Electrical activity in Koch's triangle

The authors have conducted several experimental studies of the cellular electrophysiology of the atrioventricular (AV) node employing the Langendorff-blood perfused heart of both dogs and pigs. Two types of experiments are described: experiments showing that cells with electrophysiological characteristics of typical nodal cells can be found outside Koch's triangle; and mapping experiments during the induction of ventricular echo beats in an attempt to delineate the reentrant circuit thought to underlie AV nodal reentry.

The role of insulin in the regulation of milk protein synthesis in dairy cows

We examined the role of insulin in milk protein synthesis using the hyperinsulinemic-euglycemic clamp approach in combination with abomasal infusion of casein. The two experimental periods consisted of abomasal infusion of water or 0.5 kg/d of casein. An insulin clamp was conducted over the last 4 d of each period. During the insulin clamp, circulating insulin was elevated fourfold, and euglycemia was maintained by the infusion of exogenous glucose. Casein infusion increased milk yield so that milk protein yield was 10% greater than baseline values. Use of the insulin clamp combined with casein infusion increased milk protein yield by 230 g/d (28% greater than baseline values). Milk protein composition was not altered, but content was increased from 3.13% during the baseline period to 3.44% by d 4 of the clamp; calcium concentration in milk increased about 10% to 1.2 g/kg. During the clamp, circulating concentrations of essential amino acids were dramatically reduced. The most pronounced effects were noted for branched-chain amino acids (64% reduction from baseline values). The insulin clamp resulted in alterations in circulating insulin-like growth factor (IGF)-I concentrations (increase) as well as IGF-II and IGF-binding protein-2 concentrations (decreases). Overall, results indicated that the ability of the mammary gland to synthesize milk protein does not function at maximum capacity, and there is a previously unrecognized potential to enhance milk protein percentage and yield.

Role of insulin in the regulation of milk fat synthesis in dairy cows

Five lactating Holstein cows were fitted with rumen fistulas and subjected to a hyperinsulinemic-euglycemic clamp and abomasal casein infusion to examine the effects on milk fat synthesis and the composition of milk fatty acids. The experiment consisted of two periods of abomasal infusions (water or 0.5 kg/d of casein); each period was divided into three 4-d intervals. The initial interval allowed for acclimation, and baseline measurements were established during the second interval. During the third 4-d interval, a hyperinsulinemic-euglycemic clamp was maintained, and insulin was infused continuously at the rate of 1 microgram/kg of body weight per h. Circulating concentrations of insulin were increased more than fourfold, and euglycemia was maintained by infusion of glucose at variable rates. Insulin had no effect on milk fat yield but casein infusion increased milk yield and tended to increase fat yield. A trend toward higher milk yield during the clamp, combined with a slight numerical decrease in milk fat yield, resulted in decreased fat percentage. Calculated net energy balance was positive throughout the study, although feed intake decreased during the insulin clamp, particularly for the water infusion period. Minor changes occurred in the composition of milk fatty acids during the clamp when the balance between de novo and preformed fatty acids shifted slightly toward de novo. Overall, results demonstrated that a relatively constant rate of milk fat synthesis was maintained during chronic hyperinsulinemia. Effects on milk fat yield and composition of fatty acids offered no support for the role of insulin on milk fat depression.

Effect of chronic infusion of placental lactogen on ovine fetal growth in late gestation

To test the hypothesis that placental lactogen (PL) is a humoral regulator of fetal growth, six singleton sheep fetuses received a continuous intravenous fusion of 1.2 mg/d of purified ovine PL (oPL) for 14 d, beginning on Day 122 of gestation. The plasma concentration of oPL was approximately four-fold higher in infused fetuses than in six control fetuses that received a continuous infusion of saline. The circulating insulin-like growth factor 1 (IGF-I) concentration was also significantly elevated in PL-infused fetuses (43.1 +/- 1.7 vs. 31.9 +/- 4.1 ng/ml; P < 0.05). Animals were slaughtered on Day 136, and the placenta and all major fetal tissues were dissected, weighed, and subsampled for chemical analysis. Fetal weight and crown-rump length were not significantly affected by treatment; however, the aggregate weight of the brain, liver, lungs, and heart tended to be larger (85.3 +/- 2.1 vs. 79.9 +/- 1.5 g/kg fetus; mean +/- SE, P = 0.07) and the thyroid gland was smaller (0.18 +/- 0.1 vs. 0.26 +/- 0.02 g/kg fetus; P < 0.05) in the PL-infused fetuses. The livers of the PL-infused fetuses had also accumulated additional glycogen (13.1 +/- 1.7 vs. 8.4 +/- 0.7 g; P < 0.05). In late gestation, PL within the fetal compartment increases fetal plasma IGF-I concentration and hepatic glycogen deposition and may affect the growth of several vital organs.

Electrophysiology of the A-V node in relation to A-V nodal reentry

During A-V nodal reentry the impulse is supposed to travel through two distinct pathways in the A-V nodal junction, called slow and fast pathways. Clinically, catheter ablation of these pathways has been very successful in abolishing A-V nodal reentrant tachycardias. So-called double potentials have been used as a marker for the slow pathway, and the occurrence of accelerated junctional rhythms (AJR) following ablation is an indicator of successful destruction of the slow pathway. In Langendorff, blood-perfused porcine and canine hearts, extensive mapping of extracellular potentials, combined with microelectrode recordings, was carried out to answer the following questions: 1) what is the origin of double extracellular potentials? 2) what causes post-ablation AJR? 3) what is the activation pattern of the AV junction during ventricular echoes? 1) Two types of double potentials were found: a low-frequency component followed by a high-frequency deflection, the LH potential was caused by asynchronous activation of the sinus septum above the coronary sinus and the region between the coronary sinus orifice and tricuspid annulus, where the L component is a far field potential. HL potentials (high-frequency deflection followed by a low frequency component) were caused by asynchronous activation of atrial cells and cells with AV nodal characteristics at the same location. These cells were present around the entire tricuspid annulus, and were not part of the compact node. The proximity of LH potentials to the slow pathway is probably serendipity, HL potentials could represent the slow pathway. 2) Two types of AJR could be initiated both by application of radiofrequency energy and by heat: a regular rhythm that progressively accelerated and an irregular rhythm. The discrete sites where heat application induced AJR did not correlate with areas showing double potentials, nor with exit regions during ventricular pacing. They were close to the compact node and the underlying mechanism was accelerated phase 4 depolarization in single or multiple foci, the latter accounting for irregular AJR. The association between presence of AJR and successful slow pathway ablation is probably also serendipity. 3) During ventricular pacing, two separate areas of earliest atrial activity were found. When ventricular echoes were induced by premature stimulation, the retrograde impulse activated both atrial exit sites and still returned in the ventricles as an echo. Thus, no evidence was found that atrial tissue forms part of the reentrant circuit.

Atrioventricular junctional tissue. Discrepancy between histological and electrophysiological characteristics

BACKGROUND

Previous work has demonstrated that cells with AV nodal-type action potentials are not confined to Koch's triangle but may extend along the AV orifices. The aim of this study was to examine the histological and electrophysiological characteristics of this tissue.

METHODS AND RESULTS

Studies were performed in isolated, blood-perfused dog and pig hearts. Microelectrode recordings revealed cells with nodal-type action potentials around the tricuspid and mitral valve rings. These cells were found within 1 to 2 mm of the valve annuli. A zone of cells with intermediate action potentials, approximately 1 cm wide, separated cells with nodal-type action potentials from cells with atrial-type action potentials in the body of the atria. In cells with nodal-type action potentials, adenosine caused a reduction in action potential amplitude (49 +/- 2 versus 33 +/- 2 mV, mean +/- SE; P < .001), upstroke velocity (2.5 +/- 0.2 versus 2.0 +/- 0.2 V/s, P < .05), and duration (150 +/- 4 versus 96 +/- 8 ms, P < .001). The light microscopic appearance of AV junctional cells was similar to that of myocytes in the body of the atrium. A polyclonal antibody raised against connexin-43 bound to atrial and ventricular tissue but not to the AV junctional tissue or AV nodal region. The absence of connexin-43 correlated with the sites of cells with nodal-like action potentials. With pacing techniques, the AV junctional tissue in the region of the posterior AV nodal approaches could be electrically dissociated from atrial, AV nodal, and ventricular tissue. AV nodal echoes were induced with ventricular pacing in three dog hearts. In each case, retrograde conduction was through the slow pathway, and anterograde conduction was through the fast pathway. During echoes, activation of AV junctional cells preceded atrial activation during retrograde slow pathway conduction, but these cells were not activated during anterograde fast pathway conduction.

CONCLUSIONS

AV junctional cells around both annuli are histologically similar to atrial cells but resemble nodal cells in their cellular electrophysiology, response to adenosine, and lack of connexin-43. The light microscopic appearance of AV junctional cells is a poor guide to their action potential characteristics. The AV junctional cells in the posterior AV nodal approaches appear to participate in slow pathway conduction. These cells may be the substrate of the slow "AV nodal" pathway.

Insulin regulates circulating insulin-like growth factors and some of their binding proteins in lactating cows

Four lactating Holstein cows were subjected to a hyperinsulinemic-euglycemic clamp to evaluate the effects of insulin on circulating concentrations of insulin-like growth factors (IGF) and their binding proteins (IGFBP). Baseline blood samples were taken every 4 h for 2 days. For the 4-day clamp, insulin was infused (1 microgram.kg body wt-1.h-1) into the jugular vein and exogenous glucose was infused to maintain euglycemia. Circulating insulin was increased approximately fivefold, while glucose was maintained within 10% of baseline concentrations by infusion of 0.15 g.kg body wt-1.h-1 glucose. Hyperinsulinemia-euglycemia approximately doubled IGF-I (145 vs. 286 ng/ml, SE = 20) while decreasing circulating IGF-II (285 vs. 180 ng/ml, SE = 32). Densitometry of Western blots demonstrated no change in IGFBP-3 or a 30,000 relative molecular weight (M(r)) band during the clamp. However, IGFBP-2 decreased 73% and a 26,000 M(r) band decreased 58% by the end of the clamp. Therefore, insulin, directly or via secondary changes, increased circulating concentrations of IGF-I while decreasing concentrations of IGF-II, IGFBP-2, and a 26,000 M(r) IGFBP in lactating cows.

Role of insulin in the regulation of mammary synthesis of fat and protein

Five lactating Holstein cows were subjected to a hyperinsulinemiceuglycemic clamp to examine the effects of insulin on milk yield and composition. Of special interest was the evaluation of the glucogenic-insulin theory of milk fat depression. Cows were fed every other hour to minimize postprandial effects, and blood samples were obtained via an indwelling jugular catheter every 4 h for 2 d to establish baseline glucose concentrations. For the 4-d clamp, insulin was infused continuously (1 microgram/kg of BW per h) into the contralateral jugular vein, and circulating insulin was increased approximately fivefold. Blood was sampled frequently, and blood glucose was maintained within 10% of baseline concentrations by infusion of exogenous glucose at variable rates (mean = .15 g/kg of BW per h). Dietary intake declined on the 4th d of the insulin clamp (23.0 vs. 16.3 kg/d). Milk yield, however, did not change (32.4 vs. 33.6 kg/d) in support of the lack of sensitivity of the mammary gland to insulin. Milk fat percentage (3.85 vs. 3.66) and yield (1.26 vs. 1.22 kg/d) did not change during the insulin clamp. Milk protein yield increased (.98 vs. 1.05 kg/d), and milk protein percentage tended to increase (3.04 vs. 3.14), during the insulin clamp. This modest increase in milk protein yield may have been constrained by a lack of available amino acids, as indicated by a decrease in circulating concentrations of essential amino acids, urea nitrogen, and plasma proteins. Overall, results offer no support for the glucogenic-insulin theory of milk fat depression but do indicate that the insulin infusion, either directly or indirectly, enhanced secretion of milk protein.

Nutritional modulation of the somatotropin/insulin-like growth factor system: response to feed deprivation in lactating cows

Mid-lactation Holstein cows (n = 4) were used to evaluate the effects of complete feed deprivation on circulating insulin-like growth factors (IGF) and their binding proteins (IGFBP). Comparisons were made between cows in fed and unfed conditions and included response to a single injection of bovine somatotropin (bST). Two days of feed deprivation decreased milk yield 66%. Concentrations of bST nearly doubled during feed deprivation, whereas glucose and insulin steadily decreased. Circulating concentrations of IGF-I decreased nearly 50%, IGF-II decreased 28% and IGFBP-2 increased 49% during the 2 d of feed deprivation. In contrast, IGFBP-3 was not affected. Eighteen to 24 h after the bST challenge, circulating concentrations of IGF-I rose 100% during the fed period, but there was no response during the unfed period. Blood concentrations of IGF-II decreased 17% after bST challenge in the fed period but were unchanged in the unfed period. More moderate undernutrition (80% of requirements) did not affect circulating IGFBP-2 but did alter the response of IGFBP-2 to bST. A conceptual model was developed that illustrates that nutritional regulation of the ST/IGF system represents a key component signaling the appropriate use of nutrients. Overall, results demonstrate that nutritional modulation of the ST/IGF system plays a key role in animal performance and well-being over a wide range of physiological situations.

Does the induction of ventricular flutter or fibrillation at electrophysiologic testing after myocardial infarction have any prognostic significance?

This study examines the significance of inducing sustained ventricular fibrillation (VF) or ventricular flutter by programmed stimulation after infarction. Programmed ventricular stimulation was performed for prognostic reasons from the right ventricular apex at twice diastolic threshold using a protocol containing 4 extrastimuli. Of 502 patients tested 11 +/- 4 days after acute infarction, VF was induced in 164 (33%), ventricular flutter in 134 (27%), ventricular tachycardia (VT) in 44 (9%), and no arrhythmia in 160 (32%). All groups were similar in age, sex distribution, and sites of index infarction. Those with inducible VT had a higher incidence of multiple infarctions and a lower mean left ventricular ejection fraction at the time of testing. Without antiarrhythmic drug therapy, 8 patients (18%) with inducible VT experienced spontaneous VT or died instantaneously during the first year of follow-up. By contrast, only 1 (0.6%) patient with inducible VF, 1 (0.7%) with ventricular flutter, and 1 (0.6%) without any inducible arrhythmias experienced similar events in the same period (p < 0.001). By relating the cycle length of the induced monomorphic arrhythmia to later spontaneous electrical events, induced arrhythmias with cycle length as low as 230 ms still identified patients at high risk for spontaneous arrhythmias. Only the induction of sustained monomorphic VT with a cycle length > 230 ms indicates patients with ventricular electrical instability after infarction. The induction of VF or ventricular flutter is a negative test result with no adverse long-term prognostic significance.

New insights on anatomical location of components of the reentrant circuit and ablation therapy for atrioventricular junctional reentrant tachycardia

The success of radiofrequency catheter ablation in the treatment of atrioventricular junctional, or atrioventricular nodal, reentrant tachycardia has rekindled interest in the electrophysiological and anatomical characteristics of the reentrant circuit. We conclude that there is no evidence that within the atrioventricular nodal area, which contains both the compact node and transitional cells, there are anatomically delineated dual or multiple pathways. Rather, the two main atrial inputs into the atrioventricular nodal area (posterior and anterior) seem to be the anatomically relevant structures for "slow" and "fast" pathways. Two other inputs (sinus septum and left atrial) may be the cause for multiple pathways in some individuals. Nonuniform anisotropic properties of the zone of transitional cells may account for slow or fast conduction in the same area, depending on directional differences of wavefronts. We prefer the term atrioventricular junctional reentrant tachycardia rather than atrioventricular nodal reentrant tachycardia because of mounting evidence that perinodal tissue is involved in the reentrant circuit. Finally, the role and origin of double extracellular electrograms is discussed. Further research is required to establish whether an anatomical or an electrogram-guided approach for catheter ablation is preferred.

Triggered activity and automaticity in ventricular trabeculae of failing human and rabbit hearts

OBJECTIVE

The aim of the study was to assess the occurrence of triggered activity and automaticity in ventricular trabeculae from failing human hearts and normal and failing rabbit hearts during exposure to a normal and altered extracellular environment.

METHODS

Ventricular trabeculae were harvested from failing human hearts (from patients undergoing cardiac transplantation) and from normal and failing rabbit hearts (combined volume and pressure overload). Trabeculae were superfused with normal Tyrode solution followed by a modified Tyrode solution, which mimicked the extracellular milieu in patients with severe heart failure. Modified Tyrode solution contained low potassium (3.0 mM), low magnesium (0.4 mM), and noradrenaline (1 microM).

RESULTS

During superfusion with normal Tyrode solution, early afterdepolarisations, delayed afterdepolarisations, and automaticity were not observed in trabeculae from failing hearts. In the modified Tyrode solution, early afterdepolarisations could be induced in 26% of control rabbit and 30% of failing rabbit trabeculae, but never in human trabeculae. During superfusion with the modified solution delayed afterdepolarisations or triggered activity could be induced in 50% of the human failing trabeculae, in 43% of the failing rabbit trabeculae, and in 9% of the normal rabbit trabeculae (p < 0.01); automaticity was observed in 44% of the human trabeculae, and in 7% of the failing rabbit trabeculae, but in none of the control rabbit trabeculae. In failing rabbit myocardium action potential duration was prolonged at cycle lengths > or = 350 ms, but not at shorter cycle lengths.

CONCLUSIONS

Delayed afterdepolarisations and automaticity, but not early afterdepolarisations, occur more frequently in myocardium from failing hearts, but only during superfusion with a modified Tyrode solution. This emphasises that the extracellular environment is important with respect to arrhythmogenesis in heart failure, apart from the fixed cellular defect due to heart failure per se. Prolongation of the action potential in failing hearts does not occur at physiological and higher heart rates and therefore cannot be regarded as a protective factor in the prevention of reentrant arrhythmias. The rate of triggered and automatic rhythms was slow. Therefore these mechanisms cannot be responsible for clinical ventricular tachycardias or fibrillation, but may serve as triggers for reentrant arrhythmias.

Surgical procedure for the cure of atrioventricular junctional ("AV node") reentrant tachycardia: anatomic and electrophysiologic effects of dissection of the anterior atrionodal connections in a canine model

OBJECTIVES

This study was undertaken to examine the electrophysiologic and anatomic effects of a surgical procedure that cures the anterior (common) type of atrioventricular (AV) junctional reentrant tachycardia.

BACKGROUND

The procedure was designed to interrupt the reentrant circuit at the point of earliest atrial activation during AV junctional reentrant tachycardia, the anterior atrionodal connections.

METHODS

Atrioventricular node function and the sequence of electrical excitation of Koch's triangle were examined in 18 dogs. Excitation of Koch's triangle was mapped using a 60-channel mapping system. Surgical dissection was performed in 10 dogs and a sham procedure in 8. After 28 to 35 days, AV node function and the atrial excitation pattern were reassessed. The AV junction was examined using light microscopy.

RESULTS

Some degree of AV node damage was visible in all dogs in the dissection group, but it was minor in 40% of cases. The anterior part of the AV node was disconnected from the anterior atrionodal connections in all cases. Anterograde AV node function was mildly impaired. The median AH interval was increased (62 vs. 76 ms [interquartile ranges 48 to 72 and 64 to 104, respectively], p = 0.05), and the AV Wenckebach cycle length was increased (210 vs. 245 ms [interquartile ranges 200 to 230 and 210 to 260, respectively], p = 0.02). The degree of impairment of conduction was directly proportional to the length of dissection (p < 0.05) but not to the degree of damage to the AV node. Ventriculoatrial (VA) conduction was destroyed in 50% of dogs undergoing dissection but in none of those with a sham operation (p < 0.04). The AV node remained responsive to autonomic blocking drugs, and atrial mapping during ventricular pacing revealed that the site of exit from the AV node had been altered.

CONCLUSIONS

The atrionodal connections closest to the His bundle are the preferred route of conduction through the AV node during normal AV or VA conduction. Destruction of these connections modifies AV node conduction. The surgical procedure selectively interrupts these connections, and this interruption is likely to be the mechanism of cure.

Macromineral nutrition by heat stress interactions in dairy cattle: review and original research

This paper examines whether or not responses of dairy cattle to various dietary macromineral elements differed in hot weather compared with thermoneutral conditions. The consequences of heat stress and the interrelationships of macromineral elements on feed intake, digestive function, use of dietary buffers, mineral element uptake from the portal-drained viscera, perturbation of acid-base physiology and related mineral element nutrition, effects of dietary macromineral element concentrations on lactational performance as affected by season, and influence of mineral elements in drinking water are reviewed, and new research results are presented. Dietary mineral buffers aided in alleviation of the decline in DMI and milk yield induced by heat stress. New research results showed that portal plasma flow declined with heat stress or by restriction of DMI in a thermoneutral environment and that uptake of P from the portal-drained viscera by lactating cows was reduced 50% by heat stress compared with that of cows with the same DMI in a thermoneutral environment. Accelerated respiration rate caused respiratory alkalosis and apparently compensated metabolic acidosis, changing the demand for Na and K during heat stress. There is need to characterize more accurately the nyctohemeral pattern of acid-base physiology in the heat-stressed lactating dairy cow and to relate it to macromineral element needs. A large data set (n = 1444 cow period means) was used to compare milk yield and DMI responses to varying dietary concentrations of P, Na, K, Cl, Ca, Mg, and cation-anion difference in summer compared with those in winter. Interactions of dietary concentrations of Cl, Ca, and Mg with season on DMI and K, Ca, and Mg with season on 4% FCM yield were detected. Interactions of Na by Cl, Na by P, and Cl by P with season on DMI and of Cl by P with season on 4% FCM yield were detected. High concentrations of sulfate and chloride in drinking water jeopardized productivity of cows during hot weather.

Origin and significance of double potentials near the atrioventricular node. Correlation of extracellular potentials, intracellular potentials, and histology

BACKGROUND

Atrioventricular junctional (AV nodal) reentrant tachycardia can be cured by catheter ablation of the slow pathway, which is part of the reentrant circuit. Previous work has suggested that extracellular double potentials may help identify the site of the slow pathway, but the origin and significance of these potentials are controversial. The aim of this study was to identify the source of these potentials.

METHODS AND RESULTS

Studies were performed in isolated, blood-perfused porcine (n = 8) and canine (n = 4) hearts. Several methods were used to identify the origin of potentials: microelectrode recording, extracellular mapping, pacing from multiple sites, and light microscopy. Two types of double potentials, similar to those found in humans, were found in all hearts. LH potentials consisted of a low-frequency deflection followed by a high-frequency deflection during sinus rhythm or anterior septal pacing. HL potentials consisted of a high-frequency deflection followed by a low-frequency deflection. LH potentials were found close to the coronary sinus orifice. They were caused by asynchronous activation of the sinus septum and the region between the coronary sinus orifice and tricuspid annulus. HL double potentials were found along the tricuspid annulus. They were caused by asynchronous activation of two cell layers. The high-frequency component was caused by depolarization of atrial-type cells in the deep subendocardial layer. The low-frequency component was caused by depolarization of cells with nodal characteristics close to the endocardium. These cells were present around the entire tricuspid annulus, were not part of the compact AV node, and could be dissociated from the bulk of the atria by rapid atrial pacing.

CONCLUSIONS

LH potentials are caused by asynchronous activation of muscle bundles above and below the coronary sinus orifice. Their proximity to the site of the slow pathway is probably serendipity. HL double potentials are caused by asynchronous activation of atrial cells and a band of nodal-type cells close to the tricuspid annulus. The band of nodal-type cells is not part of the compact AV node and may represent the substrate of the slow AV nodal pathway.

Electrophysiologic and histologic effects of dissection of the connections between the atrium and posterior part of the atrioventricular node

OBJECTIVES

This study was designed to examine the effects of destroying the posterior approaches to the atrioventricular (AV) node.

BACKGROUND

Surgical and catheter ablation procedures have been developed for the cure of AV junctional reentrant tachycardia. Some of these destroy the posterior approaches to the AV node.

METHODS

Atrioventricular node function and electrical excitation of Koch's triangle and the proximal coronary sinus were examined in 18 dogs. Dissection of the posterior atrionodal connections was performed in 10 dogs and a sham procedure in 8. After 28 to 35 days, repeat electrophysiologic and mapping studies were performed to assess changes in AV node function and the routes of AV and ventriculoatrial (VA) conduction. The AV junction was then examined with light microscopy.

RESULTS

The compact AV node was undamaged in eight cases (80%). In two cases minor fibrosis occurred at the posterior limit of the compact node. The right-sided posterior atrionodal connections lying between the coronary sinus orifice and the tricuspid annulus were replaced by scar tissue in all cases, but the left-sided posterior connections and the anterior connections remained intact. Atrioventricular and VA conduction intervals and refractory periods were not altered. Atrioventricular junctional echoes were present in 10 dogs before and in 7 dogs after dissection (p = 0.06). Posterior (slow pathway) retrograde exists from the AV node were present in seven dogs before and in seven dogs after dissection. However, retrograde atrial excitation was altered in four of these seven dogs, so that the site of exit from the AV node was more leftward than it had been preoperatively. The node remained responsive to autonomic blocking drugs postoperatively. Double atrial electrograms similar to slow pathway potentials were found in all dogs.

CONCLUSIONS

This procedure ablates the posterior atrionodal connections but rarely damages the compact AV node. Atrioventricular node function is not impaired and the node is not denervated. The mechanism of cure of AV junctional reentrant tachycardia is probably damage to the perinodal atrium. This suggests that part of the slow AV node pathway may lie outside the compact AV node. Dual AV node exits and double atrial electrograms are present in the normal canine heart.

Posterior ("atypical") atrioventricular junctional reentrant tachycardia

The aim of this study was to characterize a relatively rare type of atrioventricular (AV) junctional reentrant tachycardia (AVJRT). Posterior AVJRT is a type of AV nodal tachycardia in which the site of earliest atrial activation is posterior to the AV node near the coronary sinus orifice. The mechanism of this tachycardia is not well understood. The characteristics of posterior AVJRT (n = 15) were compared with those of anterior ("common") AVJRT (n = 146) and supraventricular tachycardia using single posterior septal accessory pathways (n = 13). During posterior AVJRT, the AH interval was longer than the retrograde conduction time (His to earliest atrial activity) in 11 cases (73%), indicating that these tachycardias were not fast-slow types of AVJRT. The mean ventriculoatrial (VA) interval in posterior AVJRT (93 +/- 41 ms) was longer than in anterior AVJRT (11 +/- 20 ms; p < 0.005), but was similar to that in tachycardias using accessory pathways (106 +/- 16 ms; p = NS). The site of earliest atrial activation during posterior AVJRT was similar to that in tachycardias using accessory pathways. In all cases of accessory pathway-mediated tachycardia, atrial activation could be advanced by ventricular extrastimuli delivered coincident with the His deflection, but atrial activation was not advanced in any case of posterior AVJRT unless the extrastimulus was delivered > 80 ms before the His deflection. Anterograde conduction was similar in the posterior and anterior AVJRT groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Slow potentials in the atrioventricular junctional area of patients operated on for atrioventricular node tachycardias and in isolated porcine hearts

OBJECTIVES

The purpose of this study was to 1) investigate extracellular electrograms in the atrioventricular (AV) junctional area of patients with AV node reentrant tachycardia, 2) compare them with recordings made in isolated porcine hearts, and 3) study their origin.

BACKGROUND

Electrograms with slow components have been used to target the delivery of radiofrequency energy for the cure of AV node reentrant tachycardia. The origin of these electrograms is unknown.

METHODS

In 12 human and 19 porcine hearts, extracellular recordings were made simultaneously from 64 sites. In five other porcine hearts, intracellular recordings were made at sites at which extracellular electrograms revealed slow potentials. Histologic investigations were carried out in four of these hearts.

RESULTS

Electrograms with slow components were recorded in five human and eight porcine hearts. These signals were found at sites up to 12 mm from the His bundle. Characteristics of the electrograms did not differ significantly among human and porcine hearts. Electrophysiologic evidence for multiple pathways was present in four hearts. Superficial impalements with microelectrodes at sites with slow potentials showed action potentials with AV node characteristics. In the majority of these recordings, the upstroke coincided with the downstroke of slow potentials. Histologic investigations of the sites of impalement revealed transitional cells directly underneath the endocardium.

CONCLUSIONS

Slow potentials were recorded in both human and porcine hearts in similar measure. They arise from transitional cells and have action potentials similar to N cells.

High resolution mapping of Koch's triangle using sixty electrodes in humans with atrioventricular junctional (AV nodal) reentrant tachycardia

BACKGROUND

Recent evidence suggests that atrioventricular junctional reentrant tachycardia (AVJRT) uses a reentrant circuit that involves the atrioventricular (AV) node, the atrionodal connections, and perinodal atrial tissue. Electrogram morphology has been used to target the delivery of radiofrequency energy to the site of the "slow pathway," a component of this reentrant circuit. The aim of this study was to localize precisely the sites of atrionodal connections involved in AVJRT and to examine atrial electrogram morphologies and their spatial distribution over Koch's triangle.

METHODS AND RESULTS

Electrical activation of Koch's triangle and the proximal coronary sinus was examined in 13 patients using a 60-point plaque electrode and computerized mapping system. Recordings were made during sinus rhythm (n = 12), left atrial pacing (n = 8), ventricular pacing (n = 12), and AVJRT (n = 12). During sinus rhythm electrical activation approached Koch's triangle and the AV node from the direction of the anterior limbus, activating the anterior part of the triangle before the posterior part. A zone of slow conduction during sinus rhythm was found within Koch's triangle in 64% of patients. The pattern of atrial activation in Koch's triangle during anterograde fast pathway conduction was similar to that seen during anterograde slow pathway conduction. Retrograde fast pathway conduction during ventricular pacing and during anterior (typical) AVJRT caused earliest atrial activation at the apex of Koch's triangle near the AV node-His bundle junction. In individual patients the site of earliest atrial activation was similar for both anterior AVJRT and retrograde fast pathway conduction during ventricular pacing. Retrograde slow pathway conduction during ventricular pacing and during posterior (uncommon or atypical) AVJRT caused earliest atrial activation posterior to the AV node near the orifice of the coronary sinus. This posterior or "slow pathway" exit site was 15 +/- 4 mm from the His bundle. In individual patients the site of earliest atrial activation was similar for both posterior AVJRT and retrograde slow pathway conduction during ventricular pacing. In one patient anterograde and retrograde conduction occurred via separate slow pathways during AVJRT: Complex atrial electrograms with two or more components were observed near the coronary sinus orifice and in the posterior part of Koch's triangle in all cases. These were categorized as either low or high frequency potentials according to the rapidity of the second component of the electrogram. Low frequency potentials were present at the site of earliest atrial excitation during retrograde slow pathway conduction in 5 of 5 cases (100%) and high frequency potentials in 4 of 5 cases (80%). However, both slow and high frequency potentials could be found at sites up to 16 mm from the site of earliest atrial excitation.

CONCLUSIONS

At least two distinct groups of atrionodal connections exist. The site of earliest atrial activation during anterior AVJRT is similar to that of fast pathway conduction during ventricular pacing. This site is close to the His bundle-AV node junction. The site of earliest atrial activation during posterior AVJRT is similar to that of slow pathway conduction during ventricular pacing. This site is near the coronary sinus orifice, approximately 15 mm from the His bundle. The anterograde slow pathway appears to be different from the retrograde slow pathway in some patients. Double atrial electrograms are an imprecise guide to the site of earliest atrial excitation during retrograde slow pathway conduction.

"AV nodal" reentry: Part I: "AV nodal" reentry revisited

This review is the first of a two-part series of articles on "atrioventricular [AV] nodal reentry." The early clinical literature as well as the experimental studies are reviewed, and more recent morphologic data are presented, with the aim of clarifying whether the reentrant circuit is confined to the AV node, or consists in part of extranodal components. Most of the evidence supports the concept that atrial tissue is an essential link in the reentrant pathway. Arguments will be presented to indicate that within the AV node, the separation between antegrade and retrograde pathways is functional, not anatomical, and that both pathways are in electrotonic contact.

"AV nodal" reentry: Part II: AV nodal, AV junctional, or atrionodal reentry?

The classical model of "atrioventricular (AV) nodal" reentrant tachycardia suggests that the reentrant circuit is entirely within the compact AV node and that AV nodal tissue is present proximal and distal to the circuit. Recent evidence from mapping studies and from examination of the effects of curative procedures, however, suggests that the upper end of the circuit uses perinodal atrial or transitional tissue. Moreover, the anatomical substrate of dual "AV nodal" pathways is likely to be the multiple connections between compact AV node and atrium rather than discrete intranodal pathways. The antegrade slow pathway appears to be situated at the posteroinferior approaches to the AV node in the region between the coronary sinus orifice and the tricuspid annulus. The retrograde fast pathway appears to be situated in the anterior atrionodal connections at the apex of Koch's triangle, close to the His bundle. The lower turnaround point of the circuit is likely to be within the AV node.

Older patients with COPD: benefits of exercise training

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and functional disability in older adults. In its advanced stages, it is characterized by progressive breathlessness and serious exercise curtailment. Aerobic exercise training (EXT) is recommended for patients who remain breathless despite optimal pharmacologic treatment. Although the physiologic rationale for EXT in COPD patients remains controversial, it is generally accepted that even older incapacitated COPD sufferers who participate in an individualized training program show significant reductions in breathlessness, increased exercise capacity, and enhanced psychosocial function. An 8-week outpatient program that is carefully regulated and includes an educational component is recommended.

Insulin-like growth factors and binding proteins in ruminants and their nutritional regulation

Insulin-like growth factors (IGF) are important mediators of growth, lactation, reproduction, and health. Considerable information on their role in ruminant animals has been learned in the past several years, but the precise mechanisms of their action are not known. The exact biological response of target cells is undoubtedly determined by the developmental state of the cell and synergism with other growth factors. Overall, somatomedins and their binding proteins seem to be major links between cellular developmental processes and nutrient supply. The mechanism by which nutrients control biological actions of somatomedins is not known but clearly involves the synthesis of IGF, as well as their binding proteins and receptors. In ruminants, severe feed restriction decreases circulating concentrations of IGF-I, whereas subtle alterations typical of those that occur in production systems have minimal effect. However, the responses of IGF to somatotropin are affected by modest alterations in nutritional status, including differences in nutritional status that are typically encountered in animal production systems.