Circulation, Vol 77, 1221-1237, Copyright © 1988 by American Heart Association
JP Boineau, TE Canavan, RB Schuessler, ME Cain, PB Corr and JL Cox
Atrial depolarization was analyzed in 14 patients with the Wolff-
Parkinson-White syndrome undergoing surgery to ablate accessory
atrioventricular pathways associated with tachyarrhythmias. Bipolar
potentials were recorded simultaneously from 156 atrial epicardial
electrodes arranged in three templates to fit the anterior and posterior
aspects of both atria. Spontaneous or sinus rhythms were recorded, as were
atrial escape rhythms after overdrive pacing at rates of 150 and 200
beats/min. Atrial activation maps revealed different patterns of impulse
initiation varying from typical unifocal sinus node impulse origin,
unifocal extranodal impulse origin, and multicentric impulse origin from
two to four widely distributed atrial pacemaker sites. In subjects
demonstrating only unifocal impulse origin during control or sinus rhythm,
other widely divergent pacemaker sites were recorded in other maps during
subsequent rhythms. In addition to sites located at the upper superior vena
cava-right atrium junction, pacemakers also dominated at sites anterior and
inferior to the sinus node region during both control and escape
depolarizations. Most of the subjects were found to have two or more
pacemaker sites when maps of all control and postpacing conditions were
analyzed. The right atrial pacemaker region encompassed a zone of 7.5 X 1.5
cm centered about the long axis of the sulcus terminalis posteriorly and
the precaval band anteriorly. An unexpected finding was the participation
of left atrial escape pacemakers. The functional behavior of both the
control and escape pacemakers, as assessed by sinus node recovery time, was
normal, indicating physiologic operation of the extranodal sites as part of
an overall system of distributed pacemakers involved in the control of
rate. Although functional assessment was limited in these initial patient
studies, correspondence with similar observations in extensive previous
canine studies supports the concept of a widely distributed atrial
pacemaker complex in man.
ARTICLES
Demonstration of a widely distributed atrial pacemaker complex in the human heart
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110.
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