Physiology, Bundle of His


Article Author:
Cyril Patra


Article Editor:
Mark Brady


Editors In Chief:
Tonya Dawson


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
10/27/2018 12:31:26 PM

Introduction

Wilhelm His Jr. described the physical link electrically bridging the atria and ventricles of the heart in 1893.[1] The specialized muscle bundle connecting the atrial and ventricular chambers of the heart is now known as the bundle of His.[1] The bundle of His quickly transmits the electrical impulse from the atrioventricular (AV) node to the left and right bundle branches and into the ventricles.[2] Over the years, diseases affecting the bundle of His have been discovered along with diagnostics and therapeutic interventions.

Issues of Concern

The AV conduction system propagates electrical impulses to maintain proper and efficient heart function. Malfunction of this system can lead to disruption of the heart’s normal sinus rhythm, such as by inducing arrhythmias that may require critical treatment or invasive surgical procedures.[3]

Cellular

The bundle of His comprises a complex organization of cells, predominantly consisting of Purkinje-type cells, slender transitional cells, broad transitional cells, and varying amounts of pacemaker cells.[2] The Purkinje-type cells of the bundle of His are composed of randomly oriented myofibrils, an abundance of mitochondria, Golgi apparatus, and a sporadic presence of two separate nuclei.

The pacemaker (P) cells are oval, and they include “sparse and randomly oriented myofibrils,” simple membranes, and trivial amounts of sarcoplasmic reticulum.[2]

The bundle of His is an elongated segment connecting the AV Node and the left and right bundle branches of the septal crest. It is approximately 1.8 cm long in an adult heart[4] and is primarily located deep within the dense connective tissue.

The bundle of His is characterized by longitudinal collagen partitioning histology, distinguishing it from the AV node.[2]

The intercalated discs in the bundle of His differ from the myocardial cells such that the discs in the bundle of His are oriented obliquely compared to the perpendicular alignment seen in the myocardium cross-sectional view. The bundle of His appears to have more “tongue-and-groove joints” compared to the “jagged perpendicular line” in the myocardium. Also, more tight junctions are found in the Purkinje cells of the bundle of His than in the intercalated discs of the myocardium.[2]

Development

Studies performed on the embryological development of the bundle of His are limited. The heart is derived from the lateral plate mesoderm, and as the heart continues to develop the newly formed cardiomyocytes begin to depolarize creating a slow electrical impulse.[3] In addition, studies show that the specialized conduction tissue in the atrioventricular canal is insulated by fibroblasts and fibrous tissue that stem from the migratory, multipotent neural crest cells.[5] The fibrous tissue, called the annulus fibrosus,  develops from the movement of the epicardial mesenchyme into the myocardial space and separates the developing atria and ventricles.[3] Further research suggests the bundle of His emerges from an interventricular ring during development.[5]

Function

Because the bundle of His is found deep within fibrous tissue, its precise function has been difficult to study. It is hypothesized that the “longitudinal partitioning of strands of the His bundle” and the abundant nexuses within the bundle of His aid the rapid conduction of the electrical signal from the AV node. Also, the encompassing collagen may potentially prevent the lateral spread of the propagated impulse.[2]

Pathophysiology

The standard bundle of His ECG is an invasive electrophysiology study involving inserting an electrode catheter into the femoral vein, through the inferior vena cava, and into the into the heart. It is advanced into the right ventricle and pulled back until the continuous monitor notes a spike between the P wave and the QRS complex, signifying the depolarization of the bundle of His.[6] Newer studies have suggested that noninvasive surface electrocardiograms may be sufficient to record bundle of His potentials.[7]

Because the bundle of His transmits the electrical impulse from the AV node to the bundle branches, malfunction of the bundle of His can lead to heart blocks ranging from AV conduction delays (first-degree heart block) to a complete disconnect in the electrical conduction between the atria and ventricles (third-degree heart block) causing arrhythmias. His bundle electrocardiograms may reveal important clinical findings in relation to heart blocks of the cardiac conduction system.

These include[6]:

  • First-degree heart block with normal QRS above the bundle of His.
  • Trifascualar block delay in conduction below the bundle of His in patients with left bundle branch block or intraventricular conduction defects
  • Wenckebach (Mobitz type I) demonstrate block above the bundle of His
  • Mobitz type II exhibit block potentially within His bundle
  • Mobitz type II patients may also locate a block below the His bundle during non-conducted P waves and have an intraventricular conduction defect on the ECG
  • Mobitz type II presence of a prolonged QRS interval may evoke intermittent trifascicular block leading to potential complete heart block
  • Second-degree AV block-conduction delay at AV node or perinodal area-block above the bundle of His 
  • Second-degree AV block distal to the bundle of His may indicate His-Purkinje system disease, and second-degree block proximal may indicate issues within the AV node
  • Complete (third-degree) heart block has been reported to occur within the bundle of His

Clinical Significance

There are 92.1 million Americans currently affected by some form of cardiovascular disease, and 43.9% are expected to have a type of cardiovascular disease by 2030.[8]

His-bundle pacing (HBP) is a method where leads are placed directly on the AV Node. This stimulates the bundle of His, generating conduction synchronization through the ventricles.[9] As ventricles return to their normal pump function, the risk of cardiomyopathy decreases.[9]

Studies show permanent direct His bundle pacing (DHBP) may be utilized in patients with chronic atrial fibrillation and dilated cardiomyopathy.[10] In addition, studies support the use of permanent HBP as an alternative to biventricular pacing for patients who have a low success rate with left ventricular lead placement.[10][11]

The bundle of His ECG has also been utilized to examine the effects of drugs, including vagolytic, sympathomimetic, sympatholytic, and antiarrhythmic.[6]

Vagolytic drugs, such as atropine, demonstrate a shortening between atrial depolarization and His bundle depolarization interval (P-H interval); however, they do not affect the interval between His bundle and the ventricular activation (H-Q interval).[6]

Isoproterenol, a sympathomimetic drug, works similarly to vagolytic drugs. A shortened P-H interval is observed, and there is no effect on the H-Q interval.[6]

Propranolol, a sympatholytic drug, increases P-H interval without an effect on H-Q interval.[6]

Antiarrhythmics drugs, such as lidocaine, either shorten or prolong the P-H interval with a variable effect on the H-Q interval; some patients demonstrate a modest prolongation of the intraventricular conduction.[6]

In summary, the P-H interval is the most susceptible region of the conduction system for intervention by use of therapeutic drugs.[12]


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Physiology, Bundle of His - Questions

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What is the average intrinsic rate of the bundle of His?



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Where are the special conducting cells that conduct electrical impulses from the atrioventricular node to the Purkinje fibers?

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What is the embryological origin of the bundle of His?



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A 75-year-old man with a history of hypertension presents with a single episode of dizziness while sitting on his couch and fatigue and shortness of breath on exertion for the past 2 weeks. On physical exam, his heart rate is 45 beats/min. An EKG shows a prolonged PR interval with a normal QRS wave. Which heart block in relation to the bundle of His may have occurred?



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Physiology, Bundle of His - References

References

von Knorre GH, The 125th anniversary of the His bundle discovery. Herzschrittmachertherapie     [PubMed]
James TN,Sherf L, Fine structure of the His bundle. Circulation. 1971 Jul     [PubMed]
van Weerd JH,Christoffels VM, The formation and function of the cardiac conduction system. Development (Cambridge, England). 2016 Jan 15     [PubMed]
Scherlag BJ,Lazzara R, Functional aspects of His bundle physiology and pathophysiology: Clinical implications. Journal of electrocardiology. 2017 Jan - Feb     [PubMed]
Blom NA,Gittenberger-de Groot AC,DeRuiter MC,Poelmann RE,Mentink MM,Ottenkamp J, Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity. Circulation. 1999 Feb 16     [PubMed]
Haft JI, The His bundle electrogram. Circulation. 1973 Apr     [PubMed]
Wang G,Liu R,Chang Q,Xu Z,Zhang Y,Pan D, Electrocardiogram: his bundle potentials can be recorded noninvasively beat by beat on surface electrocardiogram. BMC cardiovascular disorders. 2017 Mar 15     [PubMed]
Correction to: Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 7     [PubMed]
Sharma PS,Vijayaraman P, His Bundle Pacing Or Biventricular Pacing For Cardiac Resynchronization Therapy In Heart Failure: Discovering New Methods For An Old Problem. Journal of atrial fibrillation. 2016 Dec     [PubMed]
Deshmukh P,Casavant DA,Romanyshyn M,Anderson K, Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000 Feb 29     [PubMed]
Ellenbogen KA,Vijayaraman P, His Bundle Pacing: A New Promise in Heart Failure Therapy? JACC. Clinical electrophysiology. 2015 Dec     [PubMed]
Rosen KM, The contribution of His bundle recording to the understanding of cardiac conduction in man. Circulation. 1971 Jun     [PubMed]

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