Optical measurements of transmembrane potential changes during electric field stimulation of ventricular cells

The induction of reentry in cardiac tissue. The missing link: How electric fields alter transmembrane potential

This review examines the initiation of reentry in cardiac muscle by strong electric shocks. Specifically, it concentrates on the mechanisms by which electric shocks change the transmembrane potential of the cardiac membrane and create the physiological substrate required by the critical point theory for the initiation of rotors. The mechanisms examined include (1) direct polarization of the tissue by the stimulating current, as described by the one-dimensional cable model and its two- and three-dimensional extensions, (2) the presence of virtual anodes and cathodes, as described by the bidomain model with unequal anisotropy ratios of the intra- and extracellular spaces, (3) polarization of the tissue due to changing orientation of cardiac fibers, and (4) polarization of individual cells or groups of cells by the electric field ("sawtooth potential"). The importance of these mechanisms in the initiation of reentry is examined in two case studies: the induction of rotors using successive stimulation with a unipolar electrode, and the induction of rotors using cross-field stimulation. These cases reveal that the mechanism by which a unipolar stimulation induces arrhythmias can be explained in the framework of the bidomain model with unequal anisotropy ratios. In contrast, none of the examined mechanisms provide an adequate explanation for the induction of rotors by cross-field stimulation. Hence, this study emphasizes the need for further experimental and theoretical work directed toward explaining the mechanism of field stimulation. (c) 1998 American Institute of Physics.

The role of cardiac tissue structure in defibrillation

The purpose of this paper is to investigate the relationship between cardiac tissue structure, applied electric field, and the transmembrane potential induced in the process of defibrillation. It outlines a general understanding of the structural mechanisms that contribute to the outcome of a defibrillation shock. Electric shocks defibrillate by changing the transmembrane potential throughout the myocardium. In this process first and foremost the shock current must access the bulk of myocardial mass. The exogenous current traverses the myocardium along convoluted intracellular and extracellular pathways channeled by the tissue structure. Since individual fibers follow curved pathways in the heart, and the fiber direction rotates across the ventricular wall, the applied current perpetually engages in redistribution between the intra- and extracellular domains. This redistribution results in changes in transmembrane potential (membrane polarization): regions of membrane hyper- and depolarization of extent larger than a single cell are induced in the myocardium by the defibrillation shock. Tissue inhomogeneities also contribute to local membrane polarization in the myocardium which is superimposed over the large-scale polarization associated with the fibrous organization of the myocardium. The paper presents simulation results that illustrate various mechanisms by which cardiac tissue structure assists the changes in transmembrane potential throughout the myocardium. (c) 1998 American Institute of Physics.

The effect of gap junctional distribution on defibrillation

We summarize a mathematical theory for direct activation and defibrillation of cardiac tissue. We show that the direct stimulus and defibrillation thresholds are likely to be strongly affected by the gap junctional distribution and density, suggesting an indirect experimental test of the theory. (c) 1998 American Institute of Physics.

Models of defibrillation of cardiac tissue

Heterogeneities, such as gap junctions, defects in periodical cellular lattices, intercellular clefts and fiber curvature allow one to understand the effect of an electric field in cardiac tissue. They induce membrane potential variations even in the bulk of the myocardium, with a characteristic sawtooth shape. The sawtooth potential, induced by heterogeneities at large scales (tissue strands) can be more easily observed, and lead to stronger effects than the one induced at the cellular level. In the generic model of propagation in cardiac tissue (FitzHugh), 4 mechanisms of defibrillation were found, two mechanisms based on excitation (E(A),E(M)), and two-on de-excitation (D(A),D(M)). The lowest electric field is required by an E(M) mechanism. In the Beeler-Reuter ionic model, mechanism D(M) is impossible. We critically review the experimental basis of the theory and propose new experiments. (c) 1998 American Institute of Physics.

The relation between changes in myocyte orientation and contractile function with electrical field stimulation

The cardiac myocyte is the fundamental contractile unit of the heart, and therefore recent studies have examined myocyte function through electrical field stimulation. However, the relation between changes in electrical field orientation and myocyte contractile function remains unclear. Accordingly, the goal of the present study was to measure myocyte contractile function with known changes in myocyte orientation with respect to the electrodes. Isolated left ventricular porcine myocytes (n = 32) were field stimulated (0.5 - 1.5 Hz, 5 ms, double contraction threshold) in a thermostatically controlled chamber. Myocyte velocity of shortening was measured by high speed video microscopy. Myocyte position was altered and quantified with respect to the electrodes. When myocyte position approached alignment with the electrodes, contractile activity ceased. Contractile activity resumed when the myocyte moved greater than 25 degrees from the parallel position. When contractions could be successfully elicited, the velocity of shortening was 48+/-15 microm/s and did not differ at any orientation. These results suggest that angular orientation should be carefully considered when evaluating the contractile performance of electrically stimulated myocytes.

Shock-induced dispersion of ventricular repolarization: implications for the induction of ventricular fibrillation and the upper limit of vulnerability

INTRODUCTION

Shock-induced dispersion of ventricular repolarization (SIDR) caused by an electrical field stimulus has been suggested as a mechanism of ventricular fibrillation (VF) induction; however, this hypothesis has not been studied systematically in the intact heart. Likewise, the mechanism underlying the upper (ULV) and lower (LLV) limit of vulnerability remains unclear.

METHODS AND RESULTS

In eight Langendorff-perfused rabbit hearts, monophasic action potentials were recorded simultaneously from ten different sites of both ventricles. Truncated biphasic T wave shocks were randomly delivered at various coupling intervals and strengths, exceeding the vulnerable window, ULV, and LLV, SIDR, defined as the difference between the longest and shortest postshock repolarization times, was 64 +/- 15 msec for shocks inducing VF. SIDR was 41 +/- 17 msec for shocks delivered above the ULV, and 33 +/- 14 and 27 +/- 8 msec for shocks delivered 10 msec before and after the vulnerable window, respectively (all P < 0.01 vs VF-inducing shocks). Although SIDR was larger for shocks delivered below the LLV (93 +/- 24 msec, P < 0.01 vs VF-inducing shocks), the repolarization extension was significantly smaller for shocks below the LLV (10.3% +/- 3.9% vs 16.3% +/- 4.9%, P < 0.01).

CONCLUSION

SIDR is influenced by the shock timing and intensity. Large SIDR within the vulnerable window and an SIDR decrease toward its borders suggest that SIDR is essential for VF induction. The decrease in SIDR toward greater shock strengths may explain the ULV. Small repolarization extension for shocks below the LLV may explain why these shocks, despite producing large SIDR, fail to induce VF.

Membrane refractoriness and excitation induced in cardiac fibers by monophasic and biphasic shocks

INTRODUCTION

This modeling study examines the effect of low-intensity monophasic and biphasic waveforms on the response of a refractory cardiac fiber to the defibrillation shock.

METHODS AND RESULTS

Two cardiac fiber representations are considered in this study: a continuous fiber and a discrete fiber that incorporates gap junctions. Each fiber is undergoing a propagating action potential. Shocks of various strengths and coupling intervals are delivered extracellularly at fiber ends during the relative refractory period. In a continuous fiber, monophasic shock strengths of three times the diastolic threshold either elicit no response or, for coupling intervals above 380 msec, reinitiate propagation. In contrast, biphasic shocks of same strength are capable of terminating the existing wavefronts by either invoking a nonpropagating response (coupling intervals 370 to 382 msec) that prolongs the refractory period or inducing wavefront collision (coupling intervals above 400 msec). The fiber response is similar for other shock strengths and when cellular discontinuity is accounted for. Thus, for a refractory fiber, biphasic shocks have only a small "vulnerable" window of coupling intervals over which propagation is reinitiated.

CONCLUSION

At short coupling intervals, a significant extension of refractoriness is generated at regions where the biphasic shock induced hyperpolarization followed by depolarization. At large coupling intervals, the enhanced efficacy of biphasic shocks is associated with their ability to induce wavefront collision, thus decreasing the probability of reinitiating fibrillation. Overall, the defibrillation shock affects the tissue through the induced large-scale hyperpolarization and depolarization, and not through the small-scale transmembrane potential oscillations at cell ends.

Effects of 2,3-butanedione monoxime on atrial-atrioventricular nodal conduction in isolated rabbit heart

INTRODUCTION

2,3-Butanedione monoxime (BDM) has been found to reversibly block cardiac contraction, without blocking electrical conduction. This study characterizes the dose-dependent effects of BDM on the conduction through the atrioventricular node (AVN) of rabbit heart.

METHODS AND RESULTS

Thirteen isolated atrial-AVN preparations were used in control, during and after exposure to 5, 10, and 20 mM BDM. Anterograde and retrograde pacing protocols were used to obtain the Wenckebach cycle length, effective and functional refractory periods of the AVN, index of AVN conduction delay (the area under the AVN conduction curve), as well as index of intra-atrial conduction delay between the AVN inputs. Compared to control, 5 and 10 mM BDM produced either shortening or no effect on all of the above parameters except a slight (6% and 14%, respectively) increase in the intra-atrial delay. At 20 mM, BDM produced a further increase in the intra-atrial delay (up to 50%) as well as in the retrograde AVN conduction delay (up to 16%), while the characteristics of the anterograde conduction were still improved. The effects of perfusion with BDM on these parameters were reversible after washout.

CONCLUSIONS

Aside from its known effect as an electromechanical uncoupler, BDM reversibly altered some of the electrical responses of the AVN. Most of these alterations, however, did not impede but rather improved AVN conduction. Since a dose of 10 mM is sufficient to fully eliminate undesirable motion, BDM should be considered a safe and valuable tool in AVN studies in vitro requiring a mechanically quiescent preparation.

Prevention of action potentials during extracellular electrical stimulation of long duration

INTRODUCTION

This study investigated if action potentials can be prevented by electrical field stimuli of long duration.

METHODS AND RESULTS

The transmembrane potential was recorded by a double-barrel micro-electrode during field stimulation given across a papillary muscle from 10 guinea pigs. After 10 stimuli (S) with a 200-msec S-S interval, a 400-msec square wave shock was given just before or after the end of the effective refractory period following the 10th stimulus through electrodes 1 cm on either side of the papillary muscles. Another two stimuli (S' and S") having the same 200-msec S-S interval were given during the shock pulse to test if the action potentials induced by these two stimuli could be prevented by the shock. The shock strength was increased until the shock field prevented the action potentials induced by the S' and S" stimuli. The resting membrane potential was -85.5 +/- 2.9 mV. For shocks causing depolarization at the recording site, the field strength required to prevent S'- and S"-induced action potentials was 1.5 +/- 0.4 V/cm, which depolarized the transmembrane potential to -55.3 +/- 8.9 mV and -58.1 +/- 7.2 mV from the resting membrane potential at the time of the S' and S" stimuli, respectively. The strength of shocks causing hyperpolarization required to prevent S'- and S" -induced action potentials was 5.0 +/- 0.8 V/cm, which hyperpolarized the transmembrane potential to -105 +/- 6.5 mV and -115.6 +/- 6.9 mV from the resting membrane potential at the time of the S' and S" stimuli, respectively.

CONCLUSION

Both depolarization and hyperpolarization caused by an electrical field can prevent action potentials.

[Mechanisms of electrical defibrillation]

Ventricular fibrillation has been described as a "chaotic, random, asynchronous electrical activity of the ventricles due to repetitive reentrant excitation and/or rapid focal discharge". Reentrant and non-reentrant mechanisms are responsible for the initiation of ventricular fibrillation. After fibrillation has been induced, it is thought that multiple, disorganized, wandering wavelets follow constantly changing reentrant pathways. Electrical defibrillation is the only valid therapeutic approach for ventricular fibrillation. A successful defibrillation shock must be of sufficient strength to stop fibrillation but must not be so strong that damage to the myocardium occurs. The clinical use of the implantable cardioverter/defibrillator device has significantly stimulated research in the field of cardiac defibrillation. In order to develop more efficient shock waveforms and electrode configurations for smaller, and also longer lasting devices, we need a better understanding of the basic mechanisms of defibrillation. The development of computerized electrical mapping systems, capable of recording before, during and after a defibrillation shock, optical recording systems and microelectrodes, for action potential recording before and after the shock application and mathematical models have contributed much to the understanding of defibrillation mechanisms.An electrical shock hits the cardiac cells in different phases of their action potential. This results in 1) direct activation, 2) a "graded response", or 3) no effect. "Graded response" produces prolongation of the action potential and prolongs refractoriness without giving rise to a propagated activation front. Refractory period prolongation in an area that is still refractory at the time of the shock is critical for successful defibrillation. Mapping studies have shown that for successful defibrillation with monophasic shocks a minimal potential gradient of 5-7 V/cm is necessary (the exact value depends on the waveform and the orientation of the cells with respect to the electric field).Several hypotheses have been developed in order to explain the mechanisms that underlie successful defibrillation shocks. This paper will discuss the various theories. The "upper limit of vulnerability" hypothesis for defibrillation states that a successful defibrillation shock must stop existing activation fronts by directly exciting or by prolonging refractoriness just in front of the upcoming activation fronts and must not give rise to new activation fronts at the border of the directly excited area. Shocks slightly weaker then necessary to defibrillate stop fibrillation activation fronts, but give rise to new activation fronts that reinitiate fibrillation. These new activation fronts arise at a "critical point," where a critical shock potential gradient interferes with a critical degree of tissue refractoriness. Mappping studies support the "upper limit of vulnerability" hypothesis of defibrillation but not all defibrillation failures, however, can be explained by this hypothesis.Clinical data and experimental results have shown that biphasic shocks may have lower defibrillation thresholds than monophasic shocks. The advantage of defibrillation with a biphasic waveform is not yet clearly understood. We discuss some possible reasons why some biphasic waveforms have lower defibrillation thresholds than monophasic waveforms.

On the mechanism of ventricular defibrillation

The mechanism of ventricular defibrillation can be considered at many different levels. The highest level is considered at strength of the shock given through the defibrillation electrodes. At the next level, the mechanism of defibrillation can be examined in terms of the electrical field that the shock produces throughout the ventricles. Other levels include the effects this electric field has on the activation sequences and on the cellular action potentials that either initiate or inhibit the early sites of activation following the shock. Yet another level considers the mechanism by which the shock field initiates new action potentials or prolongs the action potential by changing the transmembrane potential during the shock. Finally, the subcellular level is considered, which involves the response of the individual ion channels to the shock. This review gives a brief overview of some salient features of defibrillation at each of these mechanistic levels.

Polarity reversal improves defibrillation efficacy in patients undergoing transvenous cardioverter defibrillator implantation with biphasic shocks

The purpose of this study was to determine the influence of polarity reversal on DFT in patients undergoing implantation of nonthoracotomy defibrillators with biphasic shocks. Previous studies have shown higher defibrillation efficacy with using the distal electrode as anode implantation of nonthoracotomy defibrillators and monophasic shocks. However, it is as yet unclear whether biphasic shock defibrillation will also be influenced by polarity reversal. Using a transvenous lead system with a proximal electrode in the superior caval vein and a distal electrode in the RV apex, 27 patients undergoing defibrillator implantation were randomized to DFT testing "initial" (distal electrode = cathode) or "reversed" polarity (distal electrode = anode). Defibrillation energy was reduced stepwise until defibrillation failure occurred. At this point, polarity was switched and testing continued until the lowest energy requirement was determined for both polarities. With reversed polarity, DFT was 11.1 +/- 5.7 J versus 13.3 +/- 5.8 J with polarity (P = 0.033). This means a 17% reduction of the DFT. In 10 patients, the threshold was lower with reversed, whereas in 3 patients it was lower with initial polarity. In conclusion, changing electrode polarity in transvenous implantable defibrillators with biphasic shocks may significantly influence defibrillation energy requirements. Therefore, polarity reversal should always be attempted before considering patch implantation.

Induction of ventricular fibrillation by T-wave field-shocks in the isolated perfused rabbit heart: role of nonuniform shock responses

OBJECTIVES

Single electrical field shocks are able to induce ventricular fibrillation (VF) if applied during the vulnerable period. During this period, a shock can either prolong the action potential duration or induce a new action potential. Whether the occurrence of different shock responses contributes to the induction of VF has not been investigated directly in the intact heart.

METHODS

In 12 isolated Langendorff-perfused rabbit hearts seven monophasic action potentials (MAPs) were recorded simultaneously during the application of 838 T-wave shocks. Post-shock repolarization was assessed by classifying the shock-induced response in each MAP recording either as a full action potential or an action potential prolongation. Heterogeneity of post-shock repolarization was defined if both response patterns were present in different MAP recordings at the same time. The heterogeneity of post-shock activation was measured as the dispersion of the post-shock activation time (PS-AT). The arrhythmogeneity of a shock was quantified as the number of rapid shock-induced repetitive responses.

RESULTS

Shocks inducing nonuniform repolarization were associated with greater arrhythmogeneity than shocks inducing uniform repolarization (17.6 +/- 30.0 versus 1.6 +/- 1.1 shock-induced repetitive responses, p < 0.001). The severity of the induced arrhythmia increased gradually with increasing nonuniformity of repolarization (p < 0.01 for a 10% increase), being maximal when the shock initiated near equal numbers of both full action potentials and action potential prolongations. The induction of severe arrhythmias by T-wave shocks was also associated with a higher dispersion of PS-AT (29 +/- 14 ms for the induction of VF, 19 +/- 12 ms for non-sustained arrhythmia, and 12 +/- 8 ms for no arrhythmic response, all p < 0.001). For VF inducing shocks, an increase in shock strength towards the upper limit of vulnerability decreased the dispersion of PS-AT from 34 +/- 15 ms to 23 +/- 11 ms (p < 0.001).

CONCLUSIONS

Nonuniform post-shock repolarization and dispersed post-shock activation contribute to the induction of VF by T-wave shocks. A decreasing dispersion of PS-AT towards higher shock strengths may contribute to the decreased or abolished inducibility by shocks above the upper limit of vulnerability.

Calcium dynamics in cultured heart cells exposed to defibrillator-type electric shocks

Spatial and temporal changes in intracellular calcium ion concentration and transmembrane voltage were recorded optically from single-isolated cultured chick-embryo heart cells exposed to high-voltage, defibrillator-type shocks. Fluorescence changes were measured during 5 msec electric shocks of field strengths up to 56 volts/cm in single myocytes stained with a Ca(++)-sensitive or voltage-sensitive dye. Shocks caused a reversible period of depolarization, elevated cytosolic Ca++, and refractoriness. Intracellular Ca++ elevation had two temporal phases: first, a Ca++ spike with morphology independent of shock intensity; and second, a prolonged Ca++ elevation with a shock-intensity-dependent magnitude and duration, and with greatest Ca++ elevation at the poles of the cell adjacent to the electrodes. The prolonged elevation (second phase) was initiated earlier at the anode-facing pole of the cell than at the cathode-facing pole. These results suggest that postshock Ca++ entry consists of two parts: early normal entry through excitation channels plus a prolonged elevation which may be related to cellular damage.

Discrete versus syncytial tissue behavior in a model of cardiac stimulation--I: Mathematical formulation

This paper presents a model describing the steady-state response of a two-dimensional (2-D) slice of myocardium to extracellular current injection. The model incorporates a continuous representation of the multicellular, syncytial cardiac tissue based on the bidomain model. The classical bidomain model is modified by introducing periodic conductivities to better represent the electrical properties of the intracellular space. Thus, junctional discontinuity between abutting myocytes is reflected in the macroscopic representation of cardiac tissue behavior. Since a solution to the resulting coupled differential equations governing the intracellular and extracellular potentials in the tissue preparation is not computationally tractable when traditional numerical approaches, such as finite element or finite difference methods are used, spectral techniques are employed to reduce the problem to the solution of a set of algebraic equations for the transform of the bidomain potentials. Further, the solution to the "periodic" bidomain problem in the Fourier space is decomposed into two separate solutions: One for the classical-bidomain potentials where it is assumed that the intracellular conductivity values along and across cells incorporate the average contribution from cytoplasm and junction, and another for the junctional potential component. The decomposition of the total solution allows to approximately solve for the junctional component thus achieving high overall computational efficiency. The results of simulation are presented in an accompanying paper.

A biophysical model for defibrillation of cardiac tissue

We propose a new model for electrical activity of cardiac tissue that incorporates the effects of cellular microstructure. As such, this model provides insight into the mechanism of direct stimulation and defibrillation of cardiac tissue after injection of large currents. To illustrate the usefulness of the model, numerical stimulations are used to show the difference between successful and unsuccessful defibrillation of large pieces of tissue.

Mechanisms of cardiac cell excitation with premature monophasic and biphasic field stimuli: a model study

The mechanisms by which extracellular electric field stimuli induce the (re)excitation of cardiac cells in various stages of refractoriness are still not well understood. We modeled the interactions between an isolated cardiac cell and imposed extracellular electric fields to determine the mechanisms by which relatively low-strength uniform monophasic and biphasic field stimuli induce premature reexcitations. An idealized ventricular cell was simulated with 11 subcellular membrane patches, each of which obeyed Luo-Rudy (phase 1) kinetics. Implementing a standard S1-S2 pulse protocol, strength-interval maps of the cellular excitatory responses were generated for rectangular monophasic and symmetric biphasic field stimuli of 2, 5, 10, and 20 ms total duration. In contrast to previously documented current injection studies, our results demonstrate that a cardiac cell exhibits a significantly nonmonotonic excitatory response to premature monophasic and, to a much lesser degree, biphasic field stimuli. Furthermore, for monophasic stimuli at low field strengths, the cell is exquisitely sensitive to the timing of the shock, demonstrating a classic all-or-none depolarizing response. However, at higher field strengths this all-or-none sensitivity reverts to a more gradual transition of excitatory responses with respect to stimulus prematurity. In contrast, biphasic stimuli produce such graded responses at all suprathreshold stimulus strengths. Similar behaviors are demonstrated at all S2 stimulus durations tested. The generation of depolarizing (sodium) currents is triggered by one or more of the sharp field gradient changes produced at the stimulus edges-i.e., make, break, and transphasic (for biphasic stimuli)-with the magnitude of these edge-induced current contributions dependent on both the prematurity and the strength of the applied field. In all cases, however, depolarizing current arises from the partial removal of sodium inactivation from at least part of the cell, because of either the natural process of repolarization or a localized acceleration of this process by the impressed field.

Virtual electrodes in cardiac tissue: a common mechanism for anodal and cathodal stimulation

Traditional cable analyses cannot explain complex patterns of excitation in cardiac tissue with unipolar, extracellular anodal, or cathodal stimuli. Epifluorescence imaging of the transmembrane potential during and after stimulation of both refractory and excitable tissue shows distinctive regions of simultaneous depolarization and hyperpolarization during stimulation that act as virtual cathodes and anodes. The results confirm bidomain model predictions that the onset (make) of a stimulus induces propagation from the virtual cathode, whereas stimulus termination (break) induces it from the virtual anode. In make stimulation, the virtual anode can delay activation of the underlying tissue, whereas in break stimulation this occurs under the virtual cathode. Thus make and break stimulations in cardiac tissue have a common mechanism that is the result of differences in the electrical anisotropy of the intracellular and extracellular spaces and provides clear proof of the validity of the bidomain model.

Electrical stimulation of cardiac myocytes

The influence of nonuniform cell shape and field orientation on the field stimulation thresholds of cardiac myocytes was studied both experimentally and computationally. The percent change in excitation threshold, which was studied with patch clamp technique, was found to be 182 +/- 83.1% (mean +/- SD) higher when the electric field (EF) was parallel to the transverse cell axis versus the longitudinal axis (p < 0.0006). On reversing the polarity of the applied EF, the percentage change in threshold was observed to increase by 98.9 +/- 71.0% (p < 0.0002), implying asymmetry of the stimulation threshold of isolated myocytes. Finite element models were made to investigate the distribution of the transmembrane potential of these experimentally studied myocytes. A typical cell model showed that the maximum transmembrane potential induced on opposite ends of the cell was 39.1 mV and -46.5 mV for longitudinal field (aligned with the long axis of the cell), but was 40.5 mV and -44.8 mV for transverse field (aligned with the short axis of the cell). More significantly, it was found that the maximum transmembrane potential occurred at discrete points or "hot spots" on the cell membrane. It is hypothesized that the depolarization of the cell initiates at the hot spot and then spreads over the entire cell. The different excitation thresholds for different polarities of the applied EF can be explained by the different maximum induced at the opposite ends of the cell.

Effects of bipolar point and line stimulation in anisotropic rabbit epicardium: assessment of the critical radius of curvature for longitudinal block

Excitation front shape and velocity were studied in anisotropic perfused rabbit epicardium stained with potentiometric fluorescent dye. In the combined results from all experiments, convex excitation fronts produced by stimulation with a single electrode propagated longitudinally 13.3% slower than flat excitation fronts produced by stimulation with a line of electrodes. For transverse propagation, the two stimulation methods produced similar flat excitation fronts and velocities. The critical excitation front radius of curvature for longitudinal block (Rcr), calculated from excitable media theory, was 92 microns in control hearts. In hearts exposed to diacetyl monoxime (20 mmol/L), which decreases inward sodium current, Rcr was 175 microns. The slower longitudinal propagation velocity of convex fronts versus flat fronts and the theoretically predicted critical radius of curvature may be important for propagation and block of ectopic depolarizations in the heart.

Characterization of shock-induced action potential extension during acute regional ischemia in rabbit hearts

INTRODUCTION

Defibrillation shocks produce extension of the myocardial action potential repolarization time (AP extension) in nonischemic myocardium. AP extension may synchronize repolarization in the heart because the extension increases when shock timing is increased. We tested whether AP extension occurs and whether it increases when shock timing is increased in regionally ischemic isolated perfused rabbit hearts stained with the transmembrane voltage sensitive fluorescent dye, di-4-ANEPPS and given diacetyl monoxime to eliminate motion artifacts.

METHODS AND RESULTS

Before and after left anterior descending (LAD) coronary artery occlusion, APs were recorded on the anterior left ventricular epicardium with an epifluorescence measurement system. Hearts were paced with a train of 10 stimuli (S1) and then during the 10th AP were given a defibrillation shock (S2) from epicardial electrodes on either side of the recording region. Before LAD occlusion, duration of the 9th S1-induced AP measured at full repolarization was 171 +/- 11 msec (mean +/- SD). Within 15 minutes after LAD occlusion, the AP duration became shorter (P < 0.05) and more variable (137 +/- 47 msec), and APs with negligible plateaus were observed. Extension of the 10th AP by S2 was significant both before (mean extension of 59 to 65 msec for three S2 waveforms tested) and after LAD occlusion (mean extension of 35 to 41 msec). Unlike the results before LAD occlusion, AP extension after occlusion was independent of absolute shock timing expressed in msec. When timing was expressed as a fraction of individual AP durations, AP extension after occlusion increased with increases in shock timing.

CONCLUSIONS

Shocks extend APs during ischemia; however, absolute time dependence of AP extension is not constant among cells that have different AP durations during ischemia. This may influence postshock repolarization synchrony when different AP durations exist in different parts of regionally ischemic hearts.

Optical multisite monitoring of cell excitation phenomena in isolated cardiomyocytes

An especially designed setup which consists of an inverted fluorescence microscope, an argon ion laser and a photodiode array system permits membrane potential monitoring in isolated guinea-pig ventricular cardiomyocytes, stained with the voltage-sensitive dye di-4-ANEPPS, which responds linearly with relative fluorescence changes (delta F/F) approximately -8% per 100 mV. About a dozen measuring spots covering a single cell were simultaneously monitored with a spatial and temporal resolution of 15 microns and about 20 microseconds, respectively. In general, the rising phases of the action potentials within a single cell were highly synchronized (i.e. all upstroke velocities peaked within about 20 microseconds); however, in one cell (out of 25 examined) significant (P < 0.05) time lags exceeding the signal-dependent time resolution were also found. Experiments, simultaneously performed with our optical system and a widely used patch-clamp setup, revealed a slowed and delayed response of the clamp amplifier depending on the cell access resistance. Optical monitoring during whole-cell voltage-clamping demonstrated the influence of graduated series resistance compensation. When field stimulation was used, our results clearly demonstrated the spatially dependent polarization of the cell membrane during the stimulus, as well as a highly synchronized upstroke development. Slight differences in the maximum upstroke velocities within a single cell were also found and were basically in agreement with mathematical models.

Determination of impulse conduction characteristics at a microscopic scale in patterned growth heart cell cultures using multiple site optical recording of transmembrane voltage

It is well established that impulse propagation in cardiac tissue is determined by the interaction between active membrane properties and the passive electrical characteristics of the network formed by individual myocytes. In the past, the intricate microarchitecture of intact cardiac tissue and the limited spatial resolution of available recording techniques had rendered a systematic evaluation of the influence of the cellular microarchitecture on impulse propagation difficult. Recently, however, successful efforts have been undertaken to: (1) simplify the cellular arrangement by designing cardiac structures with defined two-dimensional geometries; and (2) measure impulse propagation in these preparations at the cellular/subcellular scale using optical techniques. This short review considers both of these developments, i.e., patterned growth of heart cells in culture and multiple site optical recording of transmembrane voltage (MSORTV), and summarizes first results obtained with the combination of both techniques.

Spatial distribution of cardiac transmembrane potentials around an extracellular electrode: dependence on fiber orientation

Recent theoretical models of cardiac electrical stimulation or defibrillation predict a complex spatial pattern of transmembrane potential (Vm) around a stimulating electrode, resulting from the formation of virtual electrodes of reversed polarity. The pattern of membrane polarization has been attributed to the anisotropic structure of the tissue. To verify such model predictions experimentally, an optical technique using a fluorescent voltage-sensitive dye was used to map the spatial distribution of Vm around a 150-microns-radius extracellular unipolar electrode. An S1-S2 stimulation protocol was used, and vm was measured during an S2 pulse having an intensity equal to 10x the cathodal diastolic threshold of excitation. The recordings were obtained on the endocardial surface of bullfrog atrium in directions parallel and perpendicular to the cardiac fibers. In the longitudinal fiber direction, the membrane depolarized for cathodal pulses (and hyperpolarized for anodal pulses) but only in a region within 445 +/- 112 microns (and 616 +/- 78 microns for anodal pulses) from the center of the electrode (n = 9). Outside this region, vm reversed polarity and reached a local maximum at 922 +/- 136 microns (and 988 +/- 117 microns for anodal pulses) (n = 9). Beyond this point vm decayed to zero over a distance of 1.5-2 mm. In the transverse fiber direction, the membrane depolarized for cathodal pulses (and hyperpolarized for anodal pulses) at all distances from the electrode. The amplitude of the response decreased with distance from the electrode with an exponential decay constant of 343 +/- 110 microns for cathodal pulses and 253 +/- 91 microns for anodal pulses (n = 7). The results were qualitatively similar in both fiber directions when the atrium was bathed in a solution containing ionic channel blockers. A two-dimensional computer model was formulated for the case of highly anisotropic cardiac tissue and qualitatively accounts for nearly all the observed spatial and temporal behavior of vm in the two fiber directions. The relationships between vm and both the "activating function" and extracellular potential gradient are discussed.

Responses of the transmembrane potential of myocardial cells during a shock

INTRODUCTION

The purpose of this investigation was to study the transmembrane potential changes (delta Vm) during extracellular electrical field stimulation.

METHODS AND RESULTS

Vm was recorded in seven guinea pig papillary muscles in a tissue bath by a double-barrel microelectrode with one barrel in and the other just outside a cell while shocks were given across the bath. The short distance (15 to 30 microns) between the two microelectrode tips and alignment of the tips parallel to the shock electrodes eliminated the shock artifact. Following ten S1 stimuli, an S2 shock field created by a 10-msec square wave was delivered during the action potential plateau or during diastole through shock electrodes 1 cm on either side of the tissue. Four shock strengths creating field strengths of 1.7 +/- 0.1, 2.9 +/- 0.2, 6.1 +/- 0.6, and 8.8 +/- 0.9 V/cm were given for the same impalement. Both shock polarities were given at each shock strength. For shocks delivered during the action potential plateau, the magnitudes of the peak delta Vm caused by the above four potential gradients were 21.1 +/- 8.2, 33.6 +/- 13.6, 49.9 +/- 24.2, and 52.3 +/- 28.0 mV (P < 0.05 among the four groups) for the shocks causing depolarization and 37.9 +/- 14.2, 56.6 +/- 16.4, 83.1 +/- 19.4, and 92.9 +/- 29.1 mV (P < 0.05 among the four groups) for the shocks causing hyperpolarization. Though delta Vm increased as potential gradients increased, the relationship was not linear. The magnitude of hyperpolarization was 1.9 +/- 0.5 times that of depolarization when the shock polarity was reversed (P < 0.05). As potential gradients increased from 1.7 +/- 0.1 to 8.8 +/- 0.9 V/cm, the time constant of the membrane response decreased significantly from 3.5 +/- 1.8 to 1.6 +/- 0.7 msec for depolarizing shocks and from 6.0 +/- 3.1 to 3.4 +/- 1.9 msec for hyperpolarizing shocks (P < 0.01 vs depolarizing shocks). For shocks delivered during diastole, hyperpolarizing shocks induced triphasic changes in Vm during the shock, i.e., initial hyperpolarization, than depolarization, followed again by hyperpolarization.

CONCLUSION

During the action potential plateau, the membrane response cannot be represented by a classic passive RC membrane model. During diastole, activation upstrokes occur even during hyperpolarization caused by shocks creating potential gradients between approximately 2 and 9 V/cm.

Correlation among fibrillation, defibrillation, and cardiac pacing

An electrical stimulus must create an electric field of approximately 1 V/cm in the extracellular space to stimulate myocardium during diastole. To initiate fibrillation by premature stimulation during the vulnerable period or to defibrillate, an extracellular electric field of approximately 6 V/cm is required, a value approximately six times greater than that necessary for diastolic pacing. Yet, the current strength of the pulse given to the stimulating electrode to initiate fibrillation or to defibrillate is much greater than six times the diastolic pacing threshold. The ventricular fibrillation threshold is typically 40 times greater than the diastolic pacing threshold expressed in terms of current. The defibrillation threshold in terms of current is typically thousands of times greater than the diastolic pacing threshold. The reason that these thresholds vary so much more in terms of stimulus current than in terms of extracellular potential gradient is that each of the three thresholds requires creation of the required potential gradient at different distances from the stimulating electrode. Pacing requires a potential gradient of approximately 1 V/cm only in a small liminal volume of tissue immediately adjacent to the electrode. Initiation of ventricular fibrillation by premature stimulation during the vulnerable period requires a potential gradient of approximately 6 V/cm about 1 cm away from the stimulating electrode to allow sufficient space for the central common pathway of a figure-eight reentrant circuit to form. Since the potential gradient falls off rapidly with distance from the stimulating electrode, a stimulating current about 40 times greater than the diastolic pacing threshold is required to generate an electric field of 6 V/cm approximately 1 cm away from the stimulating electrode. Defibrillation requires an electric field of approximately 6 V/cm throughout all or almost all of the ventricular myocardium. Since some portions of the ventricles can be more than 10 cm away from the defibrillation electrodes, a shock of several amps is required to create this field, a current thousands of times greater than the pacing threshold.

Two-point electrical-fluorescence recording from heart with optical fibers

Optical recordings from frog myocardium, stained with a voltage-sensitive dye, have been made through a fiber optic system that uses fiber couplers to provide two excitation/detection paths and to separate excitation light from the fluorescence signal. The excitation light, from a green He-Ne laser (543 nm), is focused into a 100 microns-core fiber then is split 1:1 to two other fibers. Each of these two fibers transmits part of the excitation light through a fiber coupler (1:15 transmittance ratio) to the heart preparation which is stained with the voltage-sensitive dye RH237. The returning red fluorescence is split at the same fiber coupler (15:1 transmittance ratio) and is directed to a photomultiplier tube through a longpass filter. With this two-point mapping method, differences in action potential shape and timing have been observed.

A minimal model of the single capacitor biphasic defibrillation waveform

A quantitative model of the single capacitor biphasic defibrillation waveform is proposed. The primary hypothesis of this model is that the first phase leaves a residual charge on the membranes of the unsynchronized cells, which can then reinitiate fibrillation. The second phase diminishes this charge, reducing the potential for refibrillation. To suppress this potential refibrillation, a monophasic shock must be strong enough to synchronize a critical mass of nearly 100% of the myocytes. Since the biphasic waveform performs this protection function by removing the residual charge (with its second phase), its first phase may be of a lower strength than a monophasic shock of equivalent performance. A quantitative model was developed to calculate the residual membrane voltage, Vm, assuming a capacitive membrane being alternately charged and discharged by the first and second phases, respectively. It was further assumed that the amplitude of the first phase would be predicted by a minimum value plus a term proportional to Vm2. The model was evaluated on the pooled data of three relevant published studies comparing biphasic waveforms. The model explained 79% of the variance in the first phase amplitude and predicted optimal durations for various defibrillator capacitances and electrode resistances. Assuming a first phase of optimal duration, the optimal second phase duration appears to be about 2.5 msec for all capacitances and resistances now seen clinically.

CONCLUSION

The effectiveness of the single capacitor biphasic waveform may be explained by the second phase "burping" of the deleterious residual charge of the first phase that, in turn, reduces the synchronization requirement and the amplitude requirements of the first phase.

Response of a single cell to an external electric field

The response of a cell to an external electric field is investigated using dimensional analysis and singular perturbation. The results demonstrate that the response of a cell is a two-stage process consisting of the initial polarization that proceeds with the cellular time constant (< 1 microseconds), and of the actual change of physiological state that proceeds with the membrane time constant (several milliseconds). The second stage is governed by an ordinary differential equation similar to that of a space-clamped membrane patch but formulated in terms of intracellular rather than transmembrane potential. Therefore, it is meaningful to analyze the physiological state and the dynamics of a cell as a whole instead of the physiological states and the dynamics of the underlying membrane patches. This theoretical result is illustrated with an example of an excitation of a cylindrical cell by a transverse electric field.

Di-4-ANEPPS causes photodynamic damage to isolated cardiomyocytes

Action potential recordings from isolated guinea pig ventricular cells in the whole-cell recording mode were used to study the toxic and photodynamic properties of the voltage-sensitive fluorescent dye di-4-ANEPPS. Staining of the cardiomyocytes with di-4-ANEPPS (30 or 60 microM; 10 min) did not alter the action potential shape. When the stained cells were illuminated (1W/cm2) severe effects on the action potential were observed. There was a prolongation of the action potential duration, occurrence of early afterdepolarizations, reduction of the membrane resting potential and eventually inexcitability. Addition of the antioxidant catalase (100 IU/ml) to the extracellular solution delayed the onset of these effects, suggesting that reactive-oxygen-intermediates take part in di-4-ANEPPS induced photodynamic damage. Since di-4-ANEPPS is a very important tool for optical membrane potential recordings in heart tissue and single cardiomyocytes catalase might be useful in suppressing photodynamic damage during optical potential recordings.

Virtual electrode effects in myocardial fibers

The changes in transmembrane potential during a stimulation pulse in the heart are not known. We have used transmembrane potential sensitive dye fluorescence to measure changes in transmembrane potential along fibers in an anisotropic arterially perfused rabbit epicardial layer. Cathodal or anodal extracellular point stimulation produced changes in transmembrane potential within 60 microns of the electrode that were positive or negative, respectively. The changes in transmembrane potential did not simply decrease to zero with increasing distance, as would occur with a theoretical fiber space constant, but instead became reversed beyond approximately 1 mm from the electrode consistent with a virtual electrode effect. Even stimulation from a line of terminals perpendicular to the fibers produced negative changes in transmembrane potential for cathodal stimulation with the largest negative changes during a 50-ms pulse at 3-4 mm from the electrode terminals. Negative changes as large as the amplitude of the action potential rising phase occurred during a 50-ms pulse for 20-volt cathodal stimulation. Switching to anodal stimulation reversed the directions of changes in transmembrane potential at most recording spots, however for stimulation during the refractory period negative changes in transmembrane potential were significantly larger than positive changes in transmembrane potential. Anodal stimulation during diastole with 3-ms pulses produced excitation in the region of depolarization that accelerated when the stimulation strength was increased to > 3 times the anodal threshold strength. Thus, virtual electrode effects of unipolar stimulation occur in myocardial fibers, and for sufficiently strong stimuli the virtual electrode effects may influence electrical behavior of the myocardium.

Why do some patients have high defibrillation thresholds at defibrillator implantation? Answers from basic research

Implantable cardioverter defibrillators reduce the risk of sudden cardiac death in patients with ventricular tachyarrhythmias. However, for the few patients with unacceptably high defibrillation thresholds at implantation the risk of sudden death may remain high. If a small number of defibrillation attempts are used to determine a defibrillation threshold, then a high defibrillation threshold may occur in some patients due to the probabilistic nature of defibrillation: a small percentage of shocks will fail even at optimal shock strengths. Basic investigations have suggested mechanisms for high defibrillation thresholds in other patients. The extracellular potential gradients produced by a shock correlate with ability to defibrillate and may be used to classify mechanisms for high defibrillation thresholds. Computerized mapping studies have demonstrated that extracellular potential gradient fields produced by defibrillation shocks are uneven with high gradient areas close to the electrodes and low gradient areas distant from the electrodes. A high defibrillation threshold may occur because: (1) a shock creates a subthreshold potential gradient in the low gradient areas; (2) a patient has a higher minimum potential gradient threshold than other patients; or (3) a shock leads to refibrillation in the high gradient areas. This article reviews experimental evidence to support each of these three possibilities then suggests experimental and clinical investigations that may clarify the causes of high defibrillation thresholds in patients.

Refractory period prolongation by biphasic defibrillator waveforms is associated with enhanced sodium current in a computer model of the ventricular action potential

Mechanisms through which biphasic waveforms lower defibrillation threshold are unknown. Previous work showed that low-intensity biphasic shocks (BS2), delivered during the refractory period of a control action potential (S1), produced significantly longer responses than monophasic shocks (MS2). To test the hypothesis that longer responses are due to hyperpolarization-induced excitation channel recovery during the first portion of the biphasic waveform, we used the Beeler-Reuter ventricular action potential computer model with the Drouhard-Roberge (BRDR) modification to study refractory period stimulation with MS2 (10 msec) and symmetrical BS2 (10 msec each pulse). At 1.5 times diastolic threshold, BS2 prolonged action potential duration when delivered 50 msec into the S1 refractory period, and produced a maximum BS2 versus MS2 response duration difference of 62 msec. Longer BS2 responses corresponded to enhanced BS2-induced sodium current compared to MS2. Maximum BS2 vs MS2 sodium current difference was 400 uA/cm2. These results show that, in a computer model of the ventricular action potential, hyperpolarization by the first phase of a biphasic waveform enhances S2 sodium current and prolongs duration of refractory-period responses. This effectively shortens the cellular refractory period. Prolonged refractory period responses, produced by biphasic defibrillator waveforms, may underlie enhanced defibrillating efficacy at low shock intensities.