase II. In addition, in a rat model of pulmo-
nary hypertension with sinus node dysfunction, Yanni et al. (2009b)
observed upregulation of brosis genes in the sinus node (although
no overt brosis). However, brosis as well as an upregulation of
brosis genes has been observed in the sinus node of the ageing
mouse (Hao et al., 2011). Nevertheless, the concept that sinus node
dysfunction is the result of degenerative brosis has been challenged
no evidence has been seen in the ageing human, cat and rat (Ailings et
al., 1995; Yanni et al., 2010). Instead of degenerative brosis, remodelling
of ion channel gene expression could be responsible. Downregulation of
Nav1.5, Cav1.2 and other Ca2+ channel subunits, HCN1, HCN2, various
K+ channels, RYR2 and Cx43 has been documented in the sinus node
in the ageing guinea-pig, rat and mouse (Jones et al., 2004, 2007; Yanni
et al., 2010; Hao et al., 2011). Atrial brillation has recently been associ-
ated with downregulation of HCN2, HCN4 and minK (and corresponding
reductions in If and IK,s) and Ca2+ clock malfunction in the sinus node of a
dog atrial brillation model (Yeh et al., 2009; Joung et al., 2010).
Downregulation of HCN2 and HCN4 has been reported in the sinus
node of the failing dog heart (ventricular tachypacing-induced con-
gestive heart failure; Zicha et al., 2005). A widespread remodelling
of ion channels (e.g. a downregulation of HCN4) has been observed
in the sinus node of a rabbit heart failure model (volume and pres-
sure overload; Yanni et al., unpublished data). In the same rabbit
model, a downregulation of If and IK,s has been observed in the
sinus node (Verkerk et al., 2003). A widespread remodelling of ion
channels has been observed in the sinus node of rat models of myo-
cardial infarction (Yanni et al., 2011a, 2011b) and pulmonary hyper-
tension (Yamanushi et al., 2010). In athletically trained rats, a
widespread remodelling of ion channels has been observed in the
sinus node (Monfredi et al., 2011).
Fibrosis and ion channel remodelling may not be mutually exclusive
mechanisms there is evidence that ion channels and brosis are
linked (van Veen et al., 2005; Hao et al., 2011). In the mouse,
knock-out of one copy of the SCN5A gene (responsible for Nav1.5 and
INa) results in an age-dependent brosis in the sinus node (Hao et al.,
2011) and elsewhere (van Veen et al., 2005). Indeed, Hao et al. (2011)
showed that block of INa in cultured human cardiac myocytes and
broblasts results in an upregulation of the brosis gene, TGF1. Anoth-
er brosis gene, NF-B, has been shown to bind to the promoter region
of SCN5A and regulate transcription of the gene (Shang et al., 2008).
3.1.3.2. If blockade in clinical practice. The BEAUTIFUL trial tested a
novel selective blocker of If, ivabradine, in patients with stable coronary
artery disease and left-ventricular systolic dysfunction. The trial showed
ivabradine to reduce the heart rate and thereby the incidence of
coronary artery disease outcomes (in patients with heart rates of
70 beats/min) (Fox et al., 2008). Ivabradine is now approved for
treating angina and heart failure in Europe. Perhaps more interestingly,
the use of ivabradine for heart rate control in patients with left ventric-
ular systolic dysfunction has been shown to signicantly improve
mortality in comparison to standard medical therapy (Swedberg et al.,
2010). The mechanism of this effect is debated; clinical data have sug-
gested that the degree of heart rate reduction correlates to the
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
reduction in mortality implicating a direct adverse physiological effect
of elevated heart rate per se in heart failure patients (Bohm et al.,
2010). A more intriguing possibility is that electrical remodelling of
the myocardium in the syndrome of heart failure leads to upregulation
of If outside of the cardiac conduction system, which then acts as an
arrhythmogenic substrate (Song et al., 2011).
It is well established that electrical remodelling of ventricular
myocardium occurs in hypertension, heart failure and following
myocardial infarction; furthermore it has been demonstrated that If
is upregulated as part of this process (Cerbai et al., 1994, 1996,
2001; Cerbai & Mugelli, 2006; Stillitano et al., 2008; Xia et al.,
2010). Prevention of electrical remodelling following myocardial
infarction by established therapies such as ACE inhibitors may
include reduction of the upregulation of If, providing a mechanism
for suppression of arrhythmia by pharmacological therapy that is
not primarily antiarrhythmic (Song et al., 2011). Blocking If directly
with ivabradine both reduces ventricular remodelling and increases
ventricular brillation threshold following myocardial infarction
(Ceconi et al., 2011; Vaillant et al., 2011) and also reduces
remodelling in heart failure (Tardif et al., 2011). However, reduction
of death in the SHIFT study was primarily driven by reduction in
heart failure death rather than arrhythmia (Swedberg et al., 2010).
3.1.3.3. Biopacemaking: the status quo. Regardless of the underlying
aetiology, sinus node dysfunction and resultant bradycardia account
for a substantial proportion of electronic pacemaker implantations.
Modern electronic pacing technology is sophisticated and in many
instances provides sufcient chronotropic modulation in response
to physiological demands. Shortcomings, such as the risk of infec-
tion, inadequate sensitivity to adrenergic regulation, suboptimal
cardiac activation pathways, limited battery life and magnetic inter-
ference (Den Haan et al., 2011), nonetheless, have underscored an in-
terest in a biological pacemaker that can offer the all elusive cure
for sinus node dysfunction. The earliest proof-of-principle report of
biopacemaking described the overexpression of 2 adrenoceptors in
mouse hearts, thereby temporarily increasing rhythm but presenting
the possibility for arrythmogenicity (Edelberg et al., 1998). Since then,
the basic intent, and hence design, of the ideal biopacemaker has been
the successful mimicry of sinus node function at an ectopic site in the
working myocardium, based on gene and cell therapies. Given this de-
scription, several strategies based on ion channel manipulation have
been advanced, although identifying the optimal construct remains a
challenge (Rosen et al., 2009). Initial ion channel-based approaches in-
cluded dominant-negative inhibition of Kir2.1-encoded inward rectier
K+ channels (responsible for IK,1) by viral gene transfer, and thus sup-
pression of the repolarizing inuence of IK,1 in guinea-pig left ventricle,
resulting in the production of spontaneous ventricular rhythms from
the implant site in the intact heart (Miake et al., 2002). A major shortcom-
ing of this approach was the proarrhythmic prolongation of action poten-
tial duration resulting from the inhibition of IK,1 (Miake et al., 2002).
To overcome this limitation, more recent efforts have focussed on
the use of the pacemaker current, If, by the adenovirus-mediated
overexpression of HCN channels in the myocardium (Tse et al., 2006).
Expression of HCN2 in the canine left atrial appendage resulted in spon-
taneous activity during initial vagal stimulation (sinus node suppres-
sion; Qu et al., 2003). Higher levels of vagal stimulation suppressed
pacemaking in the engineered pacemaker, indicating the possibility of
vagal modulation. To date, pacemaking from biopacemakers in working
myocardium is relatively bradycardic. This is because If displays context
dependence; the rate of diastolic depolarization is slower when the cells
are hyperpolarized as is the case in the atrial and ventricular myocardi-
um (Zhang et al., 2011). Efforts to overcome this have included
enhancement of HCN2 kinetics using custom designed channel genes
(Kashiwakura et al., 2006), mutant or chimeric HCN channels (Bucchi
et al., 2006), and other HCN constructs such as HCN1/HCN4 (Rosen et
al., 2009).
269
A newer and novel approach is to use upstream transcription factors
to reprogramme working myocardium as pacemaker tissue. Tbx3 is one
of the most important transcription factors directing the development of
the cardiac conduction system as discussed above in Section 2. Transfec-
tion of Tbx3 into neonatal cardiomyocytes increases their automaticity
and pacing rate in vitro (Boink et al., 2008). Tbx3, however, has not
been used in animals to create a biopacemaker. Lineage analysis and
Tbx3 knockout suggests that Tbx18 is necessary for the development of
the sinus node head (Wiese et al., 2009). Transfection of Tbx18 to neona-
tal cardiomyocytes induced a pacemaker phenotype: the myocytes
shrank in size, exhibited sparse myobrils, ceased to express Cx43 and
atrial natriuretic peptide and exhibited increased levels of cAMP and
HCN4 (Kapoor et al., 2011a). Furthermore, adenoviral transduction of
Tbx18 to guinea-pig left ventricle in vivo created a biopacemaker with
a slow ventricular rhythm under conditions of heart block (Kapoor et
al., 2011b). The authors elegantly demonstrated reprogramming of the
ventricular myocytes to a pacemaker phenotype: diminished cell size,
myobrillar disorganisation and suppression of Cx43 and atrial natri-
uretic peptide expression. It has been shown that DNA histone DNA
methylation of the HCN4 gene locus is inactive in the ventricle normally
and activated after Tbx18 expression. If successful, this approach has the
advantage of changing the phenotype of the working myocardium rather
than just expressing a single additional channel and, therefore, the
biopacemaker is more likely to function like the native sinus node.
The mode of delivery of the biopacemaker product represents a
separate challenge. Adeno-associated, lentiviral, and stem cell based
strategies have been developed to temper the shortcomings of tradi-
tional adenoviral gene transfer methods such as short term expression,
in vivo immune responses, and lack of genome integration. Lentiviral
methods may allow longer term gene expression, but pose the possibil-
ity of carcinogenicity, because viral DNA is integrated into the host
genome (Wu & Burgess, 2004). An alternative approach is the use of
stem cells. These can be forced along a cardiogenic lineage to produce
a subset of cells expressing pacemaker characteristics, including diastol-
ic depolarization attributable to If and electromechanical integration in
vitro (Kehat et al., 2004; Xue et al., 2005). Stem cells have also been
used as a vector to deliver an HCN transgene on implantation into the
dog ventricle under conditions of complete heart block (Plotnikov et
al., 2007). Using this approach, stable spontaneous rhythms were
recorded, and persisted up to three months (Kehat et al., 2004). In
another innovative approach, Potapova et al. (2004) described that
HCN2-overexpressing human mesenchymal stem cells (hMSCs) are
able to spread depolarizing current to adjacent dog ventricular
myocytes in co-culture, while generating a higher spontaneous beating
rate than co-cultures with control hMSCs overexpressing enhanced
green uorescent protein alone. Taken together, currently applied cell
and viral vector based strategies show promise in that they appear to
sustain cardiac rhythm under changing physiological demands over
limited periods of time. Critical concerns, such as the eventual fate of
implanted cells, the potential for carcinogenicity, and the possibility of
immuno-rejection, nonetheless, need to be thoroughly addressed
before bedside transition can become a reality.
3.2. Atrioventricular node
3.2.1. Anatomy
The AV node is part of the AV conduction axis, which is the electrical
conduit from the atria to the ventricles. It is located at the base of the
atrial septum, at the apex of the area known as the triangle of Koch
(Fig. 7; Ko et al., 2004; Li et al., 2008; Anderson et al., 2009). The triangle
is bounded by the ostium of the coronary sinus, the tendon of Todaro
and the septal leaet of the tricuspid valve (Fig. 7). The three-
dimensional description of the different components of the AV con-
duction axis is complicated by different orientations used in clinical
electrophysiology, as well as differences amongst species. In 1999, the
Working Group on Arrhythmias of the European Society of Cardiology
270 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
Crista
terminalis
Fig. 7. Schematic diagrams of the rabbit heart and AV junction. Left, schematic diagram of the rabbit heart showing the location of the AV node. From Li et al. (2006). Right,
schematic diagram of the AV junction within the triangle of Koch. Arrows show the fast and slow pathways into the AV junction. Modied from Greener et al. (2009). Ao, aorta;
CN, compact node; CS, coronary sinus; FO, fosa ovalis; IVC, inferior vena cava; LAA, left atrial appendage; PA, pulmonary artery; PV, pulmonary vein; RA, right atrium; RAA, right
atrial appendage; RV, right ventricle; SVC, superior vena cava.
and the North American Society of Pacing and Electrophysiology highlight-
ed the importance of using anatomically-correct nomenclature (Cosio
et al, 1999). Sunao Tawara, a Japanese scientist working in the laborato-
ry of Ludwig Aschoff in Germany, pointed out that the overall ar-
rangement of the AV conduction axis can be compared to a tree,
with roots commencing in the atrial transitional myocytes (Fig. 7),
the trunk made of the bundle of His, and branches ending in the
Purkinje network (discussed in more detail in Section 3.3; Tawara,
2000). The reader can demonstrate this by inverting Tawara's dia-
gram of the human left ventricle Purkinje system in his monograph
(Tawara, 2000) the AV conduction axis resembles a weeping wil-
low. Studies since have testied to the accuracy of Tawara's
description.
Spach et al. (1971) showed that, from the sinus node, the action
potential follows two routes to the AV node: the faster route is via the
interatrial septum and the slower route is via the terminal crest. These
connect to two inputs (or pathways) into the AV node (the AV node is
said to show dual pathway electrophysiology; Moe et al., 1956;
Meijler & Janse, 1988): the route via the interatrial septum connects
to the fast pathway and the route via the terminal crest connects to
the slow pathway (Fig. 7). The fast and slow AV node pathways are
so-called because they are the fastest and slowest pathways for the
action potential through the AV node. In summary, the fastest (and,
therefore, normal) route for the action potential from the sinus node
through the AV node is via the interatrial septum and the fast pathway
of the AV node. Atrial transitional myocytes provide the fast pathway
into the AV node (Fig. 7). The transitional myocytes make contact
with the compact node, a half-oval of specialised myocytes set against
the central brous body (Figs. 3B and 7), the brous area being the
strongest part of the so-called brous skeleton (Anderson & Ho,
2003). Inferiorly, the compact node has an extension (Figs. 3B and 7),
which passes through the septal isthmus between the coronary sinus
and the hinge of the tricuspid leaet (Inoue & Becker, 1998; Hucker et
al., 2008; Li et al., 2008). This inferior nodal extension constitutes the
slow pathway into the AV node (Inoue & Becker, 1998; Hucker et al.,
2008; Li et al., 2008); it is also continuous with the right AV ring around
the tricuspid valve (Section 4.1; Yanni et al., 2009a). Traced superiorly,
to
ventricles
fast
pathway
FO
Right
CN
ventricle
Right
atrium
Transit-
ional
zone
Tricuspid
valve
IVC CS
slow
pathway
the AV conduction axis becomes embedded within the central brous
body, with the site of insulation being promoted by Tawara as the
landmark for distinction between the compact node and the penetrat-
ing bundle (Figs. 3B and 7). The bundle runs a short penetrating course,
emerging on the crest of the ventricular septum as the branching AV
(His) bundle, albeit that in some people there can be a short non-
branching component. The branching bundle divides on the crest of
the muscular ventricular septum to form the left and right bundle
branches (see Section 3.3).
3.2.2. Function
The principal function of the AV node is to conduct the action poten-
tial from the atria to the ventricles. It must conduct the action potential
slowly in order to introduce a delay between atrial and ventricular
systole. The delay allows atrial systole to take place, providing complete
ventricular lling prior to initiation of ventricular systole. The AV node
has other roles. The relatively long refractory period of the AV node
protects the ventricles from atrial tachycardias, such as atrial brillation
and focal atrial tachycardia, by reducing the frequency of action poten-
tials transmitted to the ventricles (there is no longer 1:1 conduction).
Finally, when the sinus node fails as a pacemaker, the AV node can
take over as the pacemaker, because it too shows pacemaker activity,
although it is slower than that of the sinus node (Dobrzynski et al.,
2003).
Within the AV node of the rabbit, Billette (1987) described the
presence of six types of myocytes based on their action potential charac-
teristics. Three types of myocytes have been more extensively studied:
nodal (N), atrio-nodal (AN) and nodo-His (NH; e.g. deCarvalho et al.,
1959; Anderson et al., 1974a, 1974b; N myocytes exhibit diastolic depo-
larization and are capable of pacemaking. They have a Ca2+-dependent
action potential with a slow upstroke and occupy the inferior nodal
extensions and compact node (Greener et al., 2009). AN and NH cells
are intermediate in nature, and are thought to be present in the transi-
tional zone and penetrating bundle, respectively (Greener et al., 2009).
Differences in action potential morphology in different areas within the
AV node are thought to be related to differences in ionic currents and
ion channel expression (Table 1; Hancox et al., 2003; Greener et al.,
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
2009, 2011). N myocytes exhibit a more positive diastolic membrane po-
tential compared not only to atrial and ventricular myocytes, but also AN
and NH myocytes (Inada et al., 2009a). This is due to the absence or a low
density of IK,1 (Hancox et al., 2003). mRNA for Kir2.1 (one of the principal
channels responsible for IK,1) is reduced in the AV conduction axis
compared to working myocardium in both human and rabbit (Table 1;
Greener et al., 2009, 2011). The poor expression of Kir2.1 in the AV
node will facilitate pacemaking caused by other currents. As in the
sinus node, various ionic currents are likely to be involved in pacemaking
at the AV node. Some but not all nodal myocytes exhibit the pacemaker
current, If (Noma et al., 1980a, 1980b; Hancox et al., 2003). Munk et al.
(1996) studied rod-shaped myocytes with an AN action potential prole
and oval-shaped myocytes with a N or NH action potential prole isolat-
ed from the rabbit AV node. Munk et al. (1996) reported that ~100% of
ovoid myocytes exhibit If, whereas only ~10% of rod-shaped myocytes
exhibit the current. In the AV node, HCN4 is likely to be the most impor-
tant isoform responsible for If (Greener et al., 2011). In the human, rabbit
and rat, HCN4 (both mRNA and protein) is abundant in all areas of the AV
conduction axis, particularly in the inferior nodal extension and compact
node (Table 1; Yoo et al., 2006; Greener et al., 2009, 2011). Block of If by 2
mM Cs+ slows pacemaking (increases the cycle length by 55%) at the
rabbit AV node (Dobrzynski et al., 2003). The Ca2+ clock is also impor-
tant in AV node pacemaking (in the rabbit, pacemaking is slowed by
ryanodine and inhibitors of NCX1 and SERCA2; Nikmaram et al., 2008;
Cheng et al., 2011).
N myocytes have a slow action potential upstroke: the maximum
upstroke velocity of the action potential (dV/dtmax) is high in the work-
ing myocardium, lower in the transitional AN and NH myocytes and
lowest in the N myocytes. dV/dtmax is high in the working myocardium,
because INa is responsible for the action potential upstroke in the work-
ing myocardium. Munk et al. (1996) reported that 100% of rod-shaped
myocytes (with AN-type action potentials) from the rabbit AV node
exhibit INa, whereas only ~30% of oval-shaped myocytes (with N- or
NH-type action potentials) exhibit INa (Munk et al., 1996). Whereas
atrial and ventricular myocytes are large, AV nodal myocytes are small
(Li et al., 2008). Ren et al. (2006) isolated myocytes from the rabbit
AV node and observed that the smallest (spider-like) myocytes exhibit
an N-type action potential, intermediate-sized (spindle-shaped)
myocytes exhibit a transitional AN- or NH-like action potential and
the largest (rod-shaped) myocytes exhibit an atrial-like action poten-
tial. Ren et al. (2006) showed that both dV/dtmax and the density of
INa correlate with the cell capacitance (a measure of cell size). In keep-
ing with the electrophysiological ndings, Nav1.5 (primarily responsi-
ble for INa) at both mRNA and protein levels has been shown to be
absent or poorly expressed in the inferior nodal extension and compact
node in the human, rabbit and rat (Table 1; Yoo et al., 2006; Greener et
al., 2009, 2011). In the human, the level of Nav1.5 (mRNA) has been
shown to be intermediate in the transitional zone (presumed to be
made up of AN myocytes; Greener et al., 2011). In the mouse, knock-
out of Nav1.5 slows AV nodal conduction (Papadatos et al., 2002) and
mutations in SCN5A affects AV nodal conduction in the human
(Section 6).
In the AV node, ICa,L rather than INa is responsible for the action poten-
tial upstroke (e.g. Hancox & Levi, 1994). Cav1.2 is the L-type Ca2+
channel responsible for ICa,L in much of the heart. However, in the rabbit,
there is evidence of an isoform switch from Cav1.2 to Cav1.3 in the AV
node (Greener et al., 2009). In the human, Cav1.3 is upregulated in the
AV node (Table 1; Greener et al., 2011). Cav1.3 has a more negative
activation threshold than Cav1.2 and this may be more appropriate for
a Ca2+-dependent action potential. Another Ca2+ channel with a more
negative activation threshold is Cav3.1 responsible for ICa,T. Cav3.1
(mRNA and protein) is more highly expressed in the AV node (especially
in the compact node) than in the working myocardium in the human
(Greener et al., 2011). Knock-out of the Cav3.1 channel slows AV node
conduction in the mouse (Mangoni et al., 2006). Since the pioneering
work of Pollack (Pollack, 1976), coupling is known to be poor in the AV
271
node. Pollack (1976) injected uorescein intracellularly by micro-
iontophoresis into the rabbit AV node and tracked its diffusion and
showed that the rate of passage of dye between N myocytes is at least
three orders of magnitude lower than between myocytes of the other
tissues studied; this result is consistent with published reports indicating
few gap junctions between AV node myocytes (Pollack, 1976). The poor
coupling in the AV node can be explained by the make-up of gap
junctions in the AV node as well as the paucity of gap junctions in the
AV node. Whereas the intermediate conductance Cx43 is the main
isoform expressed in the working myocardium, Cx43 (mRNA and
protein) is poorly or not expressed in the inferior nodal extension and
compact node in the human, rabbit and rat (Table 1; Yoo et al., 2006;
Greener et al., 2009, 2011). In contrast, the small conductance Cx45 is
the main connexin expressed in these regions (Table 1; Coppen et al.,
1999a,b; Severs et al., 2001; Coppen & Severs, 2002; Severs et al.,
2004). Expression of Cx43 (mRNA and protein) in the transitional zone
is also reduced in the human, rabbit and rat (Yoo et al., 2006; Greener
et al., 2009, 2011). Cx43 is expressed in the penetrating bundle in the
human and rabbit (but not the rat; Yoo et al., Greener et al., 2009,
2011). The large conductance Cx40 can be expressed in the atrial
muscle. In the human and rat, although, Cx40 (mRNA and protein)
is not expressed in the proximal part of the atrioventricular conduc-
tion axis (e.g. inferior nodal extension), it is expressed in the distal
parts (e.g. the compact node and penetrating bundle; Yoo et al.,
2006; Greener et al., 2011). Interestingly, the penetrating bundle is
divided into upper and lower bundles with different connexin expres-
sion proles: the lower bundle expresses Cx40 or Cx43, whereas the
upper bundle does not (Yoo et al., 2006; Hucker et al., 2008). This
may explain the presence of two conduction pathways within the His
bundle (Zhang et al., 2001). Interestingly, Kreuzberg et al. (2006)
showed that Cx30.2 slows atrioventricular conduction in mouse heart.
See Temple et al., 2013 for further discussion.
What are the consequences of the pattern of expression of ion chan-
nels within the atrioventricular conduction axis on electrical activity?
As with a previous study from our laboratory on the human sinus
node (Chandler et al., 2009), for the human AV conduction axis, we
have explored this question by assuming that the whole-cell conduc-
tance for a particular ionic current is roughly proportional to the abun-
dance of the mRNAs responsible for the relevant ion channel; Na+-Ca2+
exchange, SR Ca2+ release and SR Ca 2+ uptake were scaled in an anal-
ogous way (Inada et al., 2009a, 2009b). Control values for human atrial
muscle were taken from the mathematical model of Courtemanche et
al. (1998) of the human atrial action potential, which is based on exper-
imental voltage clamp data from human atrial myocytes. Fig. 8A shows
computed action potentials calculated in this way for different parts of
the AV conduction axis in the human. The predicted action potential
waveforms are feasible for example, the inferior nodal extension
and compact node are predicted to show pacemaking, whereas dV/
dtmax is high in the working myocardium and least in the inferior
nodal extension and compact node (Fig. 8A). Can the pattern of gene
expression explain the slow conduction of the action potential along
the AV conduction axis? The conduction time of the action potential
along a string of 300 electrically coupled myocytes was calculated
(Fig. 8B). In the case of atrial myocytes, the coupling conductance
(1000 nS) was chosen to give an appropriate conduction velocity
(53 cm/s). In the rst simulation (white bars in Fig. 8C), atrial myocytes
were assumed to occupy all regions, and the coupling conductance was
scaled based on the expression of connexin mRNAs in the different
regions: the predicted conduction velocity was lower in the inferior
nodal extension as a result of the low expression of connexins in this
region. In the second simulation (grey bars in Fig. 8C), the myocyte
type was appropriate for each region, but the coupling conductance
was assumed to be the same in all regions (1000 nS): the predicted
conduction velocity was lower in the inferior nodal extension, this
time as a result of the low dV/dtmax in this tissue (a consequence of
the low expression of Nav1.5 in this tissue). In the third simulation
272 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

Fig. 8. Conduction through the AV node. A, predicted action potential waveforms for the atrial muscle (AM), transitional area (TA), inferior nodal extension (INE), compact node
(CN), penetrating bundle (PB) and ventricular muscle (VM) in the human. The action potentials were based on the model of the human atrial action potential from Courtemanche
et al. (1998) and ion channel expression in the different tissues (relative to that in the atrial muscle). See Inada et al. (2009b) for details. Membrane potential is shown in the rst
row, the rate of change of membrane potential in the second row and the intracellular Ca2+ concentration in the third row. All action potentials triggered by stimuli except those in
inferior nodal extension and compact node, which are spontaneous (spontaneous cycle length, CL, shown). In simulations, the conductance for Ito was decreased by 30% in all tissues
(including the atrial muscle). B, calculation of the conduction velocity. One end of a string of 300 electrically-coupled myocytes (atrial muscle, transitional area, inferior nodal ex-
tension, compact node, penetrating bundle or ventricular muscle type) was stimulated. Pairs of action potentials (recorded at the stimulation site and the distal end of the string)
are shown. Conduction velocity was calculated from the interval between the two action potentials (assuming cells are 100 m in length and joined end to end). In examples shown,
coupling conductance was scaled according to connexin mRNA expression and the appropriate action potential model was used for each region. C, calculated conduction velocity
(D) and dV/dtmax (E) in the atrial muscle, transitional area, inferior nodal extension, compact node, penetrating bundle and ventricular muscle. In the rst set of simulations (Cx40/
Cx43/Cx45; white bars), the atrial muscle action potential model was used for all regions and the coupling conductance was scaled according to connexin mRNA expression. In the
second set of simulations (Nav1.5; grey bars), the appropriate action potential model was used for each region, but the coupling conductance not varied. In the nal set of simu-
lations (Cx40/Cx43/Cx45/Nav1.5; red bars), the coupling conductance was scaled according to connexin mRNA expression and the appropriate action potential model was used for
each region. From S. Inada (unpublished data).

(red bars in Fig. 8C), the coupling conductance was scaled based on the
expression of connexin mRNAs and the myocyte type was appropriate
for each region: the predicted conduction velocity was low in the infe-
rior nodal extension, lower than in the two previous cases. In the inferi-
or nodal extension, the predicted conduction velocity was ~4 cm/s,
similar to that recorded experimentally in the rabbit (Inada et al.,
2009b). Fig. 8C suggests that the slow conduction along the human
atrioventricular conduction axis is the result of the low expression of
both Cx43 and Nav1.5. In the third simulation, the predicted conduction
velocity was, as expected, highest in the penetrating bundle (Fig. 8C).
3.2.3. Clinical relevance
The AV node can act as a substrate for the generation of tachyar-
rhythmias transmitted to the ventricles. The dual pathways of the
AV node form the substrate for AV nodal reentrant tachycardia
(AVNRT). In AVNRT, a reentrant circuit is established, with the action
potential travelling down one pathway (usually the slow) and up the
other (usually the fast) causing incessant tachycardia. Use of mapping
strategies in the human and rabbit heart has helped elucidate these
pathways (McGuire et al., 1993; Inoue & Becker, 1998; Li et al.,
2008; Kurian et al., 2010). With the use of optical mapping tech-
niques, Emov and his colleagues have clearly shown the rotation of
the action potential around the two pathways (Nikolski et al.,
2003). Optical mapping followed by histological examination has
suggested that the fast pathway corresponds to the transitional
zone, whereas the slow pathway corresponds to the inferior nodal
extension (Figs. 3B and 7; Li et al., 2008). There are differences in
the refractory period of the two pathways: the refractory period of
the fast pathway is longer than that of the slow pathway (Inada et
al., 2009a, 2009b). Consequently, in response to a premature stimulus
there can be unidirectional block (of the fast pathway with the longer
refractory period) and this sets the scene for slow-fast AVNRT
(Nikolski et al., 2003). Slow-fast AVNRT in the rabbit AV conduction
axis has been simulated using a biophysically-detailed model of the
dual pathway electrophysiology (Inada et al., 2009a).
In the acute setting, adenosine is highly effective in terminating
AVNRT (Wilbur & Marchlinski, 1997). In nodal tissue, the effects of
adenosine are predominantly mediated via activation of the ACh-
activated K+ current (IK,ACh), which hyperpolarizes the cell and
shortens the action potential (Wilbur & Marchlinski, 1997). This leads
to a transient conduction block within the AV node, mainly in the
slow pathway, which is sufcient to terminate the reentry circuit and
restore normal sinus rhythm (Wilbur & Marchlinski, 1997). In the
chronic setting, many different pharmacological agents have been
used for the treatment of AVNRT including -blockers, Ca2+ channel
blockers, ecainide, propafenone, sotalol, dofetilide and amiodarone
(Blomstrom-Lundqvist et al., 2003). Because the maintenance of the
reentrant circuit in AVNRT is dependent on the balance of conduction
velocity and the refractory period of both the fast and slow pathways
of the AV node, any agent that alters either of these parameters in either
pathway may disrupt the AVNRT circuit. Ca2+ channel blocking drugs
bind to the L-type Ca 2+ channel directly to inhibit ICa,L, whilst
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
-blockers act indirectly by antagonising the increase in ICa,L due to
-stimulation (Abernethy & Schwartz, 1999). The reduction in ICa,L
leads to a reduction of conduction velocity within the AV node
(Van De Ven et al., 1996; Zicha et al., 2006). The VaughanWilliams
class 1 agents, ecainide and propafenone, bind to the Na + channel
reducing INa and slowing conduction in the working atrial myocardi-
um and the fast pathway (Hoff et al., 1988). The VaughanWilliams
class III agents, amiodarone and dofetilide, act by increasing the
refractory period of both the fast and the slow pathway, predomi-
nantly by block of the outward K + currents IK,r and IK,s (Kodama et
al., 1997a, 1997b). Despite the use of multiple classes of drugs, some-
times in combination, there is a high risk of recurrence of AVNRT in
addition to the medications' potential side effects and adverse
events. This has led to the adoption of catheter ablation of the slow
pathway as rst line therapy for AVNRT with success rates estimated
to be around 95% (Blomstrom-Lundqvist et al., 2003).
Conduction through the AV node can be pathologically slowed
resulting in AV or heart block (Fig. 9). First-degree heart block is a
delay in conduction of the action potential through the AV node,
resulting in prolongation of the PR interval on the ECG. In second-
degree heart block, only some atrial action potentials are transmitted
to the ventricles, which results in some P waves without an accompany-
ing QRS complex in the ECG. Third-degree heart block is the absence of
conduction from the atria to the ventricles. An escape ventricular
rhythm is usually present with third degree heart block. The higher
the degree of block, the more likely mechanical permanent pacemaker
implantation will be required to restore AV synchrony. Heart block is
commonly idiopathic. However, it may be congenital (Section 6). The
incidence of heart block increases with ageing (Piccini & Calkins,
2005). Heart block may be secondary to ischaemic heart disease, cardio-
myopathy, heart failure (Crisel et al., 2011) or increased vagal tone
(Imaizumi et al., 1990). Fig. 9 shows standard 12 lead ECG recordings
from a patient with a normal ECG (Fig. 9A) and two heart failure
patients (Fig. 9B, C). The second of the heart failure patients (Fig. 9C)
has rst-degree heart block (the PR interval in Fig. 9C is >200 ms and
approximately double that in Fig. 9A) as well as other conduction disor-
ders: mild sinus bradycardia (the heart rate in Fig. 9C is ~60 beats/min
compared to ~92 beats/min in Fig. 9A) and an intermittent left bundle
branch pattern (intermittent broad QRS complexes in Fig. 9C compared
to narrow complexes in Fig. 9A). Heart failure patients with a prolonged
PR interval have a poor outcome in terms of death, urgent transplanta-
tion or cardiovascular hospitalisation (Gervais et al., 2009). Fascinating-
ly, the incidence of heart block is increased in athletes (Maron &
Pelliccia, 2006). Finally, heart block can occur as a side-effect of medical
therapy or ablation procedures. In an analogous way as gene therapy is
being used to generate a biopacemaker (Section 3.1.3.3), gene therapy
has been used to control the AV node (Bauer et al., 2004).
3.3. His bundle, bundle branches and Purkinje network
3.3.1. Anatomy
The ventricular portion of the cardiac conduction system from the
AV node to the ventricular working myocardium is vital. The structure
of the system ensures the synchronous activation of the ventricular
myocardium to achieve the most efcient pumping activity. The His
bundle, or penetrating bundle, is the insulated component of the AV
conduction axis, becoming recognisable anatomically when the
axis becomes insulated from the surrounding atrial myocardium by
collagenous tissue (Fig. 3B). The bundle thus formed provides, in
the normal heart, the only AV conduction pathway. The asymmetric
left bundle branch and right bundle branch are formed by the bifur-
cation of the His bundle at the crest of the ventricular septum
(Miquerol et al., 2004; Atkinson et al., 2011). The Purkinje networks
formed at the terminations of the bundle branches are comparable
between species, as shown initially by Tawara (2000) and now con-
rmed by others (Massing & James, 1976; Miquerol et al., 2004). The
273
networks are complex three-dimensional structures, with a combi-
nation of subendocardial and free running bres (Fig. 10). Typically,
the left bundle branch is a fan-like structure (Fig. 10A,Ci,Cii), where-
as the right bundle branch is cord-like (Fig. 10B; Atkinson et al.,
2011). The left bundle branch extends to the mid portion of the septum
before it detaches from the underlying endocardium and forms
free-running false tendons that traverse the ventricular chamber
(Fig. 10A). The free-running strands reattach at the free wall myocardi-
um, forming a complex sub-endocardial network that covers a large
portion of the free wall, but projecting predominantly towards the pap-
illary muscles (Fig. 10A,Civ).
The cord-like right bundle branch emerges beneath the membranous
septum and runs towards the apex of the heart on the septal endocardi-
um, with free running strands extending from the bundle branch
towards the apical trabeculated portion of the ventricle (Fig. 10B). The
ventricular cavity is also bridged via connections through the moderator
band (Fig. 10Cvi). The bundle branches are insulated from the underlying
myocardium by connective tissue sheaths (Ansari et al., 1999), enabling
the transfer of action potentials to the apex of the heart without
activating the ventricular myocardium at the base of the heart rst,
ensuring the controlled activation of the ventricular myocardium. The
sub-endocardial Purkinje network covers large portions of the ventricu-
lar myocardium and forms the terminal portion of the ventricular
conduction system. At specic sites the insulating sheath is lost, allowing
action potentials to propagate to the ventricular working myocardium
(Tranum-Jensen et al., 1991; Ryu et al., 2009). Transitional myocytes
are present at the junction of the sinus node with the atrial muscle
(Section 3.1.1) and the junction of the atrial muscle with the AV node
(Section 3.2.1) and it is interesting that there also exists transitional
myocytes at the junction of the Purkinje myocytes with the ventricular
muscle (Severs, 2000). Presumably the transitional myocytes are present
to minimise source-sink mismatch.
3.3.2. Function
The principle function of the HisPurkinje system is to rapidly
conduct the action potential throughout the ventricles to ensure the
ventricular muscle contracts in the correct sequence. A second func-
tion is to act as a ventricular pacemaker in the event of heart block.
The HisPurkinje system is highly specialised for the rapid conduction
of the action potential with a conduction velocity of 2.3 m/s as com-
pared to 0.75 m/s in the ventricular muscle (Desplantez et al., 2007).
One reason for the high conduction velocity is the expression prole
of connexins: unlike the sinus node and the AV node where the small
conductance Cx45 is predominantly expressed, the HisPurkinje sys-
tem shows expression of large and medium conductance connexins,
Cx40 (Gaborit et al., 2007; Atkinson et al., 2011) and Cx43 (Gourdie et
al., 1993). In the rat, Cx40 is predominantly expressed in the proximal
His-bundle and bundle branches, whereas both Cx40 and Cx43 co-
localise in the distal Purkinje bre network (Gourdie et al., 1993).
In genetically modied mice with Cx40 deciency, action potential
conduction in the left bundle branch is impaired and a lack of ex-
pression of Cx40 in the proximal bundles correlates with right
bundle-branch block (van Rijen et al., 2001), demonstrating the
importance of connexin expression for effective conduction in the
HisPurkinje system.
A second reason for the fast conduction velocity of the action
potential in Purkinje bres concerns the nature of the action poten-
tial in the Purkinje bres. The Purkinje bre action potential is not
nodal-like. As compared to the ventricular action potential, the
action potential in Purkinje bres has a faster upstroke velocity
(dV/dtmax), higher amplitude, more prominent early phase of rapid
repolarization (phase 1) and a more negative plateau potential and,
most importantly, it is longer in duration (Fig. 11; mouse, Anumonwo
et al., 2001; rabbit, Persson et al., 2007; dog, Balti et al., 2000; Koncz
et al., 2011). The fast upstroke and large amplitude of the action poten-
tial is the second reason for the fast conduction velocity of the action
274 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 275

Fig. 10. HisPurkinje network in the left and right ventricles of the rabbit. A, macroscopic image of immunoenzyme-labelling (dark brown signal) of middle neurolament on the
endocardial surface of the left ventricle. B, macroscopic image of immunolabelling of middle neurolament on the endocardial surface of the right ventricle. C, high magnication
images. Labels in A and B indicate the location of the high magnication images in C. Ci, origin of left bundle branch (LBB) in the membranous septum near the root of the aorta. Cii,
mid-septal left bundle branch. Ciii, division of the left bundle branch prior to forming free-running Purkinje bres. Civ, left bundle branch and free-running Purkinje bres. Connec-
tion to anterior papillary muscle (PM) is visible. Cv, free-running Purkinje bres in the left ventricle. Cvi, right bundle branch (RBB) and moderator band. Cvii, right bundle branch
running around the base of the papillary muscle on the right ventricular septum with free-running Purkinje bres branching from it. The right bundle branch runs endocardially on
the septal surface crossing the ventricular chamber via the moderator band. Cviii, peripheral Purkinje bre network on the right ventricular free wall.
From Atkinson et al. (2011).

potential in Purkinje bres. Fig. 8 shows the importance of both strong
electrical coupling provided by connexins and a fast action potential in
determining a high conduction velocity in the penetrating bundle at the
start of the HisPurkinje system. The long duration of the Purkinje bre
action potential makes the Purkinje bres prone to certain drug-
induced early after depolarizations (EADs; Roden & Hoffman, 1985;
Nattel & Quantz, 1988; Kaseda et al., 1989; Boyden et al., 2000;
Cordeiro et al., 2001a, 2001b; Persson et al., 2007) can lead to torsades
des pointes, a life-threatening cardiac arrhythmia. Gender differences
have been observed in dog Purkinje bres: action potentials are longer
in female dogs in spite of there being no difference in the resting poten-
tial, dV/dtmax or action potential amplitude (Abi-Gerges et al., 2004,
2006). Such differences are thought to underlie the increased suscepti-
bility of women to torsades de pointes (Makkar et al., 1993; Abi-Gerges
et al., 2006). Computer simulation studies based on patch clamp data
have suggested that the action potential differences between Purkinje
bres and ventricular muscle in the rabbit are the result of ICa,T in
Purkinje bres but not ventricular muscle and increases in the densi-
ty of INa and the late Na + current (INa,L) and decreases in the density
of ICa,L, IK,r, IK,s and IK,1 in the Purkinje bres (Fig. 11; Aslanidi et al.,
2010). These differences are consistent with the ion channel expres-
sion prole in Purkinje bres in the human (Table 1; Gaborit et al.,
2007) and rabbit (Table 1; Atkinson et al., 2011). There is higher ex-
pression of Nav1.5 mRNA in rabbit Purkinje bres at least explaining
the higher density of INa (and possibly INa,L) and, therefore, the faster
action potential upstroke (Fig. 11; Atkinson et al., 2011). There is a
lower expression of Cav1.2, ERG, KvLQT1 and Kir2.1 mRNAs in rabbit
Purkinje bres at least explaining the lower densities of ICa,L, IK,r, IK,s
and IK,1, respectively, and, therefore, helping to explain the longer
action potential (Fig. 11; Atkinson et al., 2011).

Fig. 9. Standard 12 lead ECG recordings from normal and heart failure patients. A, ECG from normal patient in sinus rhythm. The PR interval is normal (b200 ms) and the QRS com-
plex narrow (b120 ms). B, ECG from heart failure (HF) patient with left bundle branch block (as indicated by broad QRS complexes; >120 ms), left axis deviation and atrial bril-
lation (as indicated by the absence of P waves and an irregularly irregular ventricular rhythm). C, ECG from heart failure patient with a slow heart rate (prolonged RR interval),
rst-degree heart block (prolonged PR interval; >200 ms) and intermittent left bundle branch pattern (broad QRS complexes; >120 ms).
From Dr. J. Fraser (unpublished data).
276 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
Fig. 11. Purkinje bres relating mRNA expression to function. A, current densities in
Purkinje bres comparison of the best estimates from voltage clamp experiments
with the predictions from ion channel mRNA expression levels. Black bars, current
density in rabbit left ventricular Purkinje cells (as a fraction of current density in rabbit
left ventricular endocardial myocytes; based on Aslanidi et al., 2010). The peak INa den-
sity was measured during a voltage clamp pulse to 25 mV from a holding potential of
75 mV. The peak ICa,L density was measured during a pulse to +10 mV from a hold-
ing potential 40 mV. The IK,r tail current density was measured at the holding poten-
tial of 50 mV after a 300 ms pulse to +20 mV. The IK,s tail current density was
measured at the holding potential of 50 mV after a 1 s pulse to +20 mV. The IK,1 den-
sity was measured as the positive peak value at 70 mV. Grey bars, mRNA expression
level of the ion channel or ion channels responsible for each of the ionic currents in
rabbit left ventricular Purkinje bres (as a fraction of the expression level in rabbit
left ventricular muscle). B, computed action potentials. Black trace VM, action poten-
tial computed for a rabbit ventricular endocardial myocyte using the model of Aslanidi
et al. (2010). Grey trace PF (mRNA), action potential computed using the rabbit ven-
tricular endocardial myocyte model modied by changing ionic current conductances
based on the expression of the corresponding ion channel mRNAs. The computed ac-
tion potential resembles that of a Purkinje bre. Black dashed trace PF, action poten-
tial computed from the rabbit Purkinje bre model of Aslanidi et al. (2010).
From Atkinson et al. (2011).
Purkinje bres can show pacemaking, although it is slower and
less robust than pacemaking in the two nodes. Pacemaker activity
with diastolic depolarization during phase 4 of the action potential
has been observed in isolated (non-driven) multicellular Purkinje
bre preparations of the mouse (Anumonwo et al., 2001), rabbit
(S.J.R.J. Logantha, unpublished observation) and dog (Davis &
Temte, 1969; Kus & Sasyniuk, 1975; Balti et al., 2000; Koncz et al.,
2011). In single myocyte studies, Purkinje myocytes with less nega-
tive diastolic potentials show pacemaker activity (Callewaert et al.,
1984; Robinson et al., 1987), but well polarised (85 mV) myocytes
remain quiescent even after catecholamine treatment (Robinson et
al., 1987). Several ionic currents are thought to contribute to the
diastolic depolarization in Purkinje bres. A low density of IK,1 and
poor expression of Kir2.1 in Purkinje bres is one reason why Purkinje
bres can show pacemaking (Fig. 11; Gaborit et al., 2007; Aslanidi et
al., 2010; Atkinson et al., 2011). If (DiFrancesco, 1981a, 1981b;
Callewaert et al., 1984; Yu et al., 1995; Schram et al., 2002) and the
HCN ion channel family (Shi et al., 1999; Gaborit et al., 2007; Atkinson
et al., 2011) responsible for If are present in Purkinje bres of a number
of species including human. Whole cell patch-clamp studies have
revealed that steady-state activation of If occurs at physiological poten-
tials in dog Purkinje cells (80 to 130 mV). In contrast, If activation in
dog ventricular myocytes occurs at more negative potentials (120 to
170 mV; Yu et al., 1995). Koncz et al. (2011) have shown that
inhibiting If with ivabradine blocks pacemaking in dog Purkinje bres,
suggesting an important role for this current. However, an earlier
study had reported that lidoazine, a drug that decreases If in
sheep Purkinje bres (Hart & Dukes, 1984), had no effect on the
pacemaker activity in dog Purkinje bres (Dangman & Miura,
1987). Another potential contributor to the diastolic depolarization,
ICa,T, is substantially larger in Purkinje myocytes, but its inhibition
with mibefradil does not affect pacemaking (Pinto et al., 1999).
Several other currents including a voltage- and time-dependent K + cur-
rent (IK,dd) (Vassalle et al., 1995) and a voltage- and time-dependent
inward Na + current (INa3) have been reported to contribute to pace-
making in Purkinje bres (Rota & Vassalle, 2003; Vassalle, 2007). The
pacemaker activity of Purkinje bres is usually suppressed by the
phenomenon of overdrive suppression. In normal hearts during
regular sinus rhythm, the Purkinje bres are excited at frequencies
higher than their intrinsic rate, leading to increased inux of Na+ and
a rise of the intracellular Na+ concentration (Boyett et al., 1987)
followed by enhanced electrogenic Na +/K+ pump activity that results
in hyperpolarization of the resting membrane and a suppression of
diastolic depolarization (Vassalle, 1970; Boyett & Fedida, 1984).
Purkinje bres are susceptible to another type of pacemaker activity.
However, this pacemaker activity is abnormal and occurs when the
Purkinje bres are Ca2+-overloaded and has all of the characteristics of
the Ca2+ clock (Tsien et al., 1979). Following an action potential, there
can be a spontaneous release of Ca2+ from the SR leading to a Ca2+
wave (the Ca2+ waves are sensitive to treatment with ryanodine and
thapsigargin conrming a role for Ca2+ release from the SR; Boyden et
al., 2000, 2004). Some of the released Ca2+ is extruded out of the cell
by the Na+Ca2+ exchanger resulting in a transient inward current
(ITI) that elicits a depolarization: a delayed afterdepolarization (DAD;
Boyden et al., 2000). If the DAD reaches threshold an ectopic action
potential is initiated. Purkinje bres are susceptible to DADs, which can
be triggered by rapid stimulation and drug-induced (Ferrier et al., 1973;
Lederer & Tsien, 1976). Despite this, expression of Ca2+-handling pro-
teins such as RYR2, RYR3, SERCA2a and NCX1 in the Purkinje bres is
low (Table 1; Gaborit et al., 2007; Atkinson et al., 2011). The Purkinje -
bres share this in common with the two nodes (Table 1). Perhaps this is
consistent with the limited contractile function of the Purkinje bres
and the two nodes.
It has already been mentioned that Purkinje bres have a lower den-
sity of IK,1 (Cordeiro et al., 1998) and lower expression of Kir2.1
(Atkinson et al., 2011). It is perhaps for this reason that the steady-
state currentvoltage relationship of dog Purkinje bres is shallow
and N-shaped and crosses the current axis twice, i.e. there are two
potentials at which the net current is zero (Gadsby & Craneeld, 1977;
Boyden et al., 1989). As a result, dog Purkinje bres have two levels of
stable resting potential, one near 90 mV and one near 50 mV (corre-
sponding to the two zero current potentials) and the Purkinje bre can
be ipped from one resting potential to the other by a small perturba-
tion (Wiggins & Craneeld, 1976; Gadsby & Craneeld, 1977). This is
functionally important, because at the high resting potential the action
potential has a fast INa-dependent upstroke and is fast conducting
(Callewaert et al., 1984), whereas at the low resting potential the action
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
potential is slow conducting and sensitive to treatment with Ca2+ antag-
onists (Molyvdas & Sperelakis, 1983; Amerini et al., 1985) and perhaps
has a ICa,L-dependent slow upstroke (i.e., nodal-like). Experimentally,
the slowly conducting action potential can lead to re-entry around a
network of Purkinje bres (Wit et al., 1972).
3.3.3. Clinical relevance
The HisPurkinje system plays an important role in arrhythmogenesis
and is linked with a number of different arrhythmias (Boyden et al., 2003;
Scheinman, 2009). Purkinje bres have been shown to be prone to EADs
due to their long action potential, which can lead to the torsade de
pointes arrhythmia in patients with long QT syndrome (Schram et al.,
2002; Ben et al., 2008; Dun & Boyden, 2008). Abnormal automaticity
(e.g. as a result of DADs) in the HisPurkinje system is another potential
cause of arrhythmias. Arnar et al. (1997) speculated that such abnormal
automaticity may be responsible for the episodes of spontaneous ven-
tricular tachycardia (VT) of focal Purkinje origin (60% of total) occurring
in the rst 30 min after coronary artery occlusion in a dog model. A
slowing of conduction in the HisPurkinje system is an important risk
factor for reentrant arrhythmia formation and can lead to bundle branch
reentry VT and fascicular VT. Bundle branch reentry VT typically occurs in
patients with impaired ventricular function, particularly in patients with
dilated cardiomyopathy. There are a number of different bundle branch
reentrant circuits causing ventricular tachycardia. The commonest form
involves retrograde activation of the left bundle branch and antegrade ac-
tivation of the right bundle branch (Balasundaram et al., 2008). Common-
ly, ablation of the right bundle branch is performed to abolish these
re-entrant circuits (Balasundaram et al., 2008). Ablation of the left bundle
branch is possible to perform, but due to the broad structure of the left
bundle branch it is more difcult to perform (Balasundaram et al.,
2008; Crijns et al., 1995). Reentrant HisPurkinje system circuits can
also be established in the opposite direction or involving only the two fas-
cicles of the left bundle branch. The HisPurkinje system can also be in-
volved in ventricular arrhythmias in structurally normal hearts. In
fascicular VT a reentrant circuit involving both fast conduction and slow
conduction within then Purkinje network, most commonly the left poste-
rior Purkinje network, causes VT. During ablation procedures the His
Purkinje system is mapped to identify the region of slow conduction
within the Purkinje system and then radio frequency ablation is used to
abolish the Purkinje network at this site. Ectopic beats from the Purkinje
network have also been shown to be the initiating trigger for arrhythmia
in a high proportion of survivors of VF without structural heart disease.
Ablation at the site of these triggers has been shown to be effective in re-
ducing the recurrence of VF (Hassaguerre et al., 2002; Wright et al.,
2009). The Purkinje-muscle junctions have also been shown to be impor-
tant sites for the generation of triggered activity involved in arrhythmias
(Berenfeld & Jalife, 1988; Gilmour & Watanabe, 1994; Li et al., 1994;
Mazur et al., 2005; Nogami, 2011). The HisPurkinje system may be in-
volved in catecholaminergic polymorphic ventricular tachycardia
(CPVT) and this is dealt with in Section 6. The HisPurkinje system is sen-
sitive to a number of drugs that increase action potential duration
and trigger arrhythmias (Gupta et al., 2007; Champeroux et al.,
2011). Drugs that reduce action potential duration or limit automa-
ticity (e.g. verapamil and lidocaine) can be used to treat arrhythmias
linked to the HisPurkinje system (Hirata et al., 1979; Dersham &
Han, 1980; Kuo & Reddy, 1981). Magnesium has been used as a treat-
ment for torsade de pointes arrhythmia originating in the His
Purkinje system in long QT syndrome and has been shown to behave
in a similar fashion to TTX (which blocks INa; Kaseda et al., 1989;
Gupta et al., 2007).
Another problem with the HisPurkinje system is bundle branch
block. An example of left bundle branch block in the setting of heart
failure is shown in Fig. 9B and is characterised by a broad QRS complex
(compare to the normal narrow QRS complex in Fig. 9A) as a result of
slowed ventricular activation. Right bundle branch block is thought to
be asymptomatic, but left bundle branch block has been shown to
277
cause left ventricular dysfunction with abnormal lling times and
ejection fractions (Grines et al., 1989). Just like sinus node dysfunction
and heart block, the incidence of bundle branch block (left and right) in-
creases during ageing; the prevalence of bundle-branch block increases
from 1% at age 50 years to 17% at age 80 years (Eriksson et al., 1998). Bun-
dle branch block is associated with coronary artery disease, congestive
heart failure and progression to complete heart block (Maddali, 2010).
For example, 26% of heart failure patients are reported to have left bundle
branch block (Padeletti et al., 2010). It is for this reason that some heart
failure patients require resynchronisation therapy. It is likely that bundle
branch block in the setting of heart failure at least is the result of
remodelling of ion channels etc. in the HisPurkinje network. Maguy et
al. (2009) have demonstrated a downregulation of Kir2.1, Nav1.5, Kv3.4,
Kv4.3, Cx40 and Cx43 in the Purkinje bres of a dog model of heart failure
(ventricular tachypacing model). There was a decrease in dV/dtmax
(a likely consequence of the downregulation of Nav1.5) as well as the
conduction velocity (a likely consequence of the decrease in dV/dtmax
and downregulation of Cx43) and this could explain the dyssynchronous
ventricular activation (Maguy et al., 2009). Consistent with these nd-
ings, we have shown a widespread remodelling of ion channels etc. in a
rabbit model of heart failure (Yanni et al. unpublished data).
4. Atrioventricular ring tissue:
anatomy, function and clinical relevance
4.1. Anatomy
In the normal postnatal heart, the atrial and ventricular muscle
masses are separated at the AV junctions by connective tissues, with
the plane of insulation thus formed crossed only by the AV conduction
axis, thus allowing normal conduction of the action potential generated
by the sinus node to the ventricles. In addition to the histologically-
specialised tissues forming the AV conduction axis, we now know that
additional histologically specialised rings encircle the orices of the
tricuspid and mitral valves, these rings taking their origin from inferior
extensions of the AV node (Fig. 12A; Yanni et al., 2009a). The rightward
inferior extension from the AV node extends around the vestibule of the
tricuspid valve, whereas the leftward inferior extension encircles the
orice of the mitral valve (Fig. 12A). On reaching the atrial septum,
having passed round the right AV orice, the tricuspid ring crosses
over the AV conduction axis, separated from it by the central brous
body, and reunites with the mitral ring to produce a superiorly located
retroaortic node. The retroaortic node is located within the atrial walls
immediately dorsal to the aortic root. Taken overall, therefore, the AV
rings form a gure-of-eight structure around the mitral and tricuspid
junctions, effectively creating a solitary ring of specialised tissue that
encircles the right and left AV junctions (Fig. 12A; Yanni et al., 2009a).
The histologically-specialised cardiomyocytes forming the rings are
less extensive around the mitral orice than the tricuspid orice. In
terms of their histology, the myocytes making up the rings satisfy two
of the three criteria established by Aschoff and Monckeberg in 1910
(Anderson et al., 2000) to justify recognition as being specialised, in
that the myocytes are histologically discrete, and can be traced from
section to section in serially prepared material. The rings, however,
are not insulated from the atrial myocardium, albeit being separated
by the plane of AV insulation from the ventricular myocardium.
4.2. Function
There are only a few studies of the electrophysiology of the AV ring
tissue. Studies of pig, dog and rabbit multicellular preparations have
revealed nodal-type action potentials in the AV ring region (deCarvalho
et al., 1959; Horibe, 1961; McGuire et al., 1994). In pig and dog hearts,
such nodal-type action potentials are present within 12 mm of the
annulus, surrounding the entire tricuspid valve. A circumferential zone
(1 cm wide) of myocytes with transitional action potentials separates
278 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

A B SN

RA

LR
LV
RR AVN
RV VS 1 mm

C D
RR

LR

Total RA 73% Total LA 27%

Fig. 12. AV ring tissue. A, schematic diagram of AV ring tissue and its association with the established AV conduction axis. From Yanni et al. (2009a). B, section through a rat heart
double labelled for HCN4 (green signal) and Cx43 (red signal). HCN4 labelling identies the sinus node, AV node and right and left rings, whereas Cx43 labelling identies the work-
ing myocardium of the right atrium, right ventricle, ventricular septum and left ventricle. From H. Dobrzynski et al. (unpublished image). C, location of sites (black circles) in the
atria of patients ablated to terminate atrial tachcardia. Sites around the tricuspid and mitral valves are shown. From Kistler et al. (2006). D, pacemaker action potentials recorded
from the sinus node and right AV ring in the rabbit heart. From Rozanski and Jalife (1986). AVN, atrioventricular node; LR, left ring; LV, left ventricle; MV, mitral valve; RA, right
atrium; RR, right ring; RV, right ventricle; SN, sinus node; TV, tricuspid valve; VS, ventricular septum.

the myocytes with nodal-type action potentials from atrial myocytes
(McGuire et al., 1994, 1996). When action potentials were recorded
from myocytes progressively closer to the tricuspid valve, from any
point around the AV ring, the maximum diastolic potential became
less negative and there was a gradual diminution of dV/dtmax of the
action potential, disappearance of the spiked reversal and, nally,
appearance of slowly rising, rounded nodal-type action potentials
(deCarvalho et al., 1959; Horibe, 1961; McGuire et al., 1994). The
gradual change in action potential characteristics within the AV
ring tissue is accompanied by a decrease in conduction velocity
(deCarvalho et al., 1959). Recent work in our laboratory has shown
that the AV ring tissue in the rat shows pacemaking involving both
the membrane and Ca2+ clock mechanisms: both block of If (by Cs+)
and RYR2 (by ryanodine) slows pacemaking (S.J.R.J. Logantha,
unpublished observations). In the hearts of a number of species, there
are sparsely arranged myocytes in the AV valve leaets (Wit et al.,
1973; Basset et al., 1976; Wit & Craneeld, 1976; Rozanski & Jalife,
1986). The myocytes in the AV valve leaets exhibit pacemaking
(Fig. 12D) that is sensitive to block of If (with Cs+) and ICa,L (with Ni+
or verapamil; Rozanski & Jalife, 1986; Rozanski, 1987; Anumonwo et
al., 1990). If has been recorded from myocytes from the AV valve leaets
(Anumonwo et al., 1990). Pacemaking in the valve leaets is potentiat-
ed by treatment with adrenaline and inhibited by ACh, suggesting that
intrinsic autonomic stimulation might regulate ectopic activity in this
tissue (Wit et al., 1973; Basset et al., 1976; Wit & Craneeld, 1976;
Wit et al., 1979).
The AV rings have a distinct prole of expression of major ion
channels similar to that of the sinus and AV nodes (Table 2). In the
rat, like the sinus and AV nodes, the right AV ring and the retroaortic
node express HCN1 and HCN4, but they tend to express less (as com-
pared to atrial myocardium) Kir2.1, Nav1.5 and Cx43 at the mRNA
level (Table 2). In the rabbit and the rat, it has been shown that the
left and/or right AV rings express HCN4 and less Nav1.5 and Cx43
at the protein level (Fig. 12B; Yoo et al., 2006; Yamamoto et al.,
2006; Yanni et al., 2009a). This expression prole is consistent with
the known electrophysiology of AV ring tissue.
4.3. Clinical relevance
A number of clinical investigations have identied tachycardia foci
around the tricuspid valve annulus as well as the mitral annulus
(Fig. 12C; Morton et al., 2001; Kistler et al., 2003, 2006; Tada et al.,
2007). It is likely that the tachycardia is arising in the AV ring tissue.
The AV rings in the human heart were erroneously identied by
Kent (1913) as providing multiple pathways for AV conduction in
the normal heart. The WolffParkinsonWhite syndrome is a heart
condition in which there is pre-excitation (i.e. premature excitation)
of the ventricles (Anderson et al., 1996). The WolffParkinsonWhite
syndrome is caused by the presence of an abnormal accessory electrical
conduction pathway, which bypasses the AV node, between the atria
and the ventricles. While the majority of cases are the result of an ab-
normal tract of working myocardium connecting the atria and ventricles,
the Mahaim variant of the syndrome is the result of decremental con-
duction along an abnormal tract of nodal-like myocytes (a Kent bundle)
connecting the atria and ventricles (Anderson et al., 1996). In the case of
the Mahaim variant, the tracts of nodal-like myocytes arise in the nodes
of Kent, i.e. the AV rings (Anderson et al., 1996). The accessory pathway
may form part of a macroreentrant circuit that also involves the atri-
um, AV node and ventricle termed atrioventricular reentrant tachy-
cardia (AVRT) (Blomstrom-Lundqvist et al., 2003). There is also a
risk of sudden cardiac death associated with accessory pathways
in patients with atrial brillation (pre-excited atrial brillation)
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 279

Table 2 are separated by a large muscular ridge, the supraventricular crest

Ion channel expression in the rat at the mRNA level in the sinus node, AV node, right AV
(Anderson et al., 1977). It is the basal part of the crest that forms the
ring, retroaortic node and ventricular muscle as compared to that in the atrial muscle.
AM, atrial muscle. *, signicantly upregulated; *, signicantly downregulated; , free-standing support for the leaets of the pulmonary valve.
trend to upregulation; , trend to downregulation; =, no difference. From Atkinson et
al. (unpublished data). 5.2. Function and clinical relevance
Rat
Action Region (expression relative to atrial muscle) Over the last quarter of a century, arrhythmias arising in the
Ionic potential
Ion
channel current Phase Sinus Atrial Right AV Retroaortic Ventricular
right ventricular outow tract have acquired a degree of notoriety,
AV node
4 0 1 2 3
node muscle Ring node muscle because of their propensity to afict young patients, potentially
HCN1 /f leading to sudden cardiac death. In some patients thus aficted,
HCN4 /f the arrhythmias have a clear macroscopic anatomical basis, such
Kir2.1 /K1 as those associated with arrhythmogenic right ventricular dyspla-
/Na =
Nav1.5 sia or tetralogy of Fallot. In other patients, the arrhythmias do not
Cav3.1 /CaT = = = =
appear to be associated with overt macroscopic anatomical abnor-
Cav1.2 /CaL = = = =
Cav1.3
malities, such as those seen in Brugada syndrome, or right ventric-
/CaL

Kv1.4 /to = = = =
Kv4.2 /to = =
Kv1.5 /Kur
ERG /Kr = =
KvLQT1 /Ks = = = =
Kir3.1 /KACh
Cx40 = =
Cx43
= =
Cx45 = =
NCX1 = =
SERCA2 = =
RYR2 = =
as the rapid atrial rates in atrial brillation may be conducted to the
ventricles much more rapidly than would be permitted by the AV
node (Blomstrom-Lundqvist et al., 2003). Medical therapy for AVRT is
similar to that for AVNRT (Section 3.2.3) and includes -blockers, Ca2+
channel blockers, ecainide, propafenonoe, sotalol, dofetilide and
amiodarone (Blomstrom-Lundqvist et al., 2003). Given that both the
AV node and the accessory pathways are part of the reentry circuit, ei-
ther element can be targeted. -blockers and Ca2+ channel blockers tar-
get the AV node via ICa,L, ecainide and propafenone slow conduction
via blockade of INa and amiodarone and dofetilide prolong the refractory
period predominantly by block of IK,r and IK,s (Abernethy & Schwartz,
1999; Kodama et al., 1997a, 1997b; Zicha et al., 2006). Just as medica-
tion often fails in AVNRT, it is also often unsuccessful in AVRT and, par-
ticularly given the risk of sudden death associated with AF and an
accessory pathways, catheter ablation of the accessory pathway is the
usual rst line therapy (Blomstrom-Lundqvist et al., 2003).
5. Right ventricular outow tract:
anatomy, function and clinical relevance
The right ventricular outow tract is an intriguing region of the
heart, with an embryological development and anatomy that is unique
(see Section 2), and subsequently an electrophysiological phenotype
that contributes disproportionately to arrhythmias in the adult heart.
5.1. Anatomy
The right ventricular outow tract connects the working myocardi-
um of the right ventricle with the pulmonary trunk via the pulmonary
valve. It is grossly distinct from the left ventricular outow tract in a
number of ways. On the right side, the leaets of the pulmonary valve
are completely supported by an encircling muscular infundibulum,
whilst on the left side, two of the leaets of the aortic valve are in brous
continuity with the aortic leaet of the mitral valve (Anderson &
Weinberg, 2005). This means that the pulmonary and tricuspid valves
=
ular outow tract-VT. Brugada syndrome is a genetic arrhythmia
= syndrome linked to abnormalities in the cardiac Na + channel,
= Nav1.5 (discussed in more detail in Section 6). It is a recognised
= = cause of sudden cardiac death in patients with structurally normal
= hearts. Patients affected may have a characteristic resting ECG pat-
tern, although this may only become apparent with provocation,
= =
and so estimating its true prevalence is difcult (Antzelevitch,
=
2006). Death usually occurs due to polymorphic VT or ventricular
=
brillation (Brugada et al., 2002). The right ventricular outow
= tract is often implicated in the occurrence of these terminal ar-
= = rhythmias through a number of proposed mechanisms, including
impaired or heterogeneous repolarization (Yan & Antzelevitch,
1999; Capulzini et al., 2010), conduction delay (Meregalli et al.,
2005) or even abnormalities of embryogenesis leading to erroneous
migration of neural crest cells and consequent non-homogenous
expression of connexins (Elizari et al., 2007). Right ventricular outow
tract-VT is generally a more benign condition. It belongs to the group
of disorders known as idiopathic VTs, usually presenting between the
ages of 20 and 50 with palpitations or presyncope. Idiopathic VTs are
so-called because, when investigated fully, there are no denable ab-
normalities on clinical examination, the resting ECG, echocardiography
or coronary angiography. The advent of high resolution magnetic reso-
nance imaging (MRI) has uncovered a proportion of such cases that
would previously have been dened as idiopathic VT, which have a
clearly dened pathological process, albeit often at an early stage,
including early or limited arrhythmogenic right ventricular dysplasia.
Still more patients have focal abnormalities on MRI, including wall
thinning or abnormal wall motion, though whether these are clinically
relevant is unclear (O'Donnell et al., 2003; Capulzini et al., 2010).
There then remains a signicant population, which experiences VT
despite having a completely structurally normal heart, meaning that
the classication of idiopathic VT has remained clinically relevant. This
group of disorders accounts for as many as 10% of all newly presenting
cases of VT (Brooks & Burgess, 1988; Bunch & Day, 2006; Arya et al.,
2007), with outow tract VTs representing the largest subtype of
idiopathic VTs (Joshi & Wilber, 2005; Miller et al., 2006), and right
ventricular outow tract-VT in turn making up 8090% of this particular
subgroup (Miles, 2001; Arya et al., 2007). Unlike most forms of VT, right
ventricular outow tract-VT can be terminated with adenosine (Lerman
et al., 2002). This has led to the view that the mechanism underlying
right ventricular outow tract-VT is a triggered activity due to
cAMP-mediated intracellular Ca2+ overload and DADs (Lerman et al.,
2002). Long term therapy includes Ca2+ channel blockers which act
directly on the L type Ca2+ channel to reduce ICa,L and -blockers
which act indirectly by antagonising the increase in ICa,L due to
-adrenergic stimulation (Lerman et al., 2002).
There remains debate surrounding the group of patients who expe-
rience malignant right ventricular outow tract-VT (i.e. that which
deteriorates into ventricular brillation and ultimately death), and
risk factors for sudden cardiac death in these patients have been identi-
ed (Viskin et al., 2005) in patients at risk, catheter ablation is carried
280 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

out. Mapping studies performed during catheter ablation procedures
for right ventricular outow tract-VT have identied that the site of
origin in most cases of this condition lies in the region immediately
proximal to the leaets of the pulmonary valve, especially on the
anteromedial aspect of the right ventricular outow tract (Kamakura
et al., 1988).
It remains unclear why the right ventricular outow tract should be
so arrhythmogenic, but the answer is likely to lie with its complex
development and late transformation from primary to chamber
myocardium, leading to substantial electrophysiological heterogeneity
between itself and the adjacent working right ventricular myocardium
(Boukens et al., 2009). It has also been hypothesised that the presence
of nodal remnants in the right ventricular outow tract could be
responsible for the genesis of arrhythmias (Yanni et al., 2009a). We
have demonstrated a previously undescribed population of cells that
exist within the right ventricular outow tract of guinea-pigs and rats
that have a histological and immunohistochemical phenotype interme-
diate between nodal myocytes and myocytes from the working right
ventricular myocardium (Fig. 13; Yanni et al., 2009a). Although, like
the working myocardium, they lack expression of HCN4, like nodal
tissues, they are embedded in connective tissue and lack expression of
Nav1.5, Kir2.1 and Cx43 (Fig. 13; Monfredi et al., unpublished data).
Whilst the lack of expression of Nav1.5 and Cx43 will result in slow
conduction, the lack of expression of Kir2.1 will promote ectopic
pacemaker activity. In the rat, we have recorded nodal-like pacemaker
activity from this region (S. Logantha and H. Schneider, unpublished
observations). Could it be that these myocytes hold the key to unlocking
the arrhythmogenicity of the right ventricular outow tract?
6. Channelopathies in humans responsible
for dysfunction of the cardiac conduction system
In humans, naturally occurring mutations (inherited or acquired) in
ion channels or associated proteins are the cause of a variety of cardiac
arrhythmias, including arrhythmias arising from dysfunction of the
cardiac conduction system. Channel (or channel-related) genes, muta-
tions in which are associated with dysfunction of the cardiac conduc-
tion system, are listed in the rst part of Table 3. Mutations in other

Fig. 13. Nodal myocytes in unusual places. A, cartoon of heart showing region of interest (dashed box). B, sagittal section (from boxed region in A) through the roots of the aorta and
pulmonary artery of the guinea-pig immunolabelled for Cx43 (green signal) and NCX1 (Na+Ca2+ exchanger; red signal). Nodal-like tissues are Cx43-negative and NCX1-positive
and appear red (B). C, enlargement of the boxed region in B to show the region of the right ventricular outow tract. Modied from Yanni et al. (2009a). D, high magnication image
of Masson's trichrome stained section (corresponding to the boxed region in C) from the rat heart to show the morphology of the right ventricular outow tract infundibulum, pul-
monary valve and pulmonary artery. There is a sleeve of cardiac myocytes reaching up into the pulmonary artery corresponding to the area of Cx43-negative and NCX1-positive
cells in C. Smooth muscle cells are seen in the pulmonary artery vessel wall. From H. Schneider, O. Monfredi and H. Dobrzynski (unpublished data). Ao-lumen, lumen of the
aorta; PA-lumen, lumen of the pulmonary artery; RA, right atrium, RV-infundibulum: right ventricular infundibulum.
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288 281

Table 3
Channelopathies responsible for cardiac conduction disease in the human.

Gene Protein Electrogenic process affected Disorder Associated disorders Reference

Gene mutations
KCNJ2 Kir2.1 IK,1 Sinus bradycardia Andersen syndrome Andelnger et al. (2002)
First-degree heart block Ventricular arrhythmias
Left bundle branch block
HCN4 HCN4 If Asymptomatic to severe sinus Intermittent atrial Schulze-Bahr et al. (2003)
bradycardia brillation Ueda et al. (2004)
Syncope QT prolongation Milanesi et al. (2006)
Chronotropic incompetence Polymorphic VT Nof et al. (2007)
SCN5A Nav1.5 INa Sick sinus syndrome or dysfunction Cardiomyopathy Kyndt et al. (2001)
Sinus bradycardia Brugada syndrome Grant et al. (2002)
Sinus bradyarrhythmia Long QT syndrome Benson et al. (2003)
Sinus arrest Ventricular arrhythmias Bezzina et al. (2003)
Sinus pauses Veldkamp et al. (2003)
Chronotropic incompetence Makiyama et al. (2005)
Heart block Probst et al. (2006)
Progressive cardiac conduction system Hu et al. (2010)
disease (Lengre-Lev disease) Neu et al. (2010)
Prolonged QRS interval
Prolonged His-ventricle conduction time
Right and left bundle branch block (various forms)
SCN1B Nav1 INa Cardiac conduction disease Brugada syndrome Watanabe et al. (2008)
Heart block
Left and right bundle branch block
KCNH2 ERG IK,r Sinus bradycardia Torsade de points Hoorntje et al. (1999)
Heart block QT prolongation Piipo et al. (2000)
Long QT syndrome Johnson et al. (2003)
Neonatal long QT Lupoglazoff et al. (2004)
syndrome Chevalier et al. (2007)
Oka et al. (2010)
KCNQ1 KVLQT1 IK,s Sinus bradycardia Torsade de points Lupoglazoff et al. (2004)
Heart block QT prolongation Oka et al. (2010)
Neonatal long QT
syndrome
TRPM4 TRPM4 Ca2+-activated non-specic Progressive familial heart block Kruse et al. (2009)
cation current type I Liu et al. (2010)
Heart block Stallmeyer et al. (2012)
Right bundle branch block
RYR2 Type 2 Ca2+ clock Sinus node dysfunction CPVT Bhuiyan et al. (2007)
ryanodine receptor Sinus arrest Atrial brillation Postma et al. (2005)
Sinus node exit block
Chronotropic incompetence
Heart block

Gene mutations
CASQ2 Type 2 calsequestrin Ca2+ clock Sinus bradycardia CPVT Postma et al. (2002)
ANK2 Ankyrin-B ICa,L Sinus node dysfunction Atrial brillation Le Scouarnec et al. (2008)
INaCa Sinus bradycardia Abnormal ventricular
repolarization
Supraventricular and
ventricular
arrhythmias

Other
CACNA1C Cav1.2 ICa,L/ICa,T Sinus bradycardia Boutjdir et al. (1998)
Heart block Qu et al. (2001)
Hu et al. (2004)

genes (non-channel related) giving rise to cardiac conduction system
dysfunction are listed elsewhere (Park & Fishman, 2011). Unsurpris-
ingly, the channel (or channel-related) genes, mutations in which are
responsible for cardiac conduction system dysfunction, are the major
ones involved in the electrical activity of the cardiac conduction sys-
tem. Mutation in KCNJ2 responsible for Kir2.1 and expected to lead to
a decrease in IK,1 is responsible for Andersen syndrome, but has been as-
sociated with sinus bradycardia, heart block and left bundle branch
block in some individuals (Andelnger et al., 2002). The effects on the
two nodes is surprising, because Kir2.1 and IK,1 are responsible for the
resting potential in the working myocardium and are largely absent
from the nodes (Tables 1 and 2). However, the effects could be second-
ary or the result of the expected depolarization and loss of excitability in
the working myocardium. The effect on the bundle branches is not sur-
prising, because Purkinje bres are known to express Kir2.1 and possess
IK,1 (Section 3.3.2; Table 1). Various mutations in the HCN4 gene,
expected to lead to a decrease in the pacemaker current If, have been
shown to be responsible for sinus bradycardia (Milanesi et al., 2006;
Nof et al., 2007; Schulze-Bahr et al., 2003; Ueda et al., 2004). Many mu-
tations in the SCN5A gene encoding Nav1.5 have been discovered: these
mutations lead to cardiac conduction system dysfunction: sinus brady-
cardia, sinus node dysfunction, heart block and bundle branch block as
well as other arrhythmias (e.g. Brugada syndrome and long QT
syndrome; Table 3). The mutations in SCN5A causing cardiac conduc-
tion system dysfunction are generally loss-of-function and result in a
decrease in peak INa. The loss-of-function in INa is presumably re-
sponsible for the Brugada syndrome, which can be associated with
cardiac conduction system dysfunction. However, the mutations
causing cardiac conduction system dysfunction linked with long QT
syndrome are also gain-of-function in that they increase the late current
282 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
through Nav1.5 (Grant et al., 2002; Veldkamp et al., 2003). A loss of
function mutation in a Na + channel auxiliary subunit, Nav1, also
causes heart block and bundle branch block (Watanabe et al., 2008).
In new born infants, neonatal long QT syndrome can be associated
with sinus bradycardia and/or second degree heart block and these
cases have been attributed to mutations in KCNH2 (ERG) and KCNQ1
(KvLQT1), responsible for IK,r and IK,s, respectively (Hoorntje et al.,
1999; Piipo et al., 2000; Johnson et al., 2003; Lupoglazoff et al., 2004).
In the case of IK,r at least, one of the ERG mutations is expected to
cause a decrease in IK,r, one has been shown to cause a decrease in IK,r
and another has been shown to alter the kinetics of IK,r (Hoorntje et
al., 1999; Piipo et al., 2000; Johnson et al., 2003). Mutations in KCNH2
(ERG) and KCNQ1 (KvLQT1) demonstrated to result in decreases in IK,r
and IK,s have also been shown to be responsible for heart block associat-
ed with long QT syndrome in adults (Chevalier et al., 2007; Oka et al.,
2010). In the two nodes (in the absence of IK,1) IK,r and IK,s are responsi-
ble for the maximum diastolic potential (Fig. 6) and a decrease in either
current is expected to result in depolarization and inexcitability
(Kodama et al., 1999). Mutations in TRPM4, responsible for a
Ca 2+-activated non-specic cation current, have been linked to
heart block and right bundle branch block (Kruse et al., 2009; Liu
et al., 2010; Stallmeyer et al., 2012). A number of the mutations
have been shown to be gain-of-function and increase the current
(Kruse et al., 2009; Liu et al., 2010). How TRPM4 acts is not known.
It is no surprise that mutations in components of the Ca 2+ clock also
have functional consequences for the cardiac conduction system. Muta-
tions in RYR2 (SR Ca2+ release channel) and CASQ2 (calsequestrin SR
Ca2+ storage protein) cause catecholaminergic polymorphic ventricular
tachycardia (CPVT) and this can be associated with sinus bradycardia
and heart block (Table 3; Postma et al., 2002, 2005; Bhuiyan et al.,
2007); RYR2 and CASQ2 mutations are likely to affect the Ca 2+ clock
and, therefore, it is understandable that the mutations should cause
sinus bradycardia. However, why it should cause heart block is un-
known. Interestingly in a mouse model of CPVT, there is evidence that
intracellular Ca2+ handling in Purkinje myocytes is more profoundly
affected than in ventricular myocytes and ventricular arrhythmias
arise in the Purkinje myocytes (Kang et al., 2010). Mutation in ANK2
has been shown to cause severe bradycardia (Table 3; Le Scouarnec et
al., 2008). ANK2 is responsible for ankyrin-B. Ankyrins are adaptor pro-
teins responsible for targeting channels and transporters in various cell
types. Ankyrin-B is enriched in the sinus node and heterozygous knock-
out of ankyrin-B in the mouse: disrupts cell membrane targetting of
Cav1.3 (in part responsible for ICa,L in the sinus node), NCX1 (responsi-
ble for the Na+Ca2+ exchanger), the Na+K + pump and the IP3 recep-
tor; reduces ICa,L and INaCa; disrupts intracellular Ca2+ homeostasis; and
causes bradycardia (Table 3; Le Scouarnec et al., 2008; Hund & Mohler,
2008).
Boutjdir and colleagues (Boutjdir et al., 1998; Qu et al., 2001; Hu et
al., 2004) have obtained evidence that the mothers of children born
with congenital heart block (presumably, one type of congenital
heart block, at least, because there are other causes of congenital
heart block as shown in Table 3) produce IgG autoantibodies which
enter the foetal circulation and reduce ICa,T and ICa,L. This can be
described as a channelopathy, although it is not the normal kind and
it is listed separately in Table 3. A reduction in ICa,T at least is expected
to result in heart block: knock-out of Cav3.1 in the mouse causes a
slowing of AV conduction (Mangoni et al., 2006). Knock-out of both
Cav1.3 and Cav3.1 in the mouse also causes sinus bradycardia
(Mangoni et al., 2003, 2006).
7. Conclusions
Over the last few decades, as well as developing a greater under-
standing of the embryonic development and anatomy of the cardiac
conduction system, we have learnt much about the cardiac conduc-
tion system at the molecular level, from the transcription factors
determining its embryological development to the ion channels
and related proteins underlying its electrical activity. Clinically, a
picture is emerging of dysfunction of the cardiac conduction system
in various disease states, such as heart failure and atrial brillation,
and we are uncovering the remodelling of the cardiac conduction
system in the disease states that is responsible for the dysfunction.
This raises the possibility of designing new treatments for sinus
bradycardia, heart block and bundle branch block etc. in the future.
Conict of Interest
The authors declare that there are no conicts of interests.
References
Aanhaanen, W. T., Brons, J. F., Domnguez, J. N., Rana, M. S., Norden, J., Airik, R., et al. (2009).
The Tbx2+ primary myocardium of the atrioventricular canal forms the atrioventricular
node and the base of the left ventricle. Circ Res 104, 12671274.
Abernethy, D. R., & Schwartz, J. B. (1999). Calcium-antagonist drugs. N Engl J Med 341,
14471457.
Abi-Gerges, N., Small, B. G., Lawrence, C. L., Hammond, T. G., Valentin, J. P., & Pollard, C. E.
(2004). Evidence for gender differences in electrophysiological properties of canine
Purkinje bres. Br J Pharmacol 142, 12551264.
Abi-Gerges, N., Small, B. G., Lawrence, C. L., Hammond, T. G., Valentin, J. P., & Pollard, C. E.
(2006). Gender differences in the slow delayed (IKs) but not in inward (IK1) rectier
K+ currents of canine Purkinje bre cardiac action potential: key roles for IKs,
beta-adrenoceptor stimulation, pacing rate and gender. Br J Pharmacol 147, 653660.
Adan, V., & Crown, L. A. (2003). Diagnosis and treatment of sick sinus syndrome. Am
Fam Physician 67, 17251732.
Ailings, A. M., Abbas, R. F., & Bouman, L. N. (1995). Age-related changes in structure and
relative collagen content of the human and feline sinoatrial node. A comparative
study. Eur Heart J 16, 16551667.
Amerini, S., Giotti, A., & Mugelli, A. (1985). Effect of verapamil and diltiazem on
calcium-dependent electrical activity in cardiac Purkinje bres. Br J Pharmacol 85,
8996.
Andelnger, G., Tapper, A. R., Welch, R. C., Vanoye, C. G., George, A. L., Jr., & Benson, D. W.
(2002). KCNJ2 mutation results in Andersen syndrome with sex-specic cardiac and
skeletal muscle phenotypes. Am J Hum Genet 71, 663668.
Anderson, R. H., Becker, A. E., & Van Mierop, L. H. (1977). What should we call the crista? Br
Heart J 39, 856859.
Anderson, R. H., Davies, M. J., & Becker, A. E. (1974a). Atrioventricular ring specialized
tissue in the normal heart. Eur J Cardiol 2, 219230.
Anderson, R. H., Janse, M. J., van Capelle, F. J., Billette, J., Becker, A. E., & Durrer, D. (1974b).
A combined morphological and electrophysiological study of the atrioventricular
node of the rabbit heart. Circ Res 35, 909922.
Anderson, R. H., & Ho, S. Y. (2003). The morphology of the cardiac conduction system.
Novartis Found Symp 250, 617.
Anderson, R. H., Ho, S. Y., & Becker, A. E. (2000). Anatomy of the human atrioventricular
junctions revisited. Anat Rec 260, 8191.
Anderson, R. H., Ho, S. Y., Gillette, P. C., & Becker, A. E. (1996). Mahaim, Kent and abnormal
atrioventricular conduction. Cardiovasc Res 31, 480491.
Anderson, R. H., & Weinberg, P. M. (2005). The clinical anatomy of tetralogy of fallot.
Cardiol Young 1, 3847 (Supplement).
Anderson, R. H., Yanni, J., Boyett, M. R., Chandler, N. J., & Dobrzynski, H. (2009). The
anatomy of the cardiac conduction system. Clin Anat 22, 99113.
Ansari, A., Ho, S. Y., & Anderson, R. H. (1999). Distribution of the Purkinje bres in the
sheep heart. Anat Rec (Hoboken) 254, 9297.
Antzelevitch, C. (2006). Brugada syndrome. Pacing Clin Electrophysiol 9, 11301159.
Anumonwo, J. M., Delmar, M., & Jalife, J. (1990). Electrophysiology of single heart cells
from the rabbit tricuspid valve. J Physiol 425, 145167.
Anumonwo, J. M., Tallini, Y. N., Vetter, F. J., & Jalife, J. (2001). Action potential characteristics
and arrhythmogenic properties of the cardiac conduction system of the murine heart.
Circ Res 89, 329335.
Arnar, D. O., Bullinga, J. R., & Martins, J. B. (1997). Role of the Purkinje system in spontaneous
ventricular tachycardia during acute ischemia in a canine model. Circulation 96,
24212429.
Arya, A., Piorkowski, C., Sommer, P., Gerds-Li, J. -H., Kottkamp, H., & Hindricks, G. (2007).
Idiopathic outow tract tachycardias: Current perspectives. Herz 32, 218225.
Aslanidi, O. V., Colman, M. A., Stott, J., Dobrzynski, H., Boyett, M. R., Holden, A. V., et al.
(2011). 3D virtual human atria: A computational platform for studying clinical
atrial brillation. Prog Biophys Mol Biol 107, 156168.
Aslanidi, O. V., Sleiman, R. N., Boyett, M. R., Hancox, J. C., & Zhang, H. (2010). Ionic mecha-
nisms for electrical heterogeneity between rabbit Purkinje ber and ventricular cells.
Biophys J 98, 24202431.
Atkinson, A., Inada, S., Li, J., Tellez, J. O., Yanni, J., Sleiman, R., et al. (2011). Anatomical
and molecular mapping of the left and right ventricular HisPurkinje conduction
networks. J Mol Cell Cardiol 51, 689701.
Balasundaram, R., Rao, H. B., Kalavakolanu, S., & Narasimhan, C. (2008). Catheter ablation
of bundle branch reentrant ventricular tachycardia. Hear Rhythm 5, S68S72.
Balti, B., Lost, N., Simon, J., Varr, A., & Papp, J. G. (2000). Analysis of the electrophysio-
logical effects of ambasilide, a new antiarrhythmic agent, in canine isolated ventric-
ular muscle and purkinje bers. Gen Pharmacol 34, 8593.
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
Baldesberger, S., Bauersfeld, U., Candinas, R., Seifert, B., Zuber, M., Ritter, M., et al.
(2008). Sinus node disease and arrhythmias in the long-term follow-up of former
professional cyclists. Eur Heart J 29, 7178.
Barbosky, L., Lawrence, D. K., Karunamuni, G., Wikenheiser, J. C., Doughman, Y. Q.,
Visconti, R. P., et al. (2006). Apoptosis in the developing mouse heart. Dev Dyn
235, 25922602.
Baruscotti, M., Bucchi, A., Viscomi, C., Mandelli, G., Consalez, G., Gnecchi-Rusconi, T., et al.
(2011). Deep bradycardia and heart block caused by inducible cardiac-specic knock-
out of the pacemaker channel gene Hcn4. Proc Natl Acad Sci U S A 108, 17051710.
Basset, A. L., Fenoglio, J. J., Jr., Wit, A. L., Myerburg, R. J., & Gelband, H. (1976).
Eelctrophysiologic and ultrastructural characteristics of the canine tricuspid valve.
Am J Physiol 230, 13661373.
Bauer, A., McDonald, A. D., Nasir, K., Peller, L., Rade, J. J., Miller, J. M., et al. (2004). Inhibitory
G protein overexpression provides physiologically relevant heart rate control in persis-
tent atrial brillation. Circulation 110, 31153120.
Ben, Caref E., Boutjdir, M., Himel, H. D., & El-Sherif, N. (2008). Role of subendocardial
Purkinje network in triggering torsade de pointes arrhythmia in experimental
long QT syndrome. Europace 10, 12181223.
Benditt, D. G., Sakaguchi, S., Goldstein, M. A., Lurie, K. G., Gornick, C. C., & Adler, S. W.
(1995). Sinus node dysfunction: pathophysiology, clinical features, evaluation,
and treatment. In D. P. Zipes, & J. Jalife (Eds.), Cardiac electrophysiology: from cell
to bedside (pp. 12151247). Philadelphia, Pa: WB Saunders Company.
Benson, D. W., Wang, D. W., Dyment, M., Knilans, T. K., Fish, F. A., Strieper, M. J., et al.
(2003). Congenital sick sinus syndrome caused by recessive mutations in the cardiac
sodium channel gene (SCN5A). J Clin Invest 112, 10191028.
Berenfeld, O., & Jalife, J. (1988). Purkinje-muscle reentry as a mechanism of polymorphic
ventricular arrhythmias in a 3-dimensional model of the ventricles. Circ Res 82,
10631077.
Bezzina, C. R., Rook, M. B., Groenewegen, W. A., Herfst, L. J., van der Wal, A. C., Lam, J.,
et al. (2003). Compound heterozygosity for mutations (W156X and R225W) in
SCN5A associated with severe cardiac conduction disturbances and degenerative
changes in the conduction system. Circ Res 92, 159168.
Bhuiyan, Z. A., van den Berg, M. P., van Tintelen, J. P., Bink-Boelkens, M. T., Wiesfeld, A.
C., Alders, M., et al. (2007). Expanding spectrum of human RYR2-related disease:
new electrocardiographic, structural, and genetic features. Circulation 116,
15691576.
Billette, J. (1987). Atrioventricular nodal activation during periodic premature stimula-
tion of the atrium. Am J Physiol 252, H163H177.
Blomstrom-Lundqvist, C., Scheinman, M. M., Aliot, E. M., Alpert, J. S., Calkins, H., Camm,
A. J., et al. (2003). ACC/AHA/ESC guidelines for the management of patients with
supraventricular arrhythmias-executive summary: a report of the American Col-
lege of Cardiology/American Heart Association Task Force on Practice Guidelines
and the European Society of Cardiology Committee for Practice Guidelines (Writ-
ing Committee to Develop Guidelines for the Management of Patients With Supra-
ventricular Arrhythmias). Circulation 108, 18711909.
Bogdanov, K. Y., Vinogradova, T. M., & Lakatta, E. G. (2001). Sinoatrial nodal cell ryanodine
receptor and Na+-Ca2+ exchanger: molecular partners in pacemaker regulation. Circ
Res 88, 12541258.
Bohm, M., Swedberg, K., Komajda, M., Borer, J. S., Ford, I., Dubost-Brama, A., et al. (2010).
Heart rate as a risk factor in chronic heart failure (SHIFT): the association between
heart rate and outcomes in a randomised placebo-controlled trial. Lancet 376,
886894.
Boineau, J. P., Canavan, T. E., Schuessler, R. B., Cain, M. E., Corr, P. B., & Cox, J. L. (1988).
Demonstration of a widely distributed atrial pacemaker complex in the human
heart. Circulation 77, 12211237.
Boink, G. J., Bakker, M. L., Verkerk, A. O., Bakker, D., de Bakker, J. M., Seppen, J., et al. (2008).
Inducible TBX3 overexpression as a tool for biopacemaker engineering. Circulation 118,
S340.
Boukens, B. J., Christoffels, V. M., Coronel, R., & Moorman, A. F. (2009). Developmental basis
for electrophysiological heterogeneity in the ventricular and outow tract myocardium
as a substrate for life-threatening ventricular arrhythmias. Circ Res 104, 1931.
Boutjdir, M., Chen, L., Zhang, Z. H., Tseng, C. E., El-Sherif, N., & Buyon, J. P. (1998). Serum
and antibody IgG from the mother of a child with congenital heart block induce
conduction abnormalites and inhibit L-type Ca channels in a rat heart model.
Pediatr Res 44, 1119.
Boyden, P. A., Dun, W., Barbhaiya, C., & Ter Keurs, H. E. (2004). 2APB- and
JTV519(K201)-sensitive micro Ca2+ waves in arrhythmogenic Purkinje cells that
survive in infarcted canine heart. Hear Rhythm 1, 218226.
Boyden, P. A., Pu, J., Pinto, J., & ter Keurs, H. E. (2000). Ca2+ transients and Ca2+ waves
in purkinje cells: role in action potential initiation. Circ Res 86, 448455.
Boyden, P. A., Barbhaiya, C., Lee, T., & ter Keurs, H. E. (2003). Nonuniform Ca2+ transients
in arrhythmogenic Purkinje cells that survive in the infarcted canine heart.
Cardiovasc Res 57, 681693.
Boyden, P. A., Albala, A., & Dresdner, K. P., Jr. (1989). Electrophysiology and ultrastructure
of canine subendocardial Purkinje cells isolated from control and 24-hour infarcted
hearts. Circ Res 65, 955970.
Boyett, M. R., Honjo, H., & Kodama, I. (2000). The sinoatrial node, a heterogeneous
pacemaker structure. Cardiovasc Res 47, 658687.
Boyett, M. R., Honjo, H., Yamamoto, M., Nikmaram, M. R., Niwa, R., & Kodama, I. (1999).
Downward gradient in action potential duration along the conduction path in and
around the sinoatrial node. Am J Physiol 276, H686H698.
Boyett, M. R., Inada, S., Yoo, S., Li, J., Liu, J., Tellez, J., et al. (2006). Connexins in the sinoatrial
and atrioventricular nodes. Adv Cardiol 42, 175197.
Boyett, M. R., Tellez, J. O., & Dobrzynski, H. (2009). The sinoatrial node its complex
structure and unique ion channel gene programme. In D. P. Zipes, & J. Jalife
(Eds.), Cardiac electrophysiology: from cell to bedside (5th ed.). (pp.x-x).
283
Boyett, M. R., Hart, G., Levi, A. J., & Roberts, A. (1987). Effects of repetitive activity on
developed force and intracellular sodium in isolated sheep and dog Purkinje bres.
J Physiol 388, 295322.
Boyett, M. R., & Fedida, D. (1984). Changes in the electrical activity of dog cardiac
Purkinje bres at high heart rates. J Physiol 350, 361391.
Bromberg, B. I., Hand, D. E., Schuessler, R. B., & Boineau, J. P. (1995). Primary negativity does
not predict dominant pacemaker location: implications for sinoatrial conduction. Am J
Physiol 269, H877H887.
Brooks, R., & Burgess, J. H. (1988). Idiopathic ventricular tachycardia. Medicine 67, 71294.
Brugada, J., Brugada, R., Antzelevitch, C., Towbin, J., Nademanee, K., & Brugada, P.
(2002). Long-term follow-up of individuals with the electrocardiographic pattern
of right bundle-branch block and st-segment elevation in precordial leads v1 to
v3. Circulation 105, 7378.
Bucchi, A., Tognati, A., Milanesi, R., Baruscotti, M., & DiFrancesco, D. (2006). Properties
of ivabradine-induced block of HCN1 and HCN4 pacemaker channels. J Physiol 572,
335346.
Bunch, T. J., & Day, J. D. (2006). Right meets left: A common mechanism underlying
right and left ventricular outow tract tachycardias. J Cardiovasc Electrophysiol
17, 10591061.
Cai, C. L., Liang, X., Shi, Y., Chu, P. H., Pfaff, S. L., Chen, J., et al. (2003). Isl1 identies a cardiac
progenitor population that proliferates prior to differentiation and contributes a major-
ity of cells to the heart. Dev Cell 5, 877889.
Callewaert, G., Carmeliet, E., & Vereecke, J. (1984). Single cardiac Purkinje cells: general
electrophysiology and voltage-clamp analysis of the pace-maker current. J Physiol
349, 643661.
Champeroux, P., Ouill, A., Martel, E., Fowler, J. S., Maurin, A., Richard, S., et al. (2011). A
step towards characterisation of electrophysiological prole of torsadogenic drugs.
J Pharmacol Toxicol Methods 63, 269278.
Chandler, N., Aslanidi, O., Buckley, D., Inada, S., Birchall, S., Atkinson, A., et al. (2011). A
new twist in the origin of the heartbeat. Anat Rec (Hoboken) 294, 970979.
Chandler, N. J., Greener, I. D., Tellez, J. O., Inada, S., Musa, H., Molenaar, P., et al. (2009).
Molecular architecture of the human sinus node: insights into the function of the
cardiac pacemaker. Circulation 119, 15621575.
Capulzini, L., Brugada, P., Brugada, J., & Brugada, R. (2010). Arrhythmia and right heart dis-
ease: From genetic basis to clinical practice. Rev Esp Cardiol 63, 963983.
Ceconi, C., Comini, L., Suffredini, S., Stillitano, F., Bouly, M., Cerbai, E., et al. (2011). Heart rate
reduction with ivabradine prevents the global phenotype of left ventricular remodeling.
Am J Physiol 300, H366H373.
Cheng, H., Smith, G. L., Hancox, J. C., & Orchard, C. H. (2011). Inhibition of spontaneous
activity of rabbit atrioventricular node cells by KB-R7943 and inhibitors of sarcoplasmic
reticulum Ca(2+) ATPase. Cell Calcium 49, 5665.
Chen, Y. -J., Chen, Y. C., Yeh, H. I., Lin, C. I., & Chen, S. A. (2002). Electrophysiology and
arrhythmogenic activity of single cardiomyocytes from canine superior vena cava.
Circulation 105, 26792685.
Cerbai, E., Barbieri, M., & Mugelli, A. (1994). Characterization of the hyperpolarization-
activated current, If, in ventricular myocytes isolated from hypertensive rats. J Physiol
481, 585591.
Cerbai, E., Barbieri, M., & Mugelli, A. (1996). Occurrence and properties of the
hyperpolarization-activated current If in ventricular myocytes from normotensive
and hypertensive rats during aging. Circulation 94, 16741681.
Cerbai, E., & Mugelli, A. (2006). If in non-pacemaker cells: Role and pharmacological
implications. Pharmacol Res 53, 416423.
Cerbai, E., Sartiani, L., DePaoli, P., Pino, R., Maccherini, M., Bizzarri, F., et al. (2001). The
properties of the pacemaker current If in human ventricular myocytes are modulated
by cardiac disease. J Mol Cell Cardiol 33, 441448.
Chevalier, P., Bellocq, C., Millat, G., Piqueras, E., Potet, F., Schott, J. J., et al. (2007). Torsades
de pointes complicating atrioventricular block: Evidence for a genetic predisposition.
Hear Rhythm 4, 170174.
Kapoor, N., Marbn, E., & Cho, H. C. (2011a). Tbx18-reprogrammed cardiomyocytes exhibit
pacemaker phenotype with upregulated calcium and voltage-sependent clock mecha-
nisms. Circulation 124, A14024.
Kapoor, N., Marbn, E., & Cho, H. C. (2011b). Biological pacemaker induced in vivo by focal
Tbx18 gene transfer in the guinea-pig left ventricle. Circulation 124, A15845 (2011).
Chen, P. S., Joung, B., Shinohara, T., Das, M., Chen, Z., & Lin, S. F. (2010). The initiation of
the heart beat. Circulation 74, 221225.
Coppen, S. R., Kodama, I., Boyett, M. R., Dobrzynski, H., Takagishi, Y., Honjo, H., et al. (1999a).
Connexin45, a major connexin of the rabbit sinoatrial node, is co-expressed with
connexin43 in a restricted zone at the nodal-crista terminalis border. J Histochem
Cytochem 47, 907918.
Coppen, S. R., Severs, N. J., & Gourdie, R. G. (1999b). Connexin45 (alpha 6) expression
delineates an extended conduction system in the embryonic and mature rodent
heart. J Gene Dev 24, 8290.
Coppen, S. R., & Severs, N. J. (2002). Diversity of connexin expression patterns in the
atrioventricular node: vestigial consequence or functional specialization? J
Cardiovasc Electrophysiol 13, 625626.
Cordeiro, J. M., Bridge, J. H., & Spitzer, K. W. (2001a). Early and delayed afterdepolarizations
in rabbit heart Purkinje cells viewed by confocal microscopy. Cell Calcium 29, 289297.
Cordeiro, J. M., Spitzer, K. W., & Giles, W. R. (1998). Repolarizing K+ currents in rabbit
heart Purkinje cells. J Physiol 508, 811823.
Cordeiro, J. M., Spitzer, K. W., Giles, W. R., Ershler, P. E., Cannell, M. B., & Bridge, J. H.
(2001b). Location of the initiation site of calcium transients and sparks in rabbit
heart Purkinje cells. J Physiol 531, 301314.
Cosio, F. G., Anderson, R. H., Becker, A., Borggrefe, M., Campbell, R. W., Gaita, F., et al.
(1999). Living anatomy of the atrioventricular junctions. A guide to electrophysiolog-
ical mapping. A Consensus Statement from the Cardiac Nomenclature Study Group,
Working Group of Arrythmias, European Society of Cardiology, and the Task Force
284 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
on Cardiac Nomenclature from NASPE. North American Society of Pacing and Electro-
physiology. Eur Heart J 20, 10681075.
Courtemanche, M., Ramirez, R. J., & Nattel, S. (1998). Ionic mechanisms underlying
human atrial action potential properties: insights from a mathematical model.
Am J Physiol 275, H301H321.
Crijns, H. J., Smeets, J. L., Rodriguez, L. M., Meijer, A., & Wellens, H. J. (1995). Cure of
interfascicular reentrant ventricular tachycardia by ablation of the anterior fascicle
of the left bundle branch. J Cardiovasc Electrophysiol 6, 486492.
Christoffels, V. M., Burch, J. B., & Moorman, A. F. (2004). Architectural plan for the heart:
Early patterning and delineation of the chambers and the nodes. Trends Cardiovasc
Med 14, 301307.
Christoffels, V. M., Smits, G. J., Kispert, A., & Moorman, A. F. M. (2010). Development of
the pacemaker tissues of the heart. Circ Res 106, 240254.
Crisel, R. K., Farazneh-Far, R., Na, B., & Whooley, M. A. (2011). First-degree atrioventricular
block is associated with heart failure and death in persons with stable coronary artery
disease: data from the Heart and Soul Study. Eur Heart J 32, 18751880.
Dangman, K. H., & Miura, D. S. (1987). Does if control normal automatic rate in canine
cardiac Purkinje bers? Studies on the negative chronotropic effects of lidoazine.
J Cardiovasc Pharmacol 10, 332340.
Davis, D. L., Edwards, A. V., Juraszek, A. L., Phelps, A., Wessels, A., & Burch, J. B. (2001). A gata-6
gene heart-region-specic enhancer provides a novel means to mark and probe a dis-
crete component of the mouse cardiac conduction system. Mech Dev 108, 105119.
Davis, L. D., & Temte, J. V. (1969). Electrophysiological actions of lidocaine on canine
ventricular muscle and Purkinje bers. Circ Res 24, 639655.
deCarvalho, A. P., De Mello, W. C., & Hoffman, B. F. (1959). Electrophysiological evi-
dence for specialized ber types in rabbit atrium. Am J Physiol 196, 483488.
Demion, M., Bois, P., Launay, P., & Guinamard, R. (2007). TRPM4, a Ca2+-activated
nonselective cation channel in mouse sino-atrial node cells. Cardiovasc Res 73,
531538.
DeMelo, S. R., DeSouza, R. R., & Mandarim-de-Lacerda, C. A. (2002). Stereologic study of
the sinoatrial node of rats age related changes. Biogerontology 3, 383390.
Den Haan, D., Verkerk, A. O., & Tan, H. L. (2011). Creation of a biopacemaker: lessons
from the sinoatrial node. In M. K. Das (Ed.), Modern pacemakers-present and future
(pp. 495524). : Intech.
Dersham, G. H., & Han, J. (1980). Effects of verapamil on action potentials of Purkinje
bers. J Electrocardiol 13, 6772.
Desplantez, T., Dupont, E., Severs, N. J., & Weingart, R. (2007). Gap junction channels
and cardiac impulse propagation. J Membr Biol 18, 1328.
DiFrancesco, D. (1981a). A new interpretation of the pace-maker current in calf
Purkinje bres. J Physiol 314, 359376.
DiFrancesco, D. (1981b). A study of the ionic nature of the pace-maker current in calf
Purkinje bres. J Physiol 314, 377393.
DiFrancesco, D., & Noble, D. (2012). Rebuttal: The funny current in the context of the
coupled clock pacemaker cell system. Hear Rhythm 9, 457458.
Dobrzynski, H., Boyett, M. R., & Anderson, R. H. (2007). New insights into pacemaker ac-
tivity: promoting understanding of sick sinus syndrome. Circulation 115, 19211932.
Dobrzynski, H., Li, J., Tellez, J., Greener, I. D., Nikolski, V. P., Wright, S. E., et al. (2005).
Computer three-dimensional reconstruction of the sinoatrial node. Circulation
111, 846854.
Dobrzynski, H., Nikolski, V. P., Sambelashvili, A. T., Greener, I. D., Yamamoto, M., Boyett, M.
R., et al. (2003). Site of origin and molecular substrate of atrioventricular junctional
rhythm in the rabbit heart. Circ Res 93, 11021110.
Dun, W., & Boyden, P. A. (2008). The Purkinje cell; 2008 style. J Mol Cell Cardiol 45,
617624.
Edelberg, J. M., Aird, W. C., & Rosenberg, R. D. (1998). Enhancement of murine cardiac
chronotropy by the molecular transfer of the human beta2 adrenergic receptor
cDNA. J Clin Invest 101, 337343.
Elizari, M. V., Levi, R., Acunzo, R. S., Chiale, P. A., Civetta, M. M., Ferreiro, M., et al.
(2007). Abnormal expression of cardiac neural crest cells in heart development:
A different hypothesis for the etiopathogenesis of brugada syndrome. Hear
Rhythm 4, 359365.
Elvan, A., Wylie, K., & Zipes, D. P. (1996). Pacing-induced chronic atrial brillation impairs
sinus node function in dogs. Electrophysiological remodeling. Circulation 94, 29532960.
Eriksson, P., Hansson, P. O., Eriksson, H., & Dellborg, M. (1998). Bundle-branch block in
a general male population: the study of men born 1913. Circulation 98, 24942500.
Faggiano, P., d'Aloia, A., Gualeni, A., Gardini, A., & Giordano, A. (2001). Mechanisms and
immediate outcome of in-hospital cardiac arrest in patients with advanced heart
failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 87,
655657.
Fedorov, V. V., Glukhov, A. V., Chang, R., Kostecki, G., Aferol, H. A., Hucker, W. J., et al.
(2010). Optical mapping of the isolated coronary-perfused human sinus node. J
Am Coll Cardiol 56, 13861394.
Fedorov, V. V., Glukhov, A. V., & Chang, R. (2012). Conduction barriers and pathways of the
sino-atrial pacemaker complex: their role in normal rhythm and atrial arrhythmias. Am
J Physiol 302, H1773H1783.
Fedorov, V. V., Schuessler, R. B., Hemphill, M., Ambrosi, C. M., Chang, R., Voloshina, A. S.,
et al. (2009). Structural and functional evidence for discrete exit pathways that
connect the canine sinoatrial node and atria. Circ Res 104, 915923.
Ferrier, G. R., Saunders, J. H., & Mendez, C. (1973). A cellular mechanism for the generation
of ventricular arrhythmias by acetylstrophanthidin. Circ Res 32, 600609.
Fox, K., Ford, I., Steg, P. G., Tendera, M., & Ferrari, R. (2008). Ivabradine for patients with
stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL):
a randomised, double-blind, placebo-controlled trial. Lancet 372, 807816.
Froese, A., Breher, S. S., Waldeyer, C., Schindler, R. F., Nikolaev, V. O., Rinn, S., et al. (2012).
Popeye domain containing proteins are essential for stress-mediated modulation of
cardiac pacemaking in mice. J Clin Invest 122, 11191130.
Gaborit, N., Le Bouter, S., Szuts, V., Varro, A., Escande, D., Nattel, S., et al. (2007). Regional
and tissue specic transcript signatures of ion channel genes in the non-diseased
human heart. J Physiol 582, 675693.
Gadsby, D. C., & Craneeld, P. F. (1977). Two levels of resting potential in cardiac Purkinje
bers. J Gen Physiol 70, 725746.
Gervais, R., Leclercq, C., Shankar, A., Jacobs, S., Eiskjaer, H., Johannessen, A., et al. (2009). Sur-
face electrocardiogram to predict outcome in candidates for cardiac resynchronization
therapy: a sub-analysis of the CARE-HF trial. Eur J Heart Fail 11, 699705.
Gilmour, R. F., Jr., & Watanabe, M. (1994). Dynamics of circus movement re-entry
across canine Purkinje bre-muscle junctions. J Physiol 476, 473485.
Gourdie, R. G., Severs, N. J., Green, C. R., Rothery, S., Germroth, P., & Thompson, R. P.
(1993). The spatial distribution and relative abundance of gap-junctional
connexin40 and connexin43 correlate to functional properties of components of
the cardiac atrioventricular conduction system. J Cell Sci 105, 985991.
Grant, A. O., Carboni, M. P., Neplioueva, V., Starmer, C. F., Memmi, M., Napolitano, C., et al.
(2002). Long QT syndrome, Brugada syndrome, and conduction system disease
linked to a single sodium channel mutation. J Clin Invest 110, 12011209.
Greener, I. D., Monfredi, O., Inada, S., Chandler, N. J., Tellez, J. O., Atkinson, A., et al. (2011).
Molecular architecture of the human specialised atrioventricular conduction axis.
J Mol Cell Cardiol 50, 642651.
Greener, I. D., Tellez, J. O., Dobrzynski, H., Yamamoto, M., Graham, G. M., Billeter, R., et al.
(2009). Ion channel transcript expression at the rabbit atrioventricular conduction
axis. Circ Arrhythm Electrophysiol 2, 305315.
Grines, C. L., Bashore, T. M., Boudoulas, H., Olson, S., Shafer, P., & Wooley, C. F. (1989). Func-
tional abnormalities in isolated left bundle branch block. The effect of interventricular
asynchrony. Circulation 79, 845853.
Gupta, A., Lawrence, A. T., Krishnan, K., Kavinsky, C. J., & Trohman, R. G. (2007). Current
concepts in the mechanisms and management of drug-induced QT prolongation
and torsade de pointes. Am Heart J 153, 891899.
Hassaguerre, M., Shah, D. C., Jas, P., Shoda, M., Kautzner, J., Arentz, T., et al. (2002).
Role of Purkinje conducting system in triggering of idiopathic ventricular brilla-
tion. Lancet 359, 677688.
Hancox, J. C., & Levi, A. J. (1994). L-type calcium current in rod- and spindle-shaped
myocytes isolated from rabbit atrioventricular node. Am J Physiol 267, H1670H1680.
Hancox, J. C., Yuill, K. H., Mitcheson, J. S., & Convery, M. K. (2003). Progress and gaps in un-
derstanding the electrophysiological properties of morphologically normal cells from
the cardiac atrioventricular node. Int J Bifurcation Chaos 13, 36753691.
Hao, X. Z. Y., Zhang, X., Nirmalan, M., Davies, L., Dobrzynski, H., Wang, X., et al. (2011).
TGF-1 mediated brosis and ion channel remodeling are key mechanisms producing
sinus node dysfunction associated with SCN5A deciency and aging. Circ Arrhythm
Electrophysiol 2011(4), 397406.
Hart, G., & Dukes, I. D. (1984). An analysis of the rate-dependent action of
lidoazine in mammalian sino-atrial node and Purkinje bres. J Mol Cell Cardiol
16, 3342.
Himeno, Y., Toyoda, F., Satoh, H., Amano, A., Cha, C. Y., Matsuura, H., et al. (2011). Minor
contribution of cytosolic Ca2+ transients to the pacemaker rhythm in guinea pig
sinoatrial node cells. Am J Physiol Heart Circ Physiol 300, H251H261.
Hirata, Y., Kodama, I., Iwamura, N., Shimizu, T., Toyama, J., & Yamada, K. (1979). Effects of
verapamil on canine Purkinje bres and ventricular muscle bres with particular
reference to the alternation of action potential duration after a sudden increase in
driving rate. Cardiovasc Res 13, 18.
Hoff, P. I., Tronstad, A., Oie, B., & Ohm, O. J. (1988). Electrophysiologic and clinical effects
of ecainide for recurrent paroxysmal supraventricular tachycardia. Am J Cardiol 62,
585589.
Honjo, H., Boyett, M. R., Kodama, I., & Toyama, J. (1996). Correlation between electrical
activity and the size of rabbit sinoatrial node cells. J Physiol 496, 795808.
Hoogaars, W. M., Engel, A., Brons, J. F., Verkerk, A. O., de Lange, F. J., Wong, L. Y., et al.
(2007). Tbx3 Controls the Sinoatrial Node Gene Program and Imposes Pacemaker
Function on the Atria. Genes Dev 21, 10981112.
Hoogaars, W. M., Tessari, A., Moorman, A. F., de Boer, P. A., Hagoort, J., Soufan, A. T., et al.
(2004). The Transcriptional Repressor Tbx3 Delineates the Developing Central
Conduction System of the Heart. Cardiovasc Res 62, 489499.
Hoorntje, T., Alders, M., van Tintelen, P., van der Lip, K., Sreeram, N., van der Wal, A.,
et al. (1999). Homozygous premature truncation of the HERG protein: the
human HERG knockout. Circulation 100, 12641267.
Horibe, H. (1961). Studies on the spread of the right atrial activation by means of intracel-
lular microelectrode. Jpn Circ J 25, 583593.
Howarth, F. C., Jacobson, M., Shaullah, M., & Adeghate, E. (2005). Long-term effects of
streptozotocin-induced diabetes on the electrocardiogram, physical activity and
body temperature in rats. Exp Physiol 90, 827835.
Howarth, F. C., Jacobson, M., Shaullah, M., & Adeghate, E. (2006). Effects of insulin treat-
ment on heart rhythm, body temperature and physical activity in streptozotocin-
induced diabetic rats. Clin Exp Pharmacol Physiol 33, 327331.
Hu, D., Barajas-Martinez, H., Nesterenko, V. V., Pfeiffer, R., Guerchicoff, A., Cordeiro, M.
J., et al. (2010). Dual variation in SCN5A and CACNB2b underlies the development of
cardiac conduction disease without Brugada syndrome. PACE 33, 274285.
Hu, K., Qu, Y., & Boutjdir, M. (2004). Functional basis of sinus bradycardia in congenital
heart block. Circ Res 94, 3238.
Huang, Z. M., Prasad, C., Britton, F. C., Ye, L. L., Hatton, W. J., & Duan, D. (2009). Functional
role of CLC-2 chloride inward rectier channels in cardiac sinoatrial nodal pacemaker
cells. J Mol Cell Cardiol 47, 121132.
Hucker, W. J., McCain, M. L., Laughner, J. I., Iaizzo, P. A., & Emov, I. R. (2008). Connexin
43 expression delineates two discrete pathways in the human atrioventricular
junction. Anat Rec (Hoboken) 291, 204215.
Hund, T. J., & Mohler, P. J. (2008). Ankyrin-based targeting pathway regulates human
sinoatrial node automaticity. Channels (Austin) 2, 404406.
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
Huser, J., Blatter, L. A., & Lipsius, S. L. (2000). Intracellular Ca2+ release contributes to
automaticity in cat atrial pacemaker cells. J Physiol 524, 415422.
Imaizumi, S., Mazgalev, T., Dreifus, L. S., Michelson, E. L., Miyagawa, A., Bharati, S., et al.
(1990). Morphological and electrophysiological correlates of atrioventricular nodal
response to increased vagal activity. Circulation 82, 951964.
Inada, S., Boyett, M. R., & Dobrzynski, H. (2009a). Mathematical models of human sinus
and atrioventricular node action potential. Comput Cardiol 36, 7780.
Inada, S., Hancox, J. C., Zhang, H., & Boyett, M. R. (2009b). One-dimensional mathematical
model of the atrioventricular node including atrio-nodal, nodal, and nodal-his cells.
Biophys J 97, 21172127.
Inoue, S., & Becker, A. E. (1998). Posterior extensions of the human compact atrioventricular
node: a neglected anatomic feature of potential clinical signicance. Circulation 97,
188193.
Irisawa, H., Brown, H. F., & Giles, W. (1993). Cardiac pacemaking in the sino-atrial node.
Physiol Rev 73, 197227.
Johnson, W. H., Jr., Yang, P., Yang, T., Lau, Y. R., Mostella, B. A., Wolff, D. J., et al. (2003).
Clinical, genetic, and biophysical characterization of a homozygous HERG mutation
causing severe neonatal long QT syndrome. Pediatr Res 53, 744748.
Jones, S. A., Boyett, M. R., & Lancaster, M. K. (2007). Declining into failure: the age-
dependent loss of the L-type calcium channel within the sinoatrial node. Circulation
115, 11831190.
Jones, S. A., Lancaster, M. K., & Boyett, M. R. (2004). Ageing-related changes of connexins
and conduction within the sinoatrial node. J Physiol 560, 429437.
Joshi, S., & Wilber, D. J. (2005). Ablation of idiopathic right ventricular outow tract
tachycardia: Current perspectives. J Cardiovasc Electrophysiol 16, S52S58.
Joung, B., Lin, S. F., Chen, Z., Antoun, P. S., Maruyama, M., Han, S., et al. (2010). Mechanisms
of sinoatrial node dysfunction in a canine model of pacing-induced atrial brillation.
Hear Rhythm 7, 8895.
Joung, B., Ogawa, M., Lin, S. F., & Chen, P. S. (2009). The calcium and voltage clocks in
sinoatrial node automaticity. Korean Circ J 39, 217222.
Joyner, R. W., & Van Capelle, F. J. L. (1986). Propagation through electrically coupled
cells: how a small SA node drives a large atrium. Biophys J 50, 11571164.
Kalman, J. M., Olgin, J. E., & Karch, M. R. (1998). Cristal tachycardias: origin of right atrial
tachycardias from the crista terminalis identied by intracardiac echocardiography. J
Am Coll Cardiol 31, 451459.
Kamakura, S., Shimizu, W., Matsuo, K., Taguchi, A., Suyama, K., Kurita, T., et al.
(1988). Localization of optimal ablation site of idiopathic ventricular tachycardia
from right and left ventricular outow tract by body surface ecg. Circulation 98,
15251533.
Kang, G., Giovannone, S. F., Liu, N., Liu, F. Y., Zhang, J., Priori, S. G., et al. (2010). Purkinje
cells from RyR2 mutant mice are highly arrhythmogenic but responsive to targeted
therapy. Circ Res 107, 512519.
Kaseda, S., Gilmour, R. F., Jr., & Zipes, D. P. (1989). Depressant effect of magnesium on
early afterdepolarizations and triggered activity induced by cesium, quinidine, and
4-aminopyridine in canine cardiac Purkinje bers. Am Heart J 118, 458466.
Kashiwakura, Y., Cho, H. C., Barth, A. S., Azene, E., & Marbn, E. (2006). Gene transfer of a
synthetic pacemaker channel into the heart: a novel strategy for biological pacing.
Circulation 114, 16821686.
Kehat, I., Khimovich, L., Caspi, O., Gepstein, A., Shofti, R., Arbel, G., et al. (2004). Electrome-
chanical integration of cardiomyocytes derived from human embryonic stem cells.
Nat Biotechnol 22, 12821289.
Keith, A., & Flack, M. (1907). The form and nature of the muscular connections between
the primary divisions of the vertebrate heart. J Anat Physiol 41, 172189.
Kelly, R. G., & Buckingham, M. E. (2002). The anterior heart-forming eld: Voyage to
the arterial pole of the heart. Trends Genet 18, 210216.
Kent, A. F. S. (1913). The structure of the cardiac tissues at the auricularventricular
junction. J Physiol 47, xviixviii.
Kistler, P. M., Sanders, P., Hussin, A., Morton, J. B., Vohra, J. K., Sparks, P. B., et al. (2003).
Focal atrial tachycardia arising from the mitral annulus: electrocardiographic and
electrophysiologic characterization. J Am Coll Cardiol 41, 22122219.
Kistler, P. M., Roberts-Thomson, K. C., Haqqani, H. M., Fynn, S. P., Suresh Singarayar, S.,
Jitendra, K., et al. (2006). P-Wave morphology in focal atrial tachycardia develop-
ment of an algorithm to predict the anatomic site of origin. J Am Coll Cardiol 48,
10101017.
Ko, Y. S., Yeh, H. I., Ko, Y. L., Hsu, Y. C., Chen, C. F., Wu, S., et al. (2004). Three-dimensional
reconstruction of the rabbit atrioventricular conduction axis by combining histolog-
ical, desmin, and connexin mapping data. Circulation 109, 11721179.
Kodama, I., Boyett, M. R., Nikmaram, M. R., Yamamoto, M., Honjo, H., & Niwa, R. (1999).
Regional differences in the effects of E-4031 within the sinoatrial node. Am J Physiol
276, H793H802.
Kodama, I., Kamiya, K., & Toyama, J. (1997a). Cellular electropharmacology of
amiodarone. Cardiovasc Res 35, 1329.
Kodama, I., Nikmaram, M. R., Boyett, M. R., Suzuki, R., Honjo, H., & Owen, J. M. (1997b).
Regional differences in the role of the Ca 2+ and Na + currents in pacemaker activ-
ity in the sinoatrial node. Am J Physiol 272, H2793H2806.
Koncz, I., Szl, T., Bitay, M., Cerbai, E., Jaeger, K., Flp, F., et al. (2011). Electrophysiological
effects of ivabradine in dog and human cardiac preparations: potential antiarrhythmic
actions. Eur J Pharmacol 668, 419426.
Kreuzberg, M. M., Willecke, K., & Bukauskas, F. F. (2006). Connexin-mediated cardiac
impulse propagation: connexin 30.2 slows atrioventricular conduction in mouse
heart. Trends Cardiovasc Med 16, 266272.
Kruse, M., Schulze-Bahr, E., Coreld, V., Beckmann, A., Stallmeyer, B., Kurtbay, G., et al.
(2009). Impaired endocytosis of the ion channel TRPM4 is associated with human
progressive familial heart block type I. J Clin Invest 119, 27372744.
Kuo, C. S., & Reddy, C. P. (1981). Effect of lidocaine on escape rate in patients with complete
atrioventricular block: B. Proximal His bundle block. Am J Cardiol 47, 13151320.
285
Kurian, T., Ambrosi, C., Hucker, W., Fedorov, V. V., & Emov, I. R. (2010). Anatomy
and electrophysiology of the human AV node. Pacing Clin Electrophysiol 33,
754762.
Kus, T., & Sasyniuk, B. I. (1975). Electrophysiological actions of disopyramide phosphate
on canine ventricular muscle and purkinje bers. Circ Res 37, 844854.
Kyndt, F., Probst, V., Potet, F., Demolombe, S., Chevallier, J. C., Baro, I., et al. (2001).
Novel SCN5A mutation leading either to isolated cardiac conduction defect or
Brugada syndrome in a large French family. Circulation 104, 30813086.
Lakatta, E. G., & DiFrancesco, D. (2009). What keeps us ticking: a funny current, a calcium
clock, or both? J Mol Cell Cardiol 47, 157170.
Lakatta, E. G., & Maltsev, V. (2009). A new functional pacemaker for the heart's paradigm:
Mutual entrainment of intracellular calcium clocks and surface membrane ion
channel Clocks. In D. P. Zipes, & J. Jalife (Eds.), Cardiac Electrophysiology: From Cell
to bedside (pp. 235245) (5th ed.). Philadelphia, Pa: WB Saunders Company.
Lakatta, E. G., Maltsev, V. A., & Vinogradova, T. M. (2010). A coupled SYSTEM of intracellular
calcium clocks and surface membrane voltage clocks controls the timekeepsing mech-
anism of the heart's pacemaker. Circ Res 106, 659673.
Lalevee, N., Monier, B., Senatore, S., Perrin, L., & Semeriva, M. (2006). Control of cardiac
rhythm by ORK1, a Drosophila two-pore domain potassium channel. Curr Biol 16,
15021508.
Lau, D. H., Roberts-Thomson, K. C., & Sanders, P. (2011). Sinus node revisited. Curr Opin
Cardiol 26, 5559.
Le Scouarnec, S., Le Scouarnec, S., Bhasin, N., Vieyres, C., Hund, T. J., Cunha, S. R., et al.
(2008). Dysfunction in ankyrin-B-dependent ion channel and transporter targeting
causes human sinus node disease. Proc Natl Acad Sci U S A 105, 1561715622.
Lederer, W. J., & Tsien, R. W. (1976). Transient inward current underlying arrhythmogenic
effects of cardiotonic steroids in Purkinje bres. J Physiol 263, 73100.
Lei, M., Goddard, C., Liu, J., Loni, A. L., Royer, A., Fung, S. S., et al. (2005). Sinus node
dysfunction following targeted disruption of the murine cardiac sodium channel
gene Scn5a. J Physiol 567, 387400.
Lei, M., Jones, S. A., Liu, J., Lancaster, M. K., Fung, S. S., Dobrzynski, H., et al. (2004). Re-
quirement of neuronal- and cardiac-type sodium channels for murine sinoatrial
node pacemaking. J Physiol 559, 835848.
Lerman, B. B., Stein, K. M., Markowitz, S. M., & Slotwiner, D. J. (2002). Right ventricular
outow tract tachycardia: an update. Card Electrophysiol Rev 6, 6871.
Li, J., Greener, I. D., Inada, S., Nikolski, V. P., Yamamoto, M., Hancox, J. C., et al. (2008). Com-
puter three-dimensional reconstruction of the atrioventricular node. Circ Res 102,
975985.
Li, Z. Y., Wang, Y. H., Maldonado, C., & Kupersmith, J. (1994). Role of junctional zone
cells between Purkinje bres and ventricular muscle in arrhythmogenesis.
Cardiovasc Res 28, 12771284.
Liu, J., Dobrzynski, H., Yanni, J., Boyett, M. R., & Lei, M. (2007). Organisation of the
mouse sinoatrial node: structure and expression of HCN channels. Cardiovasc
Res 73, 729738.
Liu, H. El, Zein, L., Kruse, M., Guinamard, R., Beckmann, A., Bozio, A., et al. (2010).
Gain-of-function mutations in TRPM4 cause autosomal dominant isolated cardiac
conduction disease. Circ Cardiovasc Gene 3, 374385.
Lupoglazoff, J. M., Denjoy, I., Villain, E., Fressart, V., Simon, F., Bozio, A., et al. (2004). Long
QT syndrome in neonates: conduction disorders associated with HERG mutations
and sinus bradycardia with KCNQ1 mutations. J Am Coll Cardiol 43, 826830.
Maddali, M. (2010). Cardiac pacing in left bundle/bifasciculr block patients. Ann Card
Anaesth 13, 715.
Maguy, A., Le Bouter, S., Comtois, P., Chartier, D., Villeneuve, L., Wakili, R., et al. (2009).
Ion channel subunit expression changes in cardiac Purkinje bers: a potential role
in conduction abnormalities associated with congestive heart failure. Circ Res 104,
11131122.
Makiyama, T., Akao, M., Tsuji, K., Doi, T., Ohno, S., Takenaka, K., et al. (2005). High risk
for brayarrhythmic complications in patients with Brugada syndrome caused by
SCN5A gene mutations. J Am Coll Cardiol 46, 21002106.
Makkar, R. R., Fromm, B. S., Steinman, R. T., Meissner, M. D., & Lehmann, M. H. (1993).
Female gender as a risk factor for torsades de pointes associated with cardiovascu-
lar drugs. J Am Med Assoc 270, 25902597.
Maltsev, V. A., & Lakatta, E. G. (2009). Synergism of coupled subsarcolemmal Ca2+
clocks and sarcolemmal voltage clocks confers robust and exible pacemaker func-
tion in a novel pacemaker cell model. Am J Physiol 296, H594H615.
Maltsev, V. A., & Lakatta, E. G. (2010). A novel quantitative explanation for the auto-
nomic modulation of cardiac pacemaker cell automaticity via a dynamic system
of sarcolemmal and intracellular proteins. Am J Physiol 298, H2010H2023.
Mangoni, M. E., Couette, B., Bourinet, E., Platzer, J., Reimer, D., Striessnig, J., et al. (2003).
Functional role of L-type Cav1.3 Ca2+ channels in cardiac pacemaker activity. Proc
Natl Acad Sci U S A 100, 55435548.
Mangoni, M. E., & Nargeot, J. (2008). Genesis and regulation of the heart automaticity.
Physiol Rev 88, 919982.
Mangoni, M. E., Traboulsie, A., Leoni, A. L., Couette, B., Marger, L., Le Quang, K., et al.
(2006). Bradycardia and slowing of the atrioventricular conduction in mice lacking
Cav 3.1 check T-type calcium channels. Circ Res 98, 14221430.
Maron, B. J., & Pelliccia, A. (2006). The heart of trained athletes: cardiac remodeling and
the risks of sports, including sudden death. Circulation 114, 6331644.
Massing, G. K., & James, T. N. (1976). Anatomical conguration of the His bundle and
bundle branches in the human heart. Circulation 53, 609621.
Mazur, A., Kusniec, J., & Strasberg, B. (2005). Bundle branch reentrant ventricular
tachycardia. Indian Pacing Electrophysiol J 5, 8695.
McGuire, M. A., Bourke, J. P., Robotin, M. C., Johnson, D. C., Meldrum-Hanna, W., Nunn,
G. R., et al. (1993). High resolution mapping of Koch's triangle using sixty elec-
trodes in humans with atrioventricular junctional (AV nodal) reentrant tachycar-
dia. Circulation 88, 23152328.
286 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
McGuire, M. A., de Bakker, J. M., Vermeulen, J. T., Moorman, A. F., Loh, P., Thibault, B.,
et al. (1996). Atrioventricular junctional tissue. Discrepancy between histological
and electrophysiological characteristics. Circulation 94, 571577.
McGuire, M. A., de Bakker, J. M., Vermeulen, J. T., Opthof, T., Becker, A. E., & Janse, M. J.
(1994). Origin and signicance of double potentials near the atrioventricular node.
Correlation of extracellular potentials, intracellular potentials, and histology. Circu-
lation 89, 23512360.
Meijler, F. L., & Janse, M. J. (1988). Morphology and electrophysiology of the mamma-
lian atrioventricular node. Physiol Rev 68, 608647.
Meregalli, P. G., Wilde, A. A., & Tan, H. L. (2005). Pathophysiological mechanisms of
brugada syndrome: Depolarization disorder, repolarization disorder, or more?
Cardiovasc Res 67, 367378.
Miake, J., Maraban, E., & Nuss, B. H. (2002). Gene therapy: Biological pacemaker created
by gene transfer. Nature 419, 132133.
Milanesi, R., Baruscotti, M., Gnecchi-Ruscone, T., & DiFrancesco, D. (2006). Familial
sinus bradycardia associated with a mutation in the cardiac pacemaker channel.
N Engl J Med 354, 151157.
Miller, J. M., Pezeshkian, N. G., & Yadav, A. V. (2006). Catheter mapping and ablation of
right ventricular outow tract ventricular tachycardia. J Cardiovasc Electrophysiol
17, 800802.
Miles, W. M. (2001). Idiopathic ventricular outow tract tachycardia: Where does it
originate? J Cardiovasc Electrophysiol 2, 536537.
Miquerol, L., Meysen, S., Mangoni, M., Bois, P., van Rijen, H. V., Abran, P., et al. (2004).
Architectural and functional asymmetry of the HisPurkinje system of the murine
heart. Cardiovasc Res 63, 7786.
Moe, G. K., Preston, J. B., & Burlington, H. (1956). Physiologic evidence for a dual A-V
transmission system. Circ Res 4, 357375.
Mond, H. G., & Proclemer, A. (2011). The 11th world survey of cardiac pacing and im-
plantable cardioverter-debrillators: calendar year 2009-a World Society of
Arrhythmia's project. PACE 34, 10131027.
Monfredi, O., Dobrzynski, H., Mondal, T., Boyett, M. R., & Morris, G. M. (2010a). The
anatomy and physiology of the sinoatrial nodea contemporary review. Pacing
Clin Electrophysiol 33, 13921406.
Monfredi, O. J., Johnsen, A. B., Dobrzynski, H., Lloyd, T., Yanni, J., Morris, G. M., et al.
(2011). Is athletic training-induced bradycardia caused by a downregulation
of the Ca 2+ clock pacemaker mechanism in the sinoatrial node? Eur Heart J
32, 99.
Monfredi, O. J., Anderson, R. H., Boyett, M. R., & Dobrzynski, H. (2010b). Nodal-like cells
exist in the right ventricular outow tract. Eur Heart J 311, 696.
Molyvdas, P. A., & Sperelakis, N. (1983). Comparison of the effects of several calcium
antagonistic drugs on the electrical activity of guinea pig Purkinje bers. Eur J
Pharmacol 88, 205214.
Moorman, A. F., & Christoffels, V. M. (2003). Cardiac chamber formation: Development,
genes, and evolution. Physiol Rev 83, 12231267.
Morton, J. B., Sanders, P., Das, A., Vohra, J. K., Sparks, P. B., & Kalman, J. M. (2001). Focal atrial
tachycardia arising from the tricuspid annulus: electrophysiologic and electrocardio-
graphic characteristics. J Cardiovasc Electrophysiol 12, 653659.
Munk, A. A., Adjemian, R. A., Zhao, J., Ogbaghebriel, A., & Shrier, A. (1996). Electrophys-
iological properties of morphologically distinct cells isolated from the rabbit atrio-
ventricular node. J Physiol 493, 801813.
Nattel, S., & Quantz, M. A. (1988). Pharmacological response of quinidine induced early
afterdepolarisations in canine cardiac Purkinje bres: insights into underlying
ionic mechanisms. Cardiovasc Res 22, 808817.
Neu, A., Eiselt, M., Paul, M., Sauter, K., Stallmeyer, B., Isbrandt, D., et al. (2010). A
homozigous SCN5A mutation in a severe, recessive type in a cardiac conduction
disease. Hum Mutat 31, E1609E1621.
Nikmaram, M. R., Liu, J., Abdelrahman, M., Dobrzynski, H., Boyett, M. R., & Lei, M.
(2008). Characterization of the effects of ryanodine, TTX, E-4031 and 4-AP on the
sinoatrial and atrioventricular nodes. Prog Biophys Mol Biol 96, 452464.
Nikolski, V. P., Jones, S. A., Lancaster, M. K., Boyett, M. R., & Emov, I. R. (2003). Cx43 and
dual-pathway electrophysiology of the atrioventricular node and atrioventricular
nodal reentry. Circ Res 92, 469475.
Nogami, A. (2011). Purkinje-Related Arrhythmias Part I: Monomorphic Ventricular
Tachycardias. Pacing Clin Electrophysiol 34, 624650.
Nof, E., Luria, D., Brass, D., Marek, D., Lahat, H., Reznik-Wolf, H., et al. (2007). Point mutation
in the HCN4 cardiac ion channel pore affecting synthesis, trafcking, and functional
expression is associated with familial asymptomatic sinus bradycardia. Circulation
116, 463470.
Noma, A., Irisawa, H., Kokobun, S., Kotake, H., Nishimura, M., & Watanabe, Y. (1980a).
Slow current systems in the A-V node of the rabbit heart. Nature 285, 228229.
Noma, A., Kotake, H., & Irisawa, H. (1980b). Slow inward current and its role mediating
the chronotropic effect of epinephrine in the rabbit sinoatrial node. Pugers Arch
388, 19.
O'Donnell, D., Cox, D., Bourke, J., Mitchell, L., & Furniss, S. (2003). Clinical and electrophysi-
ological differences between patients with arrhythmogenic right ventricular dysplasia
and right ventricular outow tract tachycardia. Eur Heart J 24, 801810.
Oka, Y., Itoh, H., Ding, W. G., Shimizu, W., Makiyama, T., Ohno, S., et al. (2010). Atrioventric-
ular block-induced Torsades de Pointes with clinical and molecular backgrounds similar
to congenital long QT syndrome. Circulation 74, 25622571.
Opthof, T., Coronel, R., Rademaker, H. M., Vermeulen, J. T., Wilms-Schopman, F. J., &
Janse, M. J. (2000). Changes in sinus node function in a rabbit model of heart failure
with ventricular arrhythmias and sudden death. Circulation 101, 29752980.
Padeletti, L., Valleggi, A., Vergaro, G., Luc, F., Rao, C. M., Perrotta, L., et al. (2010).
Concordant versus discordant left bundle branch block in heart failure patients:
novel clinical value of an old electrocardiographic diagnosis. J Card Fail 16,
320326.
Papadatos, G. A., Wallerstein, P. M., Head, C. E., Ratcliff, R., Brady, P. A., Benndorf, K., et al.
(2002). Slowed conduction and ventricular tachycardia after targeted disruption of
the cardiac sodium channel gene Scn5a. Proc Natl Acad Sci U S A 99, 62106215.
Park, D. S., & Fishman, G. I. (2011). The cardiac conduction system. Circulation 123,
904915.
Persson, F., Andersson, B., Duker, G., Jacobson, I., & Carlsson, L. (2007). Functional effects
of the late sodium current inhibition by AZD7009 and lidocaine in rabbit isolated
atrial and ventricular tissue and Purkinje bre. Eur J Pharmacol 558, 133143.
Piccini, J. P., & Calkins, H. (2005). Arrhythmia management in the elderly. Cardiovascular
Disease in the Elderly (pp. 261300). Totowa, New Jersey: Humana Press.
Piipo, K., Laitinen, P., Swan, H., Toivonen, L., Viitasalo, M., Pasternack, M., et al. (2000).
Homozygosity for a HERG potassium channel mutation causes a severe form of
long QT syndrome: identication of an apparent founder mutation in the Finns.
J Am Coll Cardiol 35, 19191925.
Pinto, J. M., Sosunov, E. A., Gainullin, R. Z., Rosen, M. R., & Boyden, P. A. (1999). Effects of
mibefradil, a T-type calcium current antagonist, on electrophysiology of Purkinje
bers that survived in the infarcted canine heart. J Cardiovasc Electrophysiol 10,
12241235.
Plotnikov, A. N., Shlapakova, I., Szabolcs, M. J., Danilo, P., Jr., Lorell, B. H., Potapova, I. A.,
et al. (2007). Xenografted Adult Human Mesenchymal Stem Cells Provide a Platform
for Sustained Biological Pacemaker Function in Canine Heart. Circulation 116,
706713.
Pollack, G. H. (1976). Intercellular coupling in the atrioventricular node and other tissues
of the rabbit heart. J Physiol 255, 275298.
Postma, A. V., Denjoy, I., Hoorntje, T. M., Lupoglazoff, J. M., Da Costa, A., Sebillon, P., et al.
(2002). Absence of calsequestrin 2 causes severe forms of catecholaminergic polymor-
phic ventricular tachycardia. Circ Res 91, e21e26.
Postma, A. V., Denjoy, I., Kamblock, J., Alders, M., Lupoglazoff, J. M., Vaksmann, G., et al.
(2005). Catecholaminergic polymorphic ventricular tachycardia: RYR2 mutations,
bradycardia, and follow up of the patients. J Med Genet 42, 863887.
Potapova, I., Plotnikov, A., Lu, Z., Danilo, P., Jr., Valiunas, V., Qu, J., et al. (2004). Human
mesenchymal stem cells as a gene delivery system to create cardiac pacemakers.
Circ Res 94, 952959.
Probst, V., Allouis, M., Sacher, F., Pattier, S., Babuty, D., Mabo, P., et al. (2006). Progressive
cardiac conduction defect is the prevailing phenotype in carriers of a Brugada syn-
drome SCN5A mutation5. J Cardiovasc Electrophysiol 17, 270275.
Qu, J., Plotnikov, A. N., Danilo, P., Jr., Shlapakova, I., Cohen, I. S., Robinson, R. B., et al.
(2003). Expression and function of a biological pacemaker in canine heart. Circulation
107, 11061109.
Qu, Y., Xiao, G. -Q., Chen, L., & Boutjdir, M. (2001). Autoantibodies from mothers from
children with congenital heart block down-regulate inhibit L-type Ca channels. J Mol
Cell Cardiol 33, 11531163.
Rana, M. S., Horsten, N. C., Tesink-Taekema, S., Lamers, W. H., Moorman, A. F., & van den
Hoff, M. J. (2007). Trabeculated right ventricular free wall in the chicken heart
forms by ventricularization of the myocardium initially forming the outow
tract. Circ Res 100, 10001007.
Ren, F. X., Niu, X. L., Ou, Y., Han, Z. H., Ling, F. D., Zhou, S. S., et al. (2006). Morphological
and electrophysiological properties of single myocardial cells from Koch triangle of
rabbit heart. Chin Med J (Engl) 119, 20752084.
Rentschler, S., Vaidya, D. M., Tamaddon, H., Degenhardt, K., Sassoon, D., Morley, G. E., et al.
(2001). Visualization and functional characterization of the developing murine cardiac
conduction system. Development 128, 17851792.
Robinson, R. B., Boyden, P. A., Hoffman, B. F., & Hewett, K. W. (1987). Electrical restitution
process in dispersed canine cardiac Purkinje and ventricular cells. Am J Physiol 253,
H1018H1025.
Roden, D. M., & Hoffman, B. F. (1985). Action potential prolongation and induction
of abnormal automaticity by low quinidine concentrations in canine Purkinje
bers. Relationship to potassium and cycle length. Circ Res 56, 857867.
Rosen, M. R., Brink, P. R., Cohen, I. S., & Robinson, R. B. (2009). Biologic pacing. In D. P.
Zipes, & J. Jalife (Eds.), Cardiac electrophysiology: from cell to bedside (pp. 223234)
(5th ed.). Philadelphia, Pa: WB Saunders Company.
Rota, M., & Vassalle, M. (2003). Patch-clamp analysis in canine cardiac Purkinje
cells of a novel sodium component in the pacemaker range. J Physiol 548,
147165.
Rozanski, G. J., & Jalife, J. (1986). Automaticity in atrioventricular valve leaets of rabbit
heart. Am J Physiol 19, H397H406.
Rozanski, G. J. (1987). Electrophysiological properties of automatic bers in rabbit
atrioventricular valves. Am J Physiol 253, H720H727.
Rozanski, G. J., & Lipsius, S. L. (1985). Electrophysiology of functional subsidiary pacemakers
in canine right atrium. Am J Physiol 249, H594H603.
Rubenstein, J., Schulman, C., Yurchak, P. M., & DeSanctis, R. W. (1972). Clinical Spectrum
of the Sick Sinus Syndrome. Circulation 46, 513.
Rubenstein, D. S., Fox, L. M., McNulty, J. A., & Lipsius, S. L. (1987). Electrophysiology and
ultrastructure of Eustachian ridge from cat right atrium: a comparison with SA
node. J Mol Cell Cardiol 19, 965976.
Ryu, S., Yamamoto, S., Andersen, C. R., Nakazawa, K., Miyake, F., & James, T. N. (2009).
Intramural Purkinje cell network of sheep ventricles as the terminal pathway of
conduction system. Anat Rec (Hoboken) 292, 1222.
Sano, T., & Yamagishi, S. (1965). Spread of excitation from the sinus node. Circ Res 16,
423430.
Sanchez-Quintana, D., Cabera, J. A., Farre, J., Climent, V., Anderson, R. H., & Ho, S. Y.
(2005). Sinus node revisited in the era of electroanatomical mapping and catheter
ablation. Heart 91, 189194.
Sanders, P., Kistler, P. M., Morton, J. B., Spence, S. J., & Kalman, J. M. (2004). Remodeling
of sinus node function in patients with congestive heart failure: reduction in sinus
node reserve. Circulation 110, 897903.
 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288
Schram, G., Pourrier, M., Melnyk, P., & Nattel, S. (2002). Differential distribution of cardiac
ion channel expression as a basis for regional specialization in electrical function. Circ
Res 90, 939950.
Scheinman, M. M. (2009). Role of the His.Purkinje system in the genesis of cardiac arrhyth-
mia. Hear Rhythm 6, 10501058.
Schulze-Bahr, E., Neu, A., Friederich, P., Kaupp, U. B., Breithardt, G., Pongs, O., et al.
(2003). Pacemaker channel dysfunction in a patient with sinus node disease. J
Clin Invest 111, 15371545.
Severs, N. J. (2000). The cardiac muscle cell. Bioessays 22, 188199.
Severs, N. J., Dupont, E., Coppen, S. R., Halliday, D., Inett, E., Baylis, D., et al. (2004).
Remodelling of gap junctions and connexin expression in heart disease. Biochim
Biophys Acta Biomembr 1662, 138148.
Severs, N. J., Rothery, S., Dupont, E., Coppen, S. R., Yeh, H. I., Ko, Y. S., et al. (2001). Immuno-
cytochemical analysis of connexin expression in the healthy and diseased cardiovascu-
lar system. Microsc Res Tech 52, 301322.
Shang, L. L., Sanyal, S., Pfahnl, A. E., Jiao, Z., Allen, J., Liu, H., et al. (2008). NF-
kappaB-dependent transcriptional regulation of the cardiac scn5a sodium channel by
angiotensin II. Am J Physiol 294, C372C379.
Shi, W., Wymore, R., Yu, H., Wu, J., Wymore, R. T., Pan, Z., et al. (1999). Distribution and
prevalence of hyperpolarization-activated cation channel (HCN) mRNA expression
in cardiac tissues. Circ Res 85, 16.
Song, T., Yang, J., Yao, Y., Li, H., Chen, Y., Zhang, J., et al. (2011). Spironolactone
diminishes spontaneous ventricular premature beats by reducing HCN4
protein expression in rats with myocardial infarction. Mol Med Rep 4, 569573.
Spach, M. S., Barr, R. C., Serwer, G. S., Johnson, E. A., & Kootsey, J. M. (1971). Collision of
excitation waves in the dog Purkinje system. Extracellular identication. Circ Res
29, 499511.
Stallmeyer, B., Zumhagen, S., Denjoy, I., Duthoit, G., Hbert, J. L., Ferrer, X., et al. (2012). Mu-
tational spectrum in the Ca2+-activated cation channel gene TRPM4 in patients with
cardiac conductance disturbances. Hum Mutat 33, 109117.
Stevenson, W. G., Stevenson, L. W., Middlekauff, H. R., & Saxon, L. A. (1993). Sudden
death prevention in patients with advanced ventricular dysfunction. Circulation
88, 29532961.
Stillitano, F., Lonardo, G., Zicha, S., Varro, A., Cerbai, E., Mugelli, A., et al. (2008). Molecular
basis of funny current (If) in normal and failing human heart. J Cell Mol Cardiol 45,
289299.
Swaminathan, P. D., Purohit, A., Soni, S., Voigt, N., Singh, M. V., Glukhov, A. V., et al. (2011).
Oxidized CaMKII causes cardiac sinus node dysfunction in mice. J Clin Invest 121,
32773288.
Swedberg, K., Komajda, M., Bohm, M., Borer, J. S., Ford, I., Dubost-Brama, A., et al.
(2010). Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised
placebo-controlled study. Lancet 376, 875885.
Tada, H., Tadokoro, K., Ito, S., Naito, S., Hashimoto, T., Kaseno, K., et al. (2007). Idiopathic
ventricular arrhythmias originating from the tricuspid annulus: Prevalence, electro-
cardiographic characteristics, and results of radiofrequency catheter ablation. Hear
Rhythm 4, 716.
Tardif, J. C., O'Meara, E., Komajda, M., Bhm, M., Borer, J. S., Ford, I., et al. (2011). Ef-
fects of selective heart rate reduction with ivabradine on left ventricular
remodelling and function: results from the SHIFT echocardiography substudy.
Eur Heart J 32, 25072515.
Tawara, S. (2000). The conduction system of the mammalian heart. London: Imperial College
Press.
Tellez, J. O., Dobrzynski, H., Greener, I. D., Graham, G. M., Laing, E., Honjo, H., et al. (2006).
Differential expression of ion channel transcripts in atrial muscle and sinoatrial node
in rabbit. Circ Res 99, 13841393.
Tellez, J. O., Mczewski, M., Yanni, J., Sutyagin, P., Mackiewicz, U., Atkinson, A., et al.
(2011). Ageing-dependent remodelling of ion channel and Ca2+ clock genes un-
derlying sino-atrial node pacemaking. Exp Physiol 96, 11631178.
Temple, I. P., Inada, S., Dobrzynski, H., & Boyett, M. R. (2013). Connexins and the atrioven-
tricular node. Hear Rhythm 10, 297304.
Tse, H. F., Xue, T., Lau, C. P., Siu, C. W., Wang, K., Zhang, Q. Y., et al. (2006). Bioarticial
sinus node constructed via in vivo gene transfer of an engineered pacemaker HCN
channel reduces the dependence on electronic pacemaker in a sick sinus syndrome
model. Circulation 114, 16821686.
Tsien, R. W., Kass, R. S., & Weingart, R. (1979). Cellular and subcellular mechanisms of
cardiac pacemaker oscillations. J Exp Biol 81, 205215.
Tranum-Jensen, J., Wilde, A. A., Vermeulen, J. T., & Janse, M. J. (1991). Morphology of
electrophysiologically identied junctions between Purkinje bers and ventricular
muscle in rabbit and pig hearts. Circ Res 69, 429437.
Ueda, K., Nakamura, K., Hayashi, T., Inagaki, N., Takahashi, M., Arimura, T., et al. (2004).
Functional characterization of a trafcking-defective HCN4 mutation, D553N, as-
sociated with cardiac arrhythmia. J Biol Chem 279, 2719427198.
Vaillant, F., Dehina, L., Mazzadi, A., Descotes, J., Chevalier, P., Tabib, A., et al. (2011). Heart
rate reduction with ivabradine increases ischaemia-induced ventricular brillation
threshold: Role of myocyte structure and myocardial perfusion. Resuscitation 82,
10921099.
Van De Ven, L. L. M., Crijns, H. J. G. M., De Muinck, E. D., Van Gelder, I. C., Van Wijk, L. M., &
Lie, K. I. (1996). Electrophysiologic and antiarrhythmic effects of intravenous
bisoprolol in atrioventricular nodal reentry tachycardia. Curr Ther Res 57, 950958.
van Rijen, H. V., van Veen, T. A., van Kempen, M. J., Wilms-Schopman, F. J., Potse, M.,
Krueger, O., et al. (2001). Impaired conduction in the bundle branches of mouse
hearts lacking the gap junction protein connexin40. Circulation 103, 15911598.
van Veen, T. A., Stein, M., Royer, A., Le Quang, K., Charpentier, F., Colledge, W. H., et al.
(2005). Impaired impulse propagation in Scn5a-knockout mice: combined contri-
bution of excitability, connexin expression, and tissue architecture in relation to
aging. Circulation 112, 19271935.
287
Vassalle, M. (1970). Electrogenic suppression of automaticity in sheep and dog
purkinje bers. Circ Res 27, 361377.
Vassalle, M. (2007). The vicissitudes of the pacemaker current I (Kdd) of cardiac
purkinje bers. J Biomed Sci 14, 699716.
Vassalle, M., Yu, H., & Cohen, I. S. (1995). The pacemaker current in cardiac Purkinje
myocytes. J Gen Physiol 106, 559578.
Veldkamp, M. W., Wilders, R., Baartscheer, A., Zegers, J. G., Bezzina, C. R., & Wilde, A. A.
(2003). Contribution of sodium channel mutations to bradycardia and sinus node
dysfunction in LQT3 families. Circ Res 92, 976983.
Verkerk, A. O., Wilders, R., van Borren, M. M., & Tan, H. L. (2009). Is sodium current
present in human sinoatrial node cells? Int J Biol Sci 5, 201204.
Verkerk, A. O., Wilders, R., Coronel, R., Ravesloot, J. H., & Verheijck, E. E. (2003).
Ionic remodeling of sinoatrial node cells by heart failure. Circulation 108,
760766.
Vinogradova, T. M., Maltsev, V. A., Bogdanov, K. Y., Lyashkov, A. E., & Lakatta, E. G.
(2005). Rhythmic Ca2+ oscillations drive sinoatrial nodal cell pacemaker function
to make the heart tick. Ann N Y Acad Sci 1047, 138156.
Viskin, S., Rosso, R., Rogowski, O., & Belhassen, B. (2005). The short-coupled
variant of right ventricular outow ventricular tachycardia: A not-so-benign
form of benign ventricular tachycardia? J Cardiovasc Electrophysiol 16,
912916.
Watanabe, H., Koopmann, T. T., Le Scouarnec, S., Yang, T., Ingram, C. R., Schott, J. J., et al.
(2008). Sodium channel betal subunit mutations associated with Brugada syndrome
and cardiac conduction disease in humans. J Clin Invest 118, 22602268.
Wiese, C., Grieskamp, T., Airik, R., Mommersteeg, M. T., Gardiwal, A., de Gier-de, V. C., et al.
(2009). Formation of the sinus node head and differentiation of sinus node myocardi-
um are independently regulated by tbx18 and tbx3. Circ Res 104, 388397.
Wilbur, S. L., & Marchlinski, F. E. (1997). Adenosine as an antiarrhythmic agent. Am J
Cardiol 79, 3037.
Wit, A. L., Craneeld, P. F., & Gadsby, D. C. (1981). Electrogenic sodium extrusion can stop
triggered activity in the canine coronary sinus. Circ Res 49, 10291042.
Wit, A. L., Craneeld, P. F., & Hoffman, B. F. (1972). Slow conduction and reentry in the
ventricular conducting system. II. Single and sustained circus movement in net-
works of canine and bovine Purkinje bers. Circ Res 30, 1122.
Wit, A. L., Fenoglio, J. J., Jr., Hordof, A. J., & Reemtsma, K. (1979). Ultrastructure and
transmembrane potentials of cardiac muscle in the human anterior mitral valve
leaet. Circulation 59, 12841292.
Wit, A. L., Fenoglio, J. J., Jr., & Wagner, B. M. (1973). Electrophysiological properties of
cardiac muscle in the anterior mitral valve leaet and the adjacent atrium in the
dog. Possible implications for the genesis of atrial dysrhythmias. Circ Res 32,
731745.
Wit, A. L., & Craneeld, P. F. (1976). Triggered activity in cardiac muscle bers of the
simian mitral valve. Circ Res 38, 8598.
Wit, A. L., & Craneeld, P. F. (1977). Triggered and automatic activity in the canine coronary
sinus. Circ Res 41, 434445.
Wiggins, J. R., & Craneeld, P. F. (1976). Two levels of resting potential in canine cardiac
Purkinje bers exposed to sodium-free solutions. Circ Res 39, 466474.
Wongcharoen, W., Chen, Y. C., Chen, Y. J., Chang, C. M., Yeh, H. I., Lin, C. L., et al. (2006).
Effects of a Na+/Ca2+ exchanger inhibitor on pulmonary vein electrical activity
and ouabain-induced arrhythmogenicity. Cardiovasc Res 70, 497508.
Wright, M., Sacher, F., & Hassaguerre, M. (2009). Catheter ablation for patients with
ventricular brillation. Curr Opin Cardiol 24, 5660.
Wu, X., & Burgess, S. M. (2004). Integration target site selection for retroviruses and
transposable elements. Cell Mol Life Sci 61, 25882596.
Xia, S., Wang, Y., Zhang, Y., Deng, S. -B., Du, J. -L., Wang, X. -C., et al. (2010). Dynamic
changes in HCN2, HCN4, KCNE1, and KCNE2 expression in ventricular cells from
acute myocardial infarction rat hearts. Biochem Biophys Res Commun 395,
330335.
Xue, T., Cho, H. C., Akar, F. G., Tsang, S. Y., Jones, S. P., Marbn, E., et al. (2005). Func-
tional integration of electrically active cardiac derivatives from genetically
engineered human embryonic stem cells with quiescent recipient ventricular
cardiomyocytes: insights into the development of cell-based pacemakers. Circulation
111, 1120.
Zhang, H., Holden, A. V., Kodama, I., Zhang, H., Holden, A. V., Kodama, I., et al. (2000).
Mathematical models of action potentials in the periphery and center of the rabbit
sinoatrial node. Am J Physiol 279, H397H421.
Zhang, Y., Bharati, S., Mowrey, K. A., Zhuang, S., Tchou, P., & Mazgalev, T. N. (2001). His elec-
trogram alternans reveal dual-wavefront inputs into and longitudinal dissociation
within the bundle of His. Circulation 104, 832838.
Zhang, H., Lau, D. H., Shlapakova, I. N., Zhao, X., Danilo, P., Robinson, R. B., et al.
(2011, March 8) Implantation of sinoatrial node cells into canine right ventricle:
biological pacing appears limited by the substrate. Cell Transplant 20, 1112.
Zicha, S., Fernandez-Velasco, M., Lonardo, G., L'Heureux, N., & Nattel, S. (2005). Sinus
node dysfunction and hyperpolarization-activated (HCN) channel subunit re-
modeling in a canine heart failure model. Cardiovasc Res 66, 472481.
Zicha, S., Tsuji, Y., Shiroshita-Takeshita, A., & Nattel, S. (2006). Beta-blockers as antiar-
rhythmic agents. Handb Exp Pharmacol 171235.
Yamamoto, M., Dobrzynski, H., Tellez, J., Niwa, R., Billeter, R., Honjo, H., et al. (2006).
Extended atrial conduction system characterised by the expression of the HCN4
channel and connexin45. Cardiovasc Res 72, 271281.
Yamanushi, T. T., Yanni, J., Dobrzynski, H., Kabuto, H., & Boyett, M. R. (2010). Changes
in ion channel expression in right-sided congestive heart failure. J Mol Cell
Cardiol 48, S73.
Yan, G. X., & Antzelevitch, C. (1999). Cellular basis for the brugada syndrome and other
mechanisms of arrhythmogenesis associated with st-segment elevation. Circulation
100, 16601666.
288 H. Dobrzynski et al. / Pharmacology & Therapeutics 139 (2013) 260288

Yanni, J., Boyett, M. R., Anderson, R. H., & Dobrzynski, H. (2009a). The extent of the ERG (KCNH2): channel (ether-a-go-go related gene voltage-gated K+ channel) and
specialized atrioventricular ring tissues. Hear Rhythm 6, 672680. gene responsible for IK,r
Yanni, J., Tellez, J. O., Sutyagin, P. V., Boyett, M. R., & Dobrzynski, H. (2010). Structural HCN1, HCN2, HCN4: hyperpolarization-activated cyclic nucleotide gated channels responsi-
remodelling of the sinoatrial node in obese old rats. J Mol Cell Cardiol 48, ble for If
653662. hMSC: human mesenchymal stem cells
Yanni, J., Tellez, J. O., Maczewski, M., Mackiewicz, U., Beresewicz, A., Billeter, R., et al. Ib,Na: background Na+ current
(2011a). Changes in ion channel gene expression underlying heart failure-induced ICa,L: L-type Ca2+ current
sinoatrial node dysfunction. Circ Heart Fail 4, 496508. ICa,T: T type Ca2+ current
Yanni, J., Yamanushi, T. T., Dobrzynski, H., & Boyett, M. R. (2009b). Remodelling of the If: hyperpolarization-activated or funny current
extracellular matrix in the rat sinoatrial node in congestive heart failure. Proc IK,1: background inward rectier K+ current
Physiol Soc 15, C26C. IK,ACh: acetylcholine-activated K+ current
Yanni, J., Cai, X., Jones, C. B., Corno, A. F., Hutcheon, R. C., Monfredi, O., et al. (2011b). IK,r: rapid delayed rectier K+ current
Mechanisms of delayed intraventricular conduction in heart failure. Hear Rhythm IK,s: slow delayed rectier K+ current
8, 1819. INa: Na+ current
Yeh, Y. H., Burstein, B., Qi, X. Y., Sakabe, M., Chartier, D., Comtois, P., et al. (2009). Funny INaCa: Na+Ca2+ exchange current
current downregulation and sinus node dysfunction associated with atrial tachyar- INa,L: late Na+ current
rhythmia: a molecular basis for tachycardia-bradycardia syndrome. Circulation 119, IP3: inositol trisphosphate
15761585. Ist: sustained inward current
Yoo, S., Dobrzynski, H., Fedorov, V. V., Xu, S. Z., Yamanushi, T. T., Jones, S. A., et al. Ito: transient outward K+ current
(2006). Localisation of Na+ channel isoforms at the atrioventricular junction and IK,ur: ultra-rapid delayed rectier K+ current
atrioventricular node. Circulation 114, 13601371. Kir2.1 (KCNJ2): inward rectier K+ channel and gene responsible for IK,1
Yu, H., Chang, F., & Cohen, I. S. (1995). Pacemaker current If in adult canine cardiac ventric- Kir3.1: inward rectier K+ channel in part responsible for IK,ACh
ular myocytes. J Physiol 485, 469483. Kv1.4, Kv1.5, Kv3.4, Kv4.2, Kv4.3: voltage-gated K+ channels
KvLQT1 (KCNQ1): voltage-gated K+ channel and gene responsible for IK,s
minK: auxiliary subunit responsible for IK,s
mRNA: messenger ribonucleic acid
MRI: magnetic resonance imaging
Nav1 (SCN1B): Na+ channel (and gene) subunit
Glossary Nav1.1: voltage-gated Na+ channel
Nav1.5 (SCN5A): principle voltage-gated Na+ channel and gene responsible for INa in
A, N, NH: types of myocyte at the atrioventricular node the heart
ANK2: ankyrin 2 NF-B: transcription factor
AV: atrioventricular NCX1: Na+Ca2+ exchanger
AVNRT: atrioventricular nodal reentrant tachycardia ORK1: two-pore-domain K+ channel (Drosophila)
CASQ2: calsequestrin 2 RYR2: type 2 ryanodine receptor (sarcoplasmic reticulum Ca2+ release channel)
Cav1.2 (CACNA1C): principal L-type Ca2+ channel and gene SERCA2: sarco/endoplasmic reticulum Ca2+ ATPase (sarcoplasmic reticulum Ca2+ pump)
Cav1.3: auxiliary L-type Ca2+ channel SR: sarcoplasmic reticulum
Cav3.1/Cav3.2: T-type Ca2+ channels TASK1/TREK1/TWIK1/TWIK2: two-pore-domain K+ channels
ClC-2: hyperpolarization-activated Cl channel Tbx3/Tbx18: T-box transcription factors
CPVT: catecholaminergic polymorphic ventricular tachycardia TGF1: transforming growth factor beta 1
Cx30.2, Cx40, Cx43, Cx45: connexins 30.2, 40, 43 and 45 TRP: transient receptor potential cation channels (relatively non-selective cation channels)
DAD: delayed afterdepolarization TRPM4: transient receptor potential cation channel subfamily M member 4
DNA: deoxyribonucleic acid VT: ventricular tachycardia
dV/dtmax: maximum upstroke velocity of the action potential
EAD: early afterdepolarization
ECG: electrocardiogram