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(Circulation. 2008;117:1508-1517.)
© 2008 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Epicardium-Derived Cells in Development of Annulus Fibrosis and Persistence of Accessory Pathways

Denise P. Kolditz, MD; Maurits C.E.F. Wijffels, MD, PhD; Nico A. Blom, MD, PhD; Arnoud van der Laarse, PhD; Nathan D. Hahurij, MSc; Heleen Lie-Venema, PhD; Roger R. Markwald, PhD; Robert E. Poelmann, PhD; Martin J. Schalij, MD, PhD; Adriana C. Gittenberger-de Groot, PhD

From the Department of Cardiology (D.P.K., M.C.E.F.W., A.v.d.L., M.J.S.), Department of Anatomy and Embryology (D.P.K., N.D.H., H.L.-V., R.E.P., A.C.G.-d.G.), and Department of Pediatric Cardiology (N.A.B., N.D.H.), Leiden University Medical Center, Leiden, Netherlands; and Department of Cell Biology and Anatomy (R.R.M.), Medical University of South Carolina, Charleston, SC.

Correspondence to M.J. Schalij, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, Netherlands. E-mail m.j.schalij{at}lumc.nl

Received July 12, 2007; accepted December 26, 2007.

Background— The developmental mechanisms underlying the persistence of myocardial accessory atrioventricular pathways (APs) that bypass the annulus fibrosis are mainly unknown. In the present study, we investigated the role of epicardium-derived cells (EPDCs) in annulus fibrosis formation and the occurrence of APs.

Methods and Results— EPDC migration was mechanically inhibited by in ovo microsurgery in quail embryos. In ovo ECGs were recorded in wild-type (n=12) and EPDC-inhibited (n=12) hearts at Hamburger-Hamilton (HH) stages 38 to 42. Subsequently, in these EPDC-inhibited hearts (n=12) and in additional wild-type hearts (n=45; HH 38–42), ex ovo extracellular electrograms were recorded. Electrophysiological data were correlated with differentiation markers for cardiomyocytes (MLC2a) and fibroblasts (periostin). In ovo ECGs showed significantly shorter PR intervals in EPDC-inhibited hearts (45±10 ms) than in wild-type hearts (55±8 ms, 95% CI 50 to 60 ms, P=0.030), whereas the QRS durations were significantly longer in EPDC-inhibited hearts (29±14 versus 19±2 ms, 95% CI 18 to 21 ms, P=0.011). Furthermore, ex ovo extracellular electrograms (HH 38–42) displayed base-first ventricular activation in 44% (20/45) of wild-type hearts, whereas in all EPDC-inhibited hearts (100%, 12/12), the ventricular base was activated first (P<0.001). Small periostin- and MLC2a-positive APs were found mainly in the posteroseptal region of both wild-type and EPDC-inhibited hearts. Interestingly, in all (n=10) EPDC-inhibited hearts, additional large periostin-negative and MLC2a-positive APs were found in the right and left lateral free wall coursing through marked isolation defects in the annulus fibrosis until the last stages of embryonic development.

Conclusions— EPDCs play an important role in annulus fibrosis formation. EPDC outgrowth inhibition may result in marked defects in the fibrous annulus with persistence of large APs, which results in ventricular preexcitation on ECG. These APs may provide a substrate for postnatally persistent reentrant arrhythmias.

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