Reentrant wave fronts in Wiggers' stage II ventricular fibrillation. Characteristics and mechanisms of termination and spontaneous regeneration

Preventing ventricular fibrillation by flattening cardiac restitution

Ventricular fibrillation is the leading cause of sudden cardiac death. In fibrillation, fragmented electrical waves meander erratically through the heart muscle, creating disordered and ineffective contraction. Theoretical and computer studies, as well as recent experimental evidence, have suggested that fibrillation is created and sustained by the property of restitution of the cardiac action potential duration (that is, its dependence on the previous diastolic interval). The restitution hypothesis states that steeply sloped restitution curves create unstable wave propagation that results in wave break, the event that is necessary for fibrillation. Here we present experimental evidence supporting this idea. In particular, we identify the action of the drug bretylium as a prototype for the future development of effective restitution-based antifibrillatory agents. We show that bretylium acts in accord with the restitution hypothesis: by flattening restitution curves, it prevents wave break and thus prevents fibrillation. It even converts existing fibrillation, either to a periodic state (ventricular tachycardia, which is much more easily controlled) or to quiescent healthy tissue.

Graded response and restitution hypotheses of ventricular vulnerability to fibrillation: insights into the mechanism of initiation of fibrillation

According to the upper limit of vulnerability (ULV), failed defibrillation (DF) shocks reinitiate ventricular fibrillation (VF) by falling on the vulnerable period of one or more of the fibrillation wavefronts. The failed shock first induces reentry (stage I VF), which within few cycles degenerate to stage II VF. We developed 2 hypotheses of vulnerability that explain DF failure using isolated and intact in situ ventricles. Activation maps were constructed with high-resolution electrodes and action potential (AP) recorded with microelectrodes. According to the graded response (GR) hypothesis, reentry is formed when a critical shock strength induces a GR that transiently increases local refractoriness. The GR propagates and initiates distal regenerative activity that propagates around the site of block to reenter through it as it recovers. Ultrastrong shocks prevent reentry by converting unidirectional block to bidirectional block by excessive increase in refractoriness, a finding that supports the ULV hypothesis. In situ ventricle stimulus-induced termination of reentry and stage I VF (protective zone) could be explained by the GR hypothesis. The induced functional reentry with periods of 100 to 160 ms engages the steep (unstable) portion of the AP duration restitution curves (slope >1) that promotes meandering and breakup. This leads to transition from stage I to stage II VF (the restitution hypothesis). We conclude that the GR and restitution hypotheses provide an insight into the mechanism of ventricular vulnerability to fibrillation induced by a stimulus. These hypotheses provide a new paradigm for effective antifibrillatory strategies.

Virtual electrodes and deexcitation: new insights into fibrillation induction and defibrillation

Previous models of fibrillation induction and defibrillation stressed the contribution of depolarization during the response of the heart to a shock. This article reviews recent evidence suggesting that comprehending the role of negative polarization (hyperpolarization) also is crucial for understanding the response to a shock. Negative polarization can "deexcite" cardiac cells, creating regions of excitable tissue through which wavefronts can propagate. These wavefronts can result in new reentrant circuits, inducing fibrillation or causing defibrillation to fail. In addition, deexcitation can lead to rapid propagation through newly excitable regions, resulting in the elimination of excitable gaps soon after the shock and causing defibrillation to succeed.

Relation between cellular repolarization characteristics and critical mass for human ventricular fibrillation

INTRODUCTION

The critical mass for human ventricular fibrillation (VF) and its electrical determinants are unclear. The goal of this study was to evaluate the relationship between repolarization characteristics and critical mass for VF in diseased human cardiac tissues.

METHODS AND RESULTS

Eight native hearts from transplant recipients were studied. The right ventricle was immediately excised, then perfused (n = 6) or superfused (n = 2) with Tyrode's solution at 36 degrees C. The action potential duration (APD) restitution curve was determined by an S1-S2 method. Programmed stimulation and burst pacing were used to induce VF. In 3 of 8 tissues, 10 microM cromakalim, an ATP-sensitive potassium channel opener, was added to the perfusate and the stimulation protocol repeated. Results show that, at baseline, VF did not occur either spontaneously or during rewarming, and it could not be induced by aggressive electrical stimulation in any tissue. The mean APD at 90% depolarization (APD90) at a cycle length of 600 msec was 227+/-49 msec, and the mean slope of the APD restitution curve was 0.22+/-0.08. Among the six tissues perfused, five were not treated with any antiarrhythmic agent. The weight of these five heart samples averaged 111+/-23 g (range 85 to 138). However, after cromakalim infusion, sustained VF (> 30 min in duration) was consistently induced. As compared with baseline in the same tissues, cromakalim shortened the APD90 from 243+/-32 msec to 55+/-18 msec (P < 0.001) and increased the maximum slope of the APD restitution curve from 0.24+/-0.11 to 1.43+/-0.10 (P < 0.01).

CONCLUSION

At baseline, the critical mass for VF in diseased human hearts in vitro is > 111 g. However, the critical mass for VF can vary, as it can be reduced by shortening APD and increasing the slope of the APD restitution curve.

Coherence between body surface ECG leads and intracardiac signals increases during the first 10 s of ventricular fibrillation in the human heart

Ventricular fibrillation (VF) in the human heart is not well understood. The aim of this study was to measure changes in the phase relationship between the body surface ECG and intracardiac electrograms recorded during the first 10 s of human VF. We studied 11 episodes of VF and measured the coherence of (a) ECG lead I and ECG lead V1, (b) ECG lead V1 and the right ventricular apex (RVA) electrogram, and (c) ECG lead V1 and the smoothed RVA electrogram. Each coherence measurement was the average of the magnitude squared coherence function in the range 0-60 Hz, and measurements were made 1, 3, 5, 7 and 9 s after the onset of VF. Overall, the mean (SD) coherence was 31(6)% between ECG leads I and V1, 17(3)% between ECG lead V1 and the RVA electrogram, and 20(4)% between ECG lead V1 and the smoothed RVA electrogram. All three measurements of coherence increased significantly between 1 and 9 s with mean (SD) rates of 0.97(1.01)% s(-1), 0.8(1.18)% s(-1) and 0.82(1.19)% s(-1) respectively. These results show that propagation in human VF becomes more organized during the first 10 s of VF. This may be an optimal window for defibrillation.

Azimilide decreases defibrillation voltage requirements and increases spatial organization during ventricular fibrillation

INTRODUCTION

Drugs with class III antiarrhythmic properties generally decrease defibrillation threshold (DFT). However, the concentration effect relation for this effect and drug effects on ventricular fibrillation (VF) itself are not well understood. The objectives of this study were to determine the effect of azimilide (NE-10064), a new class III agent, on DFT, and on spatial organization during VF.

METHODS

Defibrillation patch electrodes were sutured to the right and left ventricular epicardium in 12 open-chest anesthetized dogs. The delayed up-down algorithm was used to measure DFT and to estimate the shock strength (voltage) with a 50% probability of successful defibrillation (V50). The magnitude squared coherence (MSC), which measures the spatial relation in the frequency domain, was measured during VF between two unipolar epicardial electrodes 3 mm apart. The V50, MSC, electrophysiologic parameters, and plasma concentrations were determined before and after four cumulative i.v. doses of azimilide (2, 7, 17, and 30 mg/kg).

RESULTS

Azimilide elicited a dose dependent reduction of V50 and increase in MSC. Compared with baseline, azimilide lowered mean V50 by 2 +/- 9%, 10 +/- 18%, 11 +/- 14% and 19 +/- 5%, and increased MSC by 17 +/- 20%, 32 +/- 31%, 20 +/- 44% and 27 +/- 20% (p < 0.05 for dose effect) at 2, 7, 17 and 30 mg/kg, respectively. Mean increases in monophasic action potential duration at 90% repolarization (3-11%), ventricular effective refractory period (6-13%) at 400 msec paced cycle length, and VF cycle length (5-37%) (p < 0.01 for dose effect) were observed with the 4 increasing doses of azimilide, respectively.

CONCLUSION

Azimilide significantly decreases DFT and increases coherence in VF in a dose dependent manner.

Fast Fourier transform analysis of ventricular fibrillation intervals to predict ventricular refractoriness and its spatial dispersion

A technique of fast Fourier transform analysis has been used to derive mean ventricular fibrillation (VF) intervals, and to confirm that these VF intervals predict ventricular refractory periods. Twenty episodes of VF were induced by a rapid ventricular pacing in 12 sheep. VF activations in a 10-second period were simultaneously acquired from 64 epicardial sites with an electrode sock. The VF electrograms were analyzed by a fast Fourier transform analysis. The dominant peak frequency of the VF spectrum in each epicardial site was converted into milliseconds and served as a mean VF interval. The dominant peak frequency of VF electrograms ranged from 8.1 to 11.5 Hz, and the corresponding mean VF intervals were 87 to 124 ms. In five sheep, the mean VF intervals and the effective refractory periods were determined by the extrastimulus technique obtained from 29 epicardial sites. There was a very good correlation between the two parameters when the effective refractory periods were determined at a basic cycle length of 300 ms (r = 0.89, P < 0.001) and 400 ms (r = 0.87, P < 0.001), respectively. VF was induced twice in eight sheep. The maximum difference in the mean VF intervals between the two VF episodes in the same sheep was 3 ms (P > 0.05). In conclusion, mean VF intervals determined by the fast Fourier transform analysis have a good reproducibility and a good correlation with ventricular refractory periods measured by the classic extrastimulus technique. The mean VF intervals could serve as an index of ventricular refractoriness.

The initiation, continuation, and termination of spontaneous episodes of circus movements in the pregnant myometrium of the rat

OBJECTIVES

The objectives of this study were to determine the mechanisms responsible for the initiation and the termination of episodes of circus movements and to describe the characteristics of these circuits in rat myometrium.

STUDY DESIGN

By means of simultaneous recordings from 240 sites in Wistar rats at 17, 19, or 21 days' gestation, a spatial and temporal analysis was performed on the electrical activation from the beginning until the end of 22 episodes of circus movements.

RESULTS

The initiation of reentry was caused by (1) transient unexcitable areas at the beginning of the burst or (2) lines of conduction blocks. Circus movements were terminated by (1) reversal of recruitment (decruitment) at the end of the burst, (2) occurrence of lines of conduction blocks, or (3) interruption of the circuit. On average circuits rotated for 6 revolutions during 2 seconds. In most cases circuits remained stable; sometimes circuits drifted along the tissue and occasionally multiple wavelets were seen instead of a single circuit.

CONCLUSIONS

Spatial nonhomogeneities in conduction caused by transient unexcitable areas play a major role in both the initiation and the termination of episodes of circus movements in the pregnant rat myo-metrium. In addition, most circuits remained in a single location, although sometimes meandering or even fibrillatory activity was seen.

Evolution of the organization of epicardial activation patterns during ventricular fibrillation

INTRODUCTION

This study quantified how the organization of epicardial activation changes during the first 40 seconds of ventricular fibrillation (VF).

METHODS AND RESULTS

Unipolar potentials were mapped from a 504 (24 x 21) electrode array (2-mm interelectrode spacing) on the anterior right ventricle (RV) and left ventricle (LV) epicardium. The array covered approximately 20% of the epicardial surface. In each of seven pigs, six episodes of VF were induced by premature stimulation. One-half second epochs of VF were analyzed, starting 0, 10, 20, 30, and 40 seconds post induction and using novel pattern analysis algorithms. Eight parameters were quantified: (1) the number of wavefronts; (2) the epicardial area activated by wavefronts; (3) the fraction of wavefronts arising from epicardial breakthrough or from a focus; (4) the fraction of wavefronts terminated by conduction block; (5) the multiplicity index (number of distinct activation pathways in the rhythm); (6) the repeatability index (number of times activation pathways are traversed); (7) the activation rate; and (8) the wavefront propagation velocity. The results showed that VF patterns were less organized at 10 than at 0 seconds, with more, smaller wavefronts traversing a larger variety of pathways for fewer repetitions. VF activation patterns then gradually reorganized up to 40 seconds, but by a different mechanism: the spatial size of subpatterns grew, but the dynamics otherwise appeared unchanged. During both transitions, both activation rate and propagation velocity slowed monotonically.

CONCLUSION

Thus, changes in organization during VF can occur by multiple mechanisms.

Transmembrane potential properties of atrial cells at different sites of a spiral wave reentry: cellular evidence for an excitable but nonexcited core

Transmembrane action potentials (TAPs) were recorded during simultaneous mapping of a reentrant wavefront induced in canine isolated atria. The activation pattern was visualized dynamically using a high resolution electrode catheter mapping system. During functional reentry (spiral wave), cells in the core of the spiral wave remained quiescent near their resting membrane potential. Cells away from the core progressively gained TAP amplitude and duration, and at the periphery of the spiral wave the cells generated TAPs with full height and duration. During anatomical reentry, when the tip of the wavefront remained attached to the obstacle (a condition of high source-to-sink ratio), the TAP near the obstacle had normal amplitude and duration. However, when the tip of the wavefront detached from the obstacle (condition of lowered source-to-sink ratio) the TAP lost amplitude and duration. These results are consistent with the theory that the source-to-sink ratio determines the safety factor for wave propagation and wave block near the core. With decreasing source-to-sink ratio, TAP progressively decreases in amplitude and duration. In the center of the core, the cells, while excitable, remain quiescent near their resting potential. This decrease reflects a progressive decrease in the source-to-sink ratio. TAP vanishes in the core where cells remain quiescent near their resting potential. Functional and meandering reentrant wavefronts are compatible with the spiral mechanism of reentry where block at the rotating point is provided by the steep curvature of the wave tip.

Relation between ventricular fibrillation voltage and probability of defibrillation shocks. Analysis using Hilbert transforms

We used Hilbert transforms to re-evaluate the previously reported correlation between defibrillation shock outcome and absolute ventricular fibrillation voltage (AVFV). Previously in the literature, single values of AVFV acquired just prior to shock delivery were used to show a correlation between AVFV and shock outcome. In subsequent studies, a modified analysis procedure was used to show a correlation between shock outcome and moving average of AVFV. The use of single values of AVFV makes the AVFV sensitive to the local phase of the electrocardiographic (ECG) waveform, whereas moving averages are weighted by previous values of the ECG. The envelope is independent of the phase of the ECG and is not weighted by previous values of ECG as is the moving average. We explored, therefore, whether the AVFV computed from the envelopes of the ECG showed a stronger correlation with shock outcome than single values and moving averages of the AVFV. We estimated envelopes using the Hilbert transform. Orthogonal ECGs (sagittal, X; transverse, Y; and longitudinal, Z) were recorded from 11 dogs during 10 seconds of electrically induced ventricular fibrillation followed by a defibrillation shock with 50% probability of success. We used transvenous (right ventricular apex to subcutaneous patch) leads to deliver defibrillation shocks. Results from 236 successful and 249 unsuccessful trials showed, in contrast with the previously reported correlation, that moving average of AVFV was not higher for successful trials. In the Z direction, unsuccessful trials had higher voltage than successful trials (P < .05). Comparison of envelope voltages between successful and unsuccessful trials did not show any consistent and statistically significant differences. Although there were some methodological differences between ours and the previously reported studies, they are unlikely to have caused the discrepant observations. Our results suggest, therefore, that the absolute voltage of ECG during ventricular fibrillation is not robustly correlated with shock outcome.

Characteristics of wave fronts during ventricular fibrillation in human hearts with dilated cardiomyopathy: role of increased fibrosis in the generation of reentry

OBJECTIVES

We sought to evaluate the characteristics of wave fronts during ventricular fibrillation (VF) in human hearts with dilated cardiomyopathy (DCM) and to determine the role of increased fibrosis in the generation of reentry during VF.

BACKGROUND

The role of increased fibrosis in reentry formation during human VF is unclear.

METHODS

Five hearts from transplant recipients with DCM were supported by Langendorff perfusion and were mapped during VF. A plaque electrode array with 477 bipolar electrodes (1.6-mm resolution) was used for epicardial mapping. In heart no. 5, we also used 440 transmural bipolar recordings. Each mapped area was analyzed histologically.

RESULTS

Fifteen runs of VF (8 s/run) recorded from the epicardium were analyzed, and 55 episodes of reentry were observed. The life span of reentry was short (one to four cycles), and the mean cycle length was 172 +/- 24 ms. In heart no. 5, transmural scroll waves were demonstrated. The most common mode of initiation of reentry was epicardial breakthrough, followed by a line of conduction block parallel to the epicardial fiber orientation (34 [62%] of 55 episodes). In the areas with lines of block, histologic examination showed significant fibrosis separating the epicardial muscle fibers and bundles along the longitudinal axis of fiber orientation. The mean percent fibrous tissue in these areas (n = 20) was significantly higher than that in the areas without block (n = 28) (24 +/- 7.5% vs. 10 +/- 3.8%, p < 0.0001).

CONCLUSIONS

In human hearts with DCM, epicardial reentrant wave fronts and transmural scroll waves were present during VF. Increased fibrosis provides a site for conduction block, leading to the continuous generation of reentry.

Spatiotemporal evolution of ventricular fibrillation

Sudden cardiac death is the leading cause of death in the industrialized world, with the majority of such tragedies being due to ventricular fibrillation. Ventricular fibrillation is a frenzied and irregular disturbance of the heart rhythm that quickly renders the heart incapable of sustaining life. Rotors, electrophysiological structures that emit rotating spiral waves, occur in several systems that all share with the heart the functional properties of excitability and refractoriness. These re-entrant waves, seen in numerical solutions of simplified models of cardiac tissue, may occur during ventricular tachycardias. It has been difficult to detect such forms of re-entry in fibrillating mammalian ventricles. Here we show that, in isolated perfused dog hearts, high spatial and temporal resolution mapping of optical transmembrane potentials can easily detect transiently erupting rotors during the early phase of ventricular fibrillation. This activity is characterized by a relatively high spatiotemporal cross-correlation. During this early fibrillatory interval, frequent wavefront collisions and wavebreak generation are also dominant features. Interestingly, this spatiotemporal pattern undergoes an evolution to a less highly spatially correlated mechanism that lacks the epicardial manifestations of rotors despite continued myocardial perfusion.

Spatial and temporal organization during cardiac fibrillation

Cardiac fibrillation (spontaneous, asynchronous contractions of cardiac muscle fibres) is the leading cause of death in the industrialized world, yet it is not clear how it occurs. It has been debated whether or not fibrillation is a random phenomenon. There is some determinism during fibrillation, perhaps resulting from rotating waves of electrical activity. Here we present a new algorithm that markedly reduces the amount of data required to depict the complex spatiotemporal patterns of fibrillation. We use a potentiometric dye and video imaging to record the dynamics of transmembrane potentials at many sites during fibrillation. Transmembrane signals at each site exhibit a strong periodic component centred near 8 Hz. This periodicity is seen as an attractor in two-dimensional-phase space and each site can be represented by its phase around the attractor. Spatial phase maps at each instant reveal the 'sources' of fibrillation in the form of topological defects, or phase singularities, at a few sites. Using our method of identifying phase singularities, we can elucidate the mechanisms for the formation and termination of these singularities, and represent an episode of fibrillation by locating singularities. Our results indicate an unprecedented amount of temporal and spatial organization during cardiac fibrillation.

Evolving perspectives during 12 years of electrical turbulence

This Focus issue describes a problem in electrical dynamics which has fascinated generations of physiologists. There are today so many views of fibrillation that only the rarest generalization can embrace all of them. Fifty-two prominent investigators collaborate here to present aspects of the problem in these eighteen articles (including this introduction) tailored for readers whose principal expertise lies elsewhere. In "The High One's Lay" (Norse Runes, ca. 800) Odin remarks, "Much too early I came to many places: the beer was not yet ready, or was already drunk em leader " but to this one we come at very nearly the right time in 1998. This introduction attempts to guide newcomers by noting the changed or multiple meanings of novel technical terms while sorting the key facts and ideas into an order that facilitates comparison and contrast with those of a dozen years ago. This Focus issue is authored by some of the foremost innovators of both theory and experiment in this area. By assimilating their presentations the readers of Chaos can become well poised to appreciate and evaluate the definitive evidence expected in the next few years. (c) 1998 American Institute of Physics.

Self-organization and the dynamical nature of ventricular fibrillation

This article reviews recent data supporting the conjecture that, in the structurally and electrophysiologically normal heart, cardiac fibrillation is not a totally random phenomenon. Experimental and numerical studies based on the theory of excitable media suggest that fibrillation in the mammalian ventricles is the result of self-organized three-dimensional (3-D) electrical rotors giving rise to scroll waves that move continuously (i.e., drift) throughout the heart at varying speeds. A brief review of studies on the dynamics of rotors in two-dimensional (2-D) and 3-D excitable media is presented with emphasis on the experimental demonstration of such dynamics in cardiac muscle of various species. The discussion is centered on rotor dynamics in the presence and the absence of structural heterogeneities, and in the phenomena of drifting and anchoring, which in the electrocardiogram (ECG) may manifest as life-threatening cardiac rhythm disturbances. For instance, in the rabbit heart, a single electrical rotor that drifts rapidly throughout the ventricles gives rise to complex patterns of excitation. In the ECG such patterns are indistinguishable from ventricular fibrillation. On the other hand, a rotor that anchors to a discontinuity or defect in the muscle (e.g., a scar, a large artery or a bundle of connective tissue) may result in stationary rotating activity, which in the ECG is manifested as a form of so-called "monomorphic" ventricular tachycardia. More recent data show that ventricular fibrillation occurs in mammals irrespective of size or species. While in small hearts, such as those of mice and rabbits, a single drifting or meandering rotor can result in fibrillation, in larger hearts, such as the sheep and possibly the human, fibrillation occurs in the form of a relatively small number of coexisting but short-lived rotors. Overall, the work discussed here has paved the way for a better understanding of the mechanisms of fibrillation in the normal, as well as diseased human heart. (c) 1998 American Institute of Physics.

Ventricular fibrillation and atrial fibrillation are two different beasts

Although the mechanisms of fibrillation are no doubt multi-faceted, the geometry of the heart may play a major role in the dynamics of wave propagation during fibrillation [A. T. Winfree, Science 266, 1003-1006 (1994)]. The ventricles are thick chambers made up of sheets of parallel muscle fibers with the direction of fibers rotating across the ventricular walls (rotational anisotropy). The thick walls of the ventricles allow reentry to develop transmurally, provided the wavelength is sufficiently small. Depending on the kinetics of heart cells, the dynamics of rotating waves in three dimensions may be fundamentally different than in two dimensions, leading to destabilization of reentry and ventricular fibrillation (VF) in thick ventricles. The atria have an intricate geometry comprised of a thin sheet of cardiac tissue attached to a very complex network of pectinate muscles. The branching geometry of the pectinate muscles may lead to destabilization of two-dimensional reentry via "long-distance" electrical connections giving rise to atrial fibrillation (AF). Therefore, although fibrillation occurs via complex three-dimensional wave propagation in the ventricles and the atria, the underlying mechanisms and factors that sustain VF and AF are probably different.(c) 1998 American Institute of Physics.

Computerized mapping of fibrillation in normal ventricular myocardium

It is well known that the ability to fibrillate is intrinsic to a normal ventricle that exceeds a critical mass. The questions we address are how is ventricular fibrillation (VF) initiated and perpetuated in normal myocardium, and why is VF not seen more often in the general population if all ventricles have the ability to fibrillate. To study the mechanisms of VF, we used computerized mapping techniques with up to 512 channels of simultaneous multisite recordings for data acquisition. The data were then processed for dynamic display of the activation patterns and for mathematical analyses of the activation intervals. The results show that in normal ventricles, VF can be initiated by a single strong premature stimulus given during the vulnerable period of the cardiac cycle. The initial activations form a figure-eight pattern. Afterward, VF will perpetuate itself without any outside help. The self-perpetuation itself is due to at least two factors. One is that single wave fronts spontaneously break up into two or more wavelets. The second is that when two wavelets intersect perpendicular to each other, the second wavelet is broken by the residual refractoriness left over from the first wavelet. Mathematical analyses of the patterns of activation during VF revealed that VF is a form of chaos, and that transition from ventricular tachycardia (VT) to VF occurs via the quasiperiodic route. In separate experiments, we found that we can convert VF to VT by tissue size reduction. The physiological mechanism associated with the latter transition appears to be the reduction of the number of reentrant wave fronts and wandering wavelets. Based on these findings, we propose that the reentrant wave fronts and the wandering wavelets serve as the physiological equivalent of coupled oscillators. A minimal number of oscillators is needed for VF to perpetuate itself, and to generate chaotic dynamics; hence a critical mass is required to perpetuate VF. We conclude that VF in normal myocardium is a form of reentrant cardiac arrhythmia. A strong electrical stimulus initiates single or dual reentrant wave fronts that break up into multiple wavelets. Sometimes short-lived reentry is also generated during the course of VF. These organized reentrant and broken wavelets serve as coupled oscillators that perpetuate VF and maintain chaos. Although the ability to support these oscillators exists in a normal ventricle, the triggers required to generate them are nonexistent in the normal heart. Therefore, VF and sudden death do not happen to most people with normal ventricular myocardium. (c) 1998 American Institute of Physics.

Electrical turbulence as a result of the critical curvature for propagation in cardiac tissue

In cardiac tissue, the propagation of electrical excitation waves is dependent on the active properties of the cell membrane (ionic channels) and the passive electrical properties of cardiac tissue (passive membrane properties, distribution of gap junctions, and cell shapes). Initiation of cardiac arrhythmias is usually associated with heterogeneities in the active and/or passive properties of cardiac tissue. However, as a result of the effect of wave front geometry (curvature) on propagation of cardiac waves, inexcitable anatomical obstacles, like veins and arteries, may cause the formation of self-sustained vortices and uncontrolled high-frequency excitation in normal homogeneous myocardium. (c) 1998 American Institute of Physics.

Patterns of spiral tip motion in cardiac tissues

In support of the spiral wave theory of reentry, simulation studies and animal models have been utilized to show various patterns of spiral wave tip motion such as meandering and drifting. However, the demonstration of these or any other patterns in cardiac tissues have been limited. Whether such patterns of spiral tip motion are commonly observed in fibrillating cardiac tissues is unknown, and whether such patterns form the basis of ventricular tachycardia or fibrillation remain debatable. Using a computerized dynamic activation display, 108 episodes of atrial and ventricular tachycardia and fibrillation in isolated and intact canine cardiac tissues, as well as in vitro swine and myopathic human cardiac tissues, were analyzed for patterns of nonstationary, spiral wave tip motion. Among them, 46 episodes were from normal animal myocardium without pharmacological perturbations, 50 samples were from normal animal myocardium, either treated with drugs or had chemical ablation of the subendocardium, and 12 samples were from diseased human hearts. Among the total episodes, 11 of them had obvious nonstationary spiral tip motion with a life span of >2 cycles and with consecutive reentrant paths distinct from each other. Four patterns were observed: (1) meandering with an inward petal flower in 2; (2) meandering with outward petals in 5; (3) irregularly concentric in 3 (core moving about a common center); and (4) drift in 1 (linear core movement). The life span of a single nonstationary spiral wave lasted no more than 7 complete cycles with a mean of 4.6+/-4.3, and a median of 4.5 cycles in our samples. Conclusion: (1) Patently evident nonstationary spiral waves with long life spans were uncommon in our sample of mostly normal cardiac tissues, thus making a single meandering spiral wave an unlikely major mechanism of fibrillation in normal ventricular myocardium. (2) A tendency toward four patterns of nonstationary spiral tip motion was observed. (c) 1998 American Institute of Physics.

Spatiotemporal complexity of ventricular fibrillation revealed by tissue mass reduction in isolated swine right ventricle. Further evidence for the quasiperiodic route to chaos hypothesis

We have presented evidence that ventricular fibrillation is deterministic chaos arising from quasiperiodicity. The purpose of this study was to determine whether the transition from chaos (ventricular fibrillation, VF) to periodicity (ventricular tachycardia) through quasiperiodicity could be produced by the progressive reduction of tissue mass. In isolated and perfused swine right ventricular free wall, recording of single cell transmembrane potentials and simultaneous mapping (477 bipolar electrodes, 1.6 mm resolution) were performed. The tissue mass was then progressively reduced by sequential cutting. All isolated tissues fibrillated spontaneously. The critical mass to sustain VF was 19.9 +/- 4.2 g. As tissue mass was decreased, the number of wave fronts decreased, the life-span of reentrant wave fronts increased, and the cycle length, the diastolic interval, and the duration of action potential lengthened. There was a parallel decrease in the dynamical complexity of VF as measured by Kolmogorov entropy and Poincaré plots. A period of quasiperiodicity became more evident before the conversion from VF (chaos) to a more regular arrhythmia (periodicity). In conclusion, a decrease in the number of wave fronts in ventricular fibrillation by tissue mass reduction causes a transition from chaotic to periodic dynamics via the quasiperiodic route.

Spirals, chaos, and new mechanisms of wave propagation

The chaos theory is based on the idea that phenomena that appear disordered and random may actually be produced by relatively simple deterministic mechanisms. The disordered (aperiodic) activation that characterizes a chaotic motion is reached through one of a few well-defined paths that are characteristic of nonlinear dynamical systems. Our group has been studying VF using computerized mapping techniques. We found that in electrically induced VF, reentrant wavefronts (spiral waves) are present both in the initial tachysystolic stage (resembling VT) and the later tremulous incoordination stage (true VF). The electrophysiological characteristics associated with the transition from VT to VF is compatible with the quasiperiodic route to chaos as described in the Ruelle-Takens theorem. We propose that specific restitution of action potential duration (APD) and conduction velocity properties can cause a spiral wave (the primary oscillator) to develop additional oscillatory modes that lead to spiral meander and breakup. When spiral waves begin to meander and are modulated by other oscillatory processes, the periodic activity is replaced by unstable quasiperiodic oscillation, which then undergoes transition to chaos, signaling the onset of VF. We conclude that VF is a form of deterministic chaos. The development of VF is compatible with quasiperiodic transition to chaos. These results indicate that both the prediction and the control of fibrillation are possible based on the chaos theory and with the advent of chaos control algorithms.

The cardiac vulnerable period and reentrant arrhythmias: targets of anti- and proarrhythmic processes

Because sudden cardiac death is usually preceded by a reentrant arrhythmia, the precipitating arrhythmia must be multicellular in origin. Therefore clinicians seeking to reduce the incidence of reentrant arrhythmias in their patients with antiarrhythmic drugs that alter propagation may reasonably question the applicability of drug classification schemes (e.g. Sicilian Gambit) that are based on measurements in single cells. This raises a major question: are measures of a drug's anti- and proarrhythmic potential in single cells predictive of its anti- and proarrhythmic properties in tissue? The problem is as follows. From single cell measurements, one expects Class I drugs to reduce excitability, thereby attenuating the occurrence of PVCs. Similarly, one expects Class III drugs to prolong refractoriness and reduce the occurrence of PVCs. We have found in simple models of cardiac tissue that sodium channel blockade (the target of Class I drugs) extends the vulnerable period of a propagating excitation wave, whereas potassium channel blockade (the target of Class III drugs) destabilizes the reentrant path in a manner that amplifies the likelihood of polymorphic tachyarrhythmias. Using analytical, numerical, and experimental studies, we determined that sodium channel blockade was proarrhythmic. In fact, we found that any intervention that slowed conduction was proarrhythmic because slowed conduction increases the vulnerable period and reduces the spatial requirements for sustained reentry. We also found that when obstacles were placed in the path of a propagating wave, reentry occurred when the conduction velocity was less than a critical value. Once reentry was established, we observed that the ECG displayed monomorphic QRS complexes when the reentrant path did not vary from cycle to cycle. Moreover, when the reentry path did vary from cycle to cycle, the ECG displayed polymorphic QRS complexes. The cycle-to-cycle variation in QRS morphology was caused by the spatial variability of the reentry path. The variability of reentry paths (and hence the degree of polymorphic variation in QRS complexes) was amplified by Class III agents. The results presented here show that multicellular proarrhythmic effects are derived from the same mechanisms that exhibit antiarrhythmic properties in single cells.