The Wolff-Parkinson-White syndrome: the cellular substrate for conduction in the accessory atrioventricular pathway

The longstanding quest for the anatomical basis of the Wolff-Parkinson-White syndrome has left many unanswered questions. The ultrastructuralmorphology of the myocytes comprising accessory atrioventricularpathways, which are capable of rapid and variable conduction,is central to understanding the development and behaviour ofthis congenital anomaly, but remains unknown. Examination ofthree surgically resected pathways was performed to determinetheir underlying cellular morphology and the pattern of intercellularcoupling, by correlative light microscopy, electron microscopyand confocal scanning laser microscopy combined with immunohistochemicallocalization of the cardiac gap-junctional protein, connexin43. Two left-sided pathways were composed of myocardium of ‘normalworking ventricular’ type. The right-sided pathway wascomposed almost entirely of highly abnormal myocytes characterizedby aberrant myofibril organisation, with a lack of A-band materialand abnormal mitochondria, but normal intact intercalated disksno different from those seen in left-sided pathways. The gapjunctions of all pathways were composed of connexin43 distributedas in ventricular myocardium, and not as found in atrial oratrioventricular nodal tissues. While myocytes of abnormal structure were present in one ofthe accessory atrioventricular pathways examined, all pathwayshad morphologically normal gap junctions, the structures responsiblefor efficient intercellular coupling, with a pattern of distributionsuggestive of working ventricular myocardium.