How does the cardiac impulse pass from the sinus to the atrioventricular node?

ABSTRACT

More than a century has passed since Tawara demonstrated the presence of the insulated pathways that extend from the "knoten" at the base of the atrial septum to their ramifications at the ventricular apexes. Having initially doubted the existence of the atrioventricular bundle until reading the monograph produced by Tawara, Keith, together with Flack, soon revealed the presence of the sinus node. Shortly thereafter, Thorel suggested that a special system might be found within the atrial walls, connecting the newly discovered atrial nodes. This prompted the convening of a special session of the German Pathological Society in 1910. The consensus was that no tracts existed within the atrial walls, with Aschoff and Mönckeberg establishing criteria to be met by those proposing recognition of "specialized" atrial conducting pathways. None of those who subsequently proposed the presence of such pathways have discussed their findings on the basis of the criteria established at the meeting of 1910. It remains the case, nonetheless, that drawings continue to be offered by cardiological experts showing narrow pathways within the atrial walls that parallel the arrangement used to show the ventricular conduction pathways. A similar drawing adorns the front cover of Heart Rhythm Journal. We are unaware of any evidence supporting the presence of pathways as illustrated existing within the overall walls of the atrial chambers. In this review, we summarize the evidence that shows, instead, that it is the aggregation of the working atrial cardiomyocytes within the atrial walls that underscores preferential anisotropic interatrial conduction.