Heterogeneity within the ventricular wall. Electrophysiology and pharmacology of epicardial, endocardial, and M cells

Blockade by N-3 polyunsaturated fatty acid of the Kv4.3 current stably expressed in Chinese hamster ovary cells

1. The Kv4.3 gene is believed to encode a large proportion of the transient outward current (Ito), responsible for the early phase of repolarization of the human cardiac action potential. There is evidence that this current is involved in the dispersion of refractoriness which develops during myocardial ischaemia and which predisposes to the development of potentially fatal ventricular tachyarrhythmias. 2. Epidemiological, clinical, animal, and cellular studies indicate that these arrhythmias may be ameliorated in myocardial ischaemia by n-3 polyunsaturated fatty acids (n-3 PUFA) present in fish oils. 3. We describe stable transfection of the Kv4.3 gene into a mammalian cell line (Chinese hamster ovary cells), and using patch clamp techniques have shown that the resulting current closely resembles human Ito. 4. The current is rapidly activating and inactivating, with both processes being well fit by double exponential functions (time constants of 3.8 +/- 0.2 and 5.3 +/- 0.4 ms for activation and 20.0 +/- 1.2 and 96.6+/-6.7 ms for inactivation at +45 mV at 23 degrees C). Activation and steady state inactivation both show voltage dependence (V1/2 of activation= -6.7+/-2.5 mV, V1,2 of steady state inactivation= -51.3+/-0.2 mV at 23 degrees C). Current inactivation and recovery from inactivation are faster at physiologic temperature (37 degrees C) compared to room temperature (23 degrees C). 5. The n-3 PUFA docosahexaenoic acid blocks the Kv4.3 current with an IC50 of 3.6 micromol L(-1). Blockade of the transient outward current may be an important mechanism by which n-3 PUFA provide protection against the development of ventricular fibrillation during myocardial ischaemia.

Ion channels and ventricular arrhythmias: cellular and ionic mechanisms underlying the Brugada syndrome

Brugada syndrome is characterized by ST segment elevation in the right precordial leads, V1-V3 (unrelated to ischemia or structural disease), normal QT intervals, apparent right bundle branch block, and sudden cardiac death, particularly in men of Asian origin. An autosomal dominant mode of inheritance with variable expression has been described. The only gene thus far linked to the Brugada syndrome is the cardiac sodium channel gene, SCN5A. The possible cellular and ionic basis for these features of the Brugada syndrome are discussed. Strong sodium channel block, among other modalities, has been shown to be capable of inducing epicardial and transmural dispersion of repolarization, thus providing the substrate for the development of phase 2 and circus movement reentry, which underlies ventricular tachycardia/ventricular fibrillation.

Mechanism of arrhythmogenicity of the short-long cardiac sequence that precedes ventricular tachyarrhythmias in the long QT syndrome

OBJECTIVES

The purpose of this study was to investigate the electrophysiologic mechanism(s) that underlie the transition of one or more short-long (S-L) cardiac sequences to ventricular tachyarrhythmias (VTs) in the long QT syndrome.

BACKGROUND

One or more S-L cardiac cycles, usually the result of a ventricular bigeminal rhythm, frequently precedes the onset of VT in patients with either normal or prolonged QT interval. Electrophysiologic mechanisms that underlie this relationship have not been fully explained.

METHODS

We investigated electrophysiologic changes associated with the transition of a S-L cardiac sequence to VT in the canine anthopleurin-A model, a surrogate of LQT3. Experiments were performed on 12 mongrel puppies after administration of anthopleurin-A. Correlation of tridimensional activation and repolarization patterns was obtained from up to 384 electrograms. Activation-recovery intervals were measured from unipolar electrograms and were considered to represent local repolarization.

RESULTS

We analyzed 24 different episodes of a S-L sequence that preceded VT obtained from 12 experiments. The VT followed one S-L sequence (five episodes), two to five S-L sequences (12 episodes) and more than five S-L sequences (seven episodes). The single premature ventricular beats coupled to the basic beats were consistently due to a subendocardial focal activity (SFA). There were two basic mechanisms for the development of VT after one or more S-L sequences: 1) in 10 examples of a S-L sequence due to a stable unifocal bigeminal rhythm, the occurrence of a second SFA, which arose consistently from a different site, infringed on the pattern of dispersion of repolarization (DR) of the first SFA to initiate reentrant excitation; 2) in the remaining 14 episodes of a S-L sequence, a slight lengthening (50 to 150 ms) in one or more preceding cycle lengths (CLs) resulted in alterations of the spatial pattern of DR at key sites to promote reentry. The lengthening of the preceding CL produced differentially a greater degree of prolongation of repolarization at midmyocardial and endocardial sites compared with epicardial sites with consequent increase of DR. The increased DR at key adjacent sites resulted in the development of de novo zones of functional conduction block and/or slowed conduction to create the necessary prerequisites for successful reentry.

CONCLUSIONS

The occurrence of VT after one or more S-L cardiac sequences was due to well defined electrophysiologic changes with predictable consequences that promoted reentrant excitation.

Heterogeneity of 4-aminopyridine-sensitive current in rabbit sinoatrial node cells

The electrophysiological properties of sinoatrial (SA) node pacemaker cells vary in different regions of the node. In this study, we have investigated variation of the 4-aminopyridine (4-AP)-sensitive current as a function of the size (as measured by the cell capacitance) of SA node cells to elucidate the ionic mechanisms. The 10 mM 4-AP-sensitive current recorded from rabbit SA node cells was composed of transient and sustained components (Itrans and Isus, respectively). The activation and inactivation properties [activation: membrane potential at which conductance is half-maximally activated (Vh) = 19.3 mV, slope factor (k) = 15.0 mV; inactivation: Vh = -31.5 mV, k = 7.2 mV] as well as the density of Itrans (9.0 pA/pF on average at +50 mV) were independent of cell capacitance. In contrast, the density of Isus (0.97 pA/pF on average at +50 mV) was greater in larger cells, giving rise to a significant correlation with cell capacitance. The greater density of Isus in larger cells (presumably from the periphery) can explain the shorter action potential in the periphery of the SA node compared with that in the center. Thus variation of the 4-AP-sensitive current may be involved in regional differences in repolarization within the SA node.

Sodium pentobarbital reduces transmural dispersion of repolarization and prevents torsades de Pointes in models of acquired and congenital long QT syndrome

INTRODUCTION

Sodium pentobarbital is widely used for anesthesia in experimental studies as well as in clinics, and it is known to prevent the development of torsades de pointes (TdP) in in vivo models of the long QT syndrome (LQTS).

METHODS AND RESULTS

This study examines the effects of pentobarbital on transmural dispersion of repolarization (TDR) and induction of TdP in arterially perfused canine left ventricular wedge preparations in which transmembrane action potentials were simultaneously recorded from epicardial, M, and endocardial regions using floating glass microelectrodes together with a transmural ECG. d-Sotalol and ATX-II were used to mimic the LQT2 and LQT3 forms of congenital LQTS. Both d-sotalol (100 micromol/L, n = 6) and ATX-II (20 nmol/L, n = 6) preferentially prolonged the action potential duration (APD90) of the M cell, thus increasing in the QT interval and TDR, and leading to the development of spontaneous and stimulation-induced TdP. In the absence and presence of d-sotalol, pentobarbital (10, 20, and 50 microg/mL) prolonged the APD90 of epicardial and endocardial cells, and, to a lesser extent, that of the M cell, thus prolonging the QT interval but reducing TDR. In the ATX-II model, the effects of pentobarbital on the QT interval and APD90 were biphasic: 10 microg/mL pentobarbital further prolonged APD90 of epicardial and endocardial cells more than that of the M cell; 20 to 50 microg/mL pentobarbital abbreviated the APD90 of epicardial and endocardial cells less than that of the M cell, thus abbreviating the QT interval and markedly reducing TDR. Twenty to 50 microg/mL pentobarbital totally suppressed spontaneous as well as stimulation-induced TdP in both models

CONCLUSION

Our data indicate that pentobarbital reduces TDR in control and under conditions of congenital and acquired LQTS, and suggest that this mechanism may contribute to the ability of the anesthetic to prevent the development of spontaneous as well as stimulation-induced TdP under conditions mimicking LQT2, LQT3, and acquired (drug-induced) forms of the LQTS. The data also serve to illustrate that there are circumstances under which QT prolongation may not be arrhythmogenic.

The controversial M cell

A recent publication by us has been interpreted by some as arguing against the existence and importance of M cells. We suppose this is the reason we have been asked to write this "controversy." Regrettably for the controversy, neither our work nor we deny the existence of M cells. Rather, we have confirmed, conceivably ad nauseum, that M cells do exist and contribute importantly to the expression of electrical activity in the intact myocardium. What controversy there is relates to (1) whether there is an inhomogeneous transmural gradient for ventricular repolarization in normal hearts, and (2) why the electrophysiologic properties of different myocardial sites differ so markedly at the level of the isolated tissue and single cell and yet become so much more homogenous in the intact ventricle. These issues are addressed on the following pages.

Downward gradient in action potential duration along conduction path in and around the sinoatrial node

Regional differences in electrical activity in rabbit sinoatrial node have been investigated by recording action potentials throughout the intact node or from small balls of tissue from different regions. In the intact node, action potential duration was greatest at or close to the leading pacemaker and declined markedly in all directions from it, e.g., by 74 +/- 4% (mean +/- SE, n = 4) to the crista terminalis. Similar data were obtained from the small balls. The gradient is down the conduction pathway and will help prevent reentry. In the intact node, a zone of inexcitable tissue with small depolarizations of <25 mV or stable resting potentials was discovered in the inferior part of the node, and this will again help prevent reentry. The intrinsic pacemaker activity of the small balls was slower in tissue from more inferior (as well as more central) parts of the node [e.g., cycle length increased from 339 +/- 13 ms (n = 6) to 483 +/- 13 ms (n = 6) in transitional tissue from more superior and inferior sites], and this may help explain pacemaker shift.

The Brugada syndrome: clinical, electrophysiologic and genetic aspects

This review deals with the clinical, basic and genetic aspects of a recently highlighted form of idiopathic ventricular fibrillation known as the Brugada syndrome. Our primary objective in this review is to identify the full scope of the syndrome and attempt to correlate the electrocardiographic manifestations of the Brugada syndrome with cellular and ionic heterogeneity known to exist within the heart under normal and pathophysiologic conditions so as to identify the cellular basis and thus potential diagnostic and therapeutic approaches. The available data suggest that the Brugada syndrome is a primary electrical disease resulting in abnormal electrophysiologic activity in right ventricular epicardium. Recent genetic data linking the Brugada syndrome to an ion channel gene mutation (SCN5A) provides further support for the hypothesis. The electrocardiographic manifestations of the Brugada syndrome show transient normalization in many patients, but can be unmasked using sodium channel blockers such as flecainide, ajmaline or procainamide, thus identifying patients at risk. The available data suggest that loss of the action potential dome in right ventricular epicardium but not endocardium underlies the ST segment elevation seen in the Brugada syndrome and that electrical heterogeneity within right ventricular epicardium leads to the development of closely coupled premature ventricular contractions via a phase 2 reentrant mechanism that then precipitates ventricular tachycardia/ventricular fibrillation (VT/VF). Currently, implantable cardiac defibrillator implantation is the only proven effective therapy in preventing sudden death in patients with the Brugada syndrome and is indicated in symptomatic patients and should be considered in asymptomatic patients in whom VT/VF is inducible at time of electrophysiologic study.

The long QT syndrome and torsade de pointes

The LQTS is a prime example of how molecular biology, ion channel, cellular, and organ physiology, coupled with clinical observations, promise to be the future paradigm for advancement of medical knowledge. Both the congenital and acquired LQTS are due to abnormalities (intrinsic and/or acquired) of the ionic currents underlying cardiac repolarization. In this review, the continually unraveling molecular biology of congenital LQTS is discussed. The various pharmacological agents associated with the acquired LQTS are listed. Although it is difficult to predict which patients are at risk for TdP, careful assessment of the risk-benefit ratio is important before prescribing drugs known to be able to cause QT prolongation. The in vivo electrophysiological mechanism of TdP in the LQTS is described using, as a paradigm, the anthopleurin-A canine model, a surrogate for LQT3. In the LQTS, prolonged repolarization is associated with increased spatial dispersion of repolarization. Prolongation of repolarization also acts as a primary step for the generation of EADs. The focal EAD induced triggered beat(s) can infringe on the underlying substrate of inhomogeneous repolarization to initiate polymorphic reentrant VT, sometimes having the characteristic twisting QRS configuration known as TdP. The review concludes by discussion of the clinical manifestations and current management of both the congenital and acquired LQTS. The initial therapy of choice for the large majority of patients with the congenital LQTS is a beta-blocking drug. This therapy seems to be effective in LQT1 and LQT2 patients, but may not be as effective in LQT3 patients. Other therapeutic options include pacemakers, cervicothoracic sympathectomy, and the implantable cardioverter defibrillator. Recent molecular genetic studies have suggested several genotype specific therapies; however, long-term efficacy data are not available.

Spatiotemporal effects of syncytial heterogeneities on cardiac far-field excitations during monophasic and biphasic shocks

INTRODUCTION

It has recently been postulated that syncytial (anatomic) heterogeneities inherent within cardiac tissue might represent a significant mechanism underlying field-induced polarization of the bulk myocardium. This simulation study examines and characterizes the spatiotemporal excitatory dynamics associated with this newly hypothesized mechanism.

METHODS AND RESULTS

Two-dimensional regions of syncytially heterogeneous cardiac tissue were simulated with active membrane kinetics. Heterogeneities were manifested via random spatial variations of intracellular volume fractions over multiple length scales. Excitation thresholds were determined for uniform rectangular monophasic (M) and symmetric biphasic (B) far-field stimuli, from which strength-duration and strength-interval relationships were constructed. For regions measuring 5.4 x 5.4 mm, baseline diastolic thresholds for longitudinal (L) and transverse (T) shocks of 5-msec total duration averaged (in V/cm, n = 10) M-L = 2.87+/-0.26, M-T = 6.71+/-0.83, B-L = 3.22+/-0.25, and B-T = 7.93+/-0.51. These thresholds decreased by 15% to 25% when the region sizes were increased to 10.8 x 10.8 mm. Strength-duration relationships correlated strongly with the Weiss-Lapicque hyperbolic relationship, with rheobases and chronaxies of 2.33 V/cm and 1.15 msec for M-L stimuli, and 2.28 V/cm and 2.04 msec for B-L stimuli. Strength-interval relationships for M-L and B-L stimuli decreased monotonically with increasing coupling intervals, with similar minimum coupling intervals at absolute refractoriness. However, the B-L thresholds were substantially less sensitive to changes in coupling intervals than their M-L counterparts.

CONCLUSION

This study provides strong additional support for and understanding of the syncytial heterogeneity hypothesis and its manifested properties. Furthermore, these results predict that syncytial heterogeneities of even modest proportions could represent a significant mechanism contributing to the far-field excitation process.

ST segment elevation induced by class IC antiarrhythmic agents: underlying electrophysiologic mechanisms and insights into drug-induced proarrhythmia

Three patients in whom Class IC sodium channel blockers induced ST segment elevation in leads V1 through V3 are described. The underlying electrophysiologic mechanism, implications for drug-induced proarrhythmia, and the relationship of the finding to the Brugada syndrome type of idiopathic ventricular fibrillation are discussed.

Prediction of the onset of atrial fibrillation after cardiac surgery using the monophasic action potential

OBJECTIVE

To show that the monophasic action potential (MAP) recorded continuously from human epicardium may be used to predict the imminent onset of atrial fibrillation or flutter (AF) following surgery, thus allowing prophylactic treatment to be started.

PATIENTS

22 patients (14 male, 8 female; mean (SD) age 64 (12) years) undergoing aortic valve replacement.

SETTING

Tertiary referral centre.

METHODS

Over a mean observation period of 8 (2.7) days (range 4 to 14), nine episodes of AF were seen in six patients. Before AF, specific and significant alterations of the MAP morphology were observed. In seven of nine episodes the MAP shortened (25 (4)% 60 minutes before AF), developed a triangular shape, and the plateau amplitude decreased from 5.3 (1.2) to 2 (0.2) mV. In the two remaining episodes the beat to beat variability of cycle length and MAP duration at 90% repolarisation (MAPd90) increased significantly from 24 (7) ms and 12 (8) ms (24 hours before AF) to 137 (27) ms and 56 (11) ms (30 minutes before AF) respectively. AF was successfully treated by the administration of sotalol in three cases and by a combination of verapamil and digoxin in a further four. Previously observed changes of MAPd90 and MAP morphology regressed after conversion to sinus rhythm.

CONCLUSIONS

The continuous and intermediate term recording of the MAP from atrial epicardium appears to be a valid tool for detecting imminent AF after cardiac surgery with a high sensitivity (99%) and specificity (88%). Optimised antiarrhythmic treatment may thus be given selectively for prophylaxis.

Comparison of the cellular electrophysiological characteristics of canine left ventricular epicardium, M cells, endocardium and Purkinje fibres

Electrophysiological differences among M cells, epicardium, endocardium and Purkinje fibres of the canine ventricle were studied over a wide range of stimulation cycle lengths, and the pharmacological response of these cell types to the sodium channel blocker tetrodotoxin, calcium channel blocker nifedipine and ATP-sensitive potassium channel activator pinacidil was compared. The experiments were carried out by applying standard intracellular microelectrode technique in isolated dog left ventricular preparations. The results confirmed the existence of M cells in the canine ventricle, in addition, the distribution of the rate of rise of the action potential upstroke and action potential amplitude values reflecting probably the inhomogeneity of the fast sodium current in these cells was revealed. It was also demonstrated that M cells differ from Purkinje fibres in some aspects which were not expected from previous investigations: (1) The early portion of the action potential duration restitution curve in M cells is more similar to that of endocardial and epicardial cells than to Purkinje fibres. (2) The plateau phase of the action potentials in Purkinje fibres developed at a more negative potential range than that in the other cell types studied. (3) The pharmacological response to tetrodotoxin and pinacidil in M cells resembles to that in the endocardial and epicardial cells more than in the Purkinje fibres. Our results provide further evidence in support of the existence of M cells but also indicate that there are important electrophysiological as well as pharmacological differences between M cells and Purkinje fibres.

Amiodarone reduces transmural heterogeneity of repolarization in the human heart

OBJECTIVES

The present work was designed to test the effects of amiodarone therapy on action potential characteristics of the three cell types observed in human left ventricular preparations.

BACKGROUND

The electrophysiologic basis for amiodarone's exceptional antiarrhythmic efficacy and low proarrhythmic profile remains unclear.

METHODS

We used standard microelectrode techniques to investigate the effects of chronic amiodarone therapy on transmembrane activity of the three predominant cellular subtypes (epicardial, midmyocardial [M] and endocardial cells) spanning the human left ventricle in hearts explanted from normal, heart failure and amiodarone-treated heart failure patients.

RESULTS

Tissues isolated from the ventricles of heart failure patients receiving chronic amiodarone therapy displayed M cell action potential duration (404+/-12 ms) significantly briefer (p < 0.05) than that recorded in tissues isolated from normal hearts (439+/-22 ms) or from heart failure patients not treated with amiodarone (449+/-18 ms). Endocardial cells from amiodarone-treated heart failure patients displayed longer (p < 0.05) action potential duration (363+/-10 ms) than endocardial cells isolated from normal hearts (330+/-6 ms). As a consequence, the heterogeneity of ventricular repolarization in tissues from patients treated with amiodarone was considerably smaller than in the two other groups, especially at long pacing cycle lengths.

CONCLUSIONS

These findings may explain, at least in part, the reduction of ventricular repolarization dispersion and the lower incidence of torsade de pointes observed with chronic amiodarone therapy as compared with other class III agents.

Modulation of transient outward current by extracellular protons and Cd2+ in rat and human ventricular myocytes

1. The effects of extracellular acidosis and Cd2+ on the transient outward current (Ito) have been investigated in rat and human ventricular myocytes, using the whole-cell patch-clamp technique. 2. In rat myocytes, exposure to acidic extracellular solution (pH 6.0) shifted both steady-state activation and inactivation curves to more positive potentials, by 20.5 +/- 2.7 mV (mean +/- S.E.M.; n = 4) and 19.8 +/- 1.2 mV, respectively. Cd2+ also shifted the activation and inactivation curves in a positive direction in a concentration-dependent manner. 3. In human myocytes, the steady-state activation and inactivation curves were located at more positive potentials. The effect of Cd2+ was similar, but acidosis had less effect than in rat myocytes (e.g. pH 6.0 shifted activation by only 7.2 +/- 2.2 mV and inactivation by 13.7 +/- 0.5 mV; n = 4). 4. In both species, the effect of acidosis decreased with increasing concentrations of Cd2+ and vice versa, suggesting competition between H+ and Cd2+ for a common binding site. 5. The data indicate that acidosis and divalent cations influence Ito via a similar mechanism and act competitively in both rat and human myocytes, but that human cells are less sensitive to the effects of acidosis.

Acceleration-induced action potential prolongation and early afterdepolarizations

INTRODUCTION

Precipitation of torsades de pointes (TdP) has been shown to be associated with acceleration of heart rate in both experimental and clinical studies. To gain insight into the cellular mechanism(s) responsible for the initiation of acceleration-induced TdP, we studied the effect of acceleration of pacing rate in canine left ventricular epicardial, M region, endocardial, and Purkinje fiber preparations pretreated with E-4031, an IKr blocker known to induce the long QT syndrome and TdP.

METHODS AND RESULTS

Standard microelectrode techniques were used. E-4031 (1 to 2 microM) induced early after depolarization (EAD) activity in 31 of 36 M cell, 0 of 10 epicardial, 0 of 10 endocardial, and 9 of 12 Purkinje fiber preparations at basic cycle lengths (BCLs) > or = 800 msec. In 30 of 36 M cells, sudden acceleration from a BCL range of 900 to 4,000 msec to a range of 500 to 1,500 msec induced transient EAD activity if none existed before or increased the amplitude of EADs if already present. Acceleration-induced augmentation of EAD activity was far less impressive and less readily demonstrable in Purkinje fibers (4/12). In M cells, appearance of EAD activity during acceleration usually was accompanied by an abbreviation of action potential duration (APD). Within discrete ranges of rates in the physiologic range, acceleration caused a transient prolongation of APD in 38% of M cells, whether or not a distinct EAD was generated. Acceleration produced still more dramatic APD prolongation and EADs in M cells after the BCL was returned to the original slow rate. Epicardium and endocardium APD showed little change immediately after acceleration. A decrease of BCL as small as 10% and, in some cases, a single premature beat could promote EAD activity and APD prolongation in some M cells. Ryanodine (1 microM, 10/10), flunarizine (10 microM, 3/6), and low Na (97 vs 129 mM, 5/5) abolished the acceleration-induced EAD activity and APD prolongation as well as the EAD activity observed at slow rates in M cells pretreated with E-4031.

CONCLUSION

Our results suggest that acceleration from an initially slow rate or a single premature beat can induce or facilitate transient EAD activity and APD prolongation in canine ventricular M cell preparations pretreated with an IKr blocker via a mechanism linked to intracellular calcium loading. Our data provide evidence in support of an important contribution of electrogenic Na/Ca exchange current to this process. These acceleration-induced changes can result in the development of triggered activity as well as a marked dispersion of repolarization in ventricular myocardium and, thus, may contribute to the precipitation of TdP in patients with the congenital (HERG defect) and acquired (drug-induced) long QT syndrome.

Differences in regional distribution of K+ current densities in rat ventricle

The objective of the present work is to study the ionic mechanisms for the regional differences in action potential duration in rat ventricle. This regional diversity has been related to differences in the regional distribution of some potassium currents in several species. Single cells were obtained by enzymatic dispersion of tissue segments from rat ventricular muscle. Whole cell voltage-clamp methods were used to identify the K+ currents involved in action potential repolarisation in the different regions. 4-Aminopiridine, TEA and voltage protocols were used to isolate the following potassium currents: transient outward, Ito, delayed rectifier, Ik, and sustained current, Iss. In the present work, we have studied the distribution of these three repolarising currents, and that of the inward rectifier, Ikl, in the free wall of the right ventricle, the subepicardium of the apex of the left ventricle and in the subendocardium of the base of the left ventricle. Action potential duration was longer in the left than in the right ventricle, and in the former it was longer in the subendocardium of the base than in the subepicardium of the apex. The main difference was in the phase 1, suggesting the implication of Ito. This was confirmed with voltage-clamp experiments. In conclusion, this work shows that Ito current density is higher in the regions with the shorter action potential, whereas there are no differences in the regional distribution of Ik, Iss or Ikl.

Class IC antiarrhythmic drugs, flecainide and pilsicainide, produce ST segment elevation simulating inferior myocardial ischemia

Flecainide and pilsicainide, Class IC antiarrhythmic drugs with slow kinetics, were administered to a 64-year-old man experiencing ventricular tachycardia. Both drugs suppressed the arrhythmia, but caused ST segment elevation in leads II, III, and aVF. No evidence of ischemic heart disease was detected. Withdrawal of the drugs eliminated the ST change. Because these drugs frequently are used to treat tachyarrhythmias in patients who may present with chest pain, this rare ECG manifestation of Class IC drugs should be recognized to avoid misdiagnosis of acute inferior myocardial infarction.

Transmural heterogeneity of action potentials and Ito1 in myocytes isolated from the human right ventricle

Limited information is available about transmural heterogeneity in cardiac electrophysiology in man. The present study was designed to evaluate heterogeneity of cardiac action potential (AP), transient outward K+ current (Ito1) and inwardly rectifying K+ current (IK1) in human right ventricle. AP and membrane currents were recorded using whole cell current- and voltage-clamp techniques in myocytes isolated from subepicardial, midmyocardial, and subendocardial layers of the right ventricle of explanted failing human hearts. AP morphology differed among the regional cell types. AP duration (APD) at 0.5-2 Hz was longer in midmyocardial cells (M cells) than in subepicardial and subendocardial cells. At room temperature, observed Ito1, on step to +60 mV, was significantly greater in subepicardial (6.9 +/- 0.8 pA/pF) and M cells (6.0 +/- 1.1 pA/pF) than in subendocardial cells (2.2 +/- 0.7 pA/pF, P < 0.01). Slower recovery of Ito1 was observed in subendocardial cells. The half-inactivation voltage of Ito1 was more negative in subendocardial cells than in M and subepicardial cells. At 36 degrees C, the density of Ito1 increased, the time-dependent inactivation and reactivation accelerated, and the frequency-dependent reduction attenuated in all regional cell types. No significant difference was observed in IK1 density among the regional cell types. The results indicate that M cells in humans, as in canines, show the greatest APD and that a gradient of Ito1 density is present in the transmural ventricular wall. Therefore, the human right ventricle shows significant transmural heterogeneity in AP morphology and Ito1 properties.

Azimilide causes reverse rate-dependent block while reducing both components of delayed-rectifier current in canine ventricular myocytes

Most class III antiarrhythmic drugs reduce the rapidly activating component of delayed-rectifier current (IKr) without affecting the slowly activating component (IKs). Recently the novel antiarrhythmic agent azimilide (NE-10064) was reported to enhance IKs at low (nanomolar) concentrations and to block both IKr and IKs at higher (micromolar) concentrations. Further to understand the electrophysiologic effects of azimilide, we compared its effects on IKr and IKs (by using whole cell clamp techniques) and action potentials (microelectrode and perforated-patch techniques) on canine ventricular myocytes. A lower azimilide concentration (50 nM) did not enhance IKs. In contrast, a therapeutic azimilide concentration (2 microM) was equieffective in reducing IKr (300-ms isochrones) and IKs (3-s isochrones) by approximately 40% during depolarizing test pulses, as well as reducing IKr (38% decrease) and IKs (33% decrease) tail currents on repolarization. Block of IKs was independent of voltage at positive test potentials. In action-potential studies, 50 nM azimilide had no effect on the action-potential duration (APD), whereas 2 microM azimilide delayed repolarization and caused reverse rate-dependent effects on the APD. Whereas the extent of APD prolongation by azimilide was not correlated with the drug-free APD, azimilide preferentially exaggerated the APD-rate relationship of myocytes displaying the steepest APD-rate relationship under drug-free conditions. In conclusion, therapeutic concentrations of azimilide that cause comparable reduction of canine ventricular IKr and IKs exert reverse rate-dependent effects, which are dependent on the steepness of the APD-rate relationship.

Cellular basis for QT dispersion

The cellular basis for the dispersion of the QT interval recorded at the body surface is incompletely understood. Contributing to QT dispersion are heterogeneities of repolarization time in the three-dimensional structure of the ventricular myocardium, which are secondary to regional differences in action potential duration (APD) and activation time. While differences in APD occur along the apicobasal and anteroposterior axes in both epicardium and endocardium of many species, transitions are usually gradual. Recent studies have also demonstrated important APD gradients along the transmural axis. Because transmural heterogeneities in repolarization time are more abrupt than those recorded along the surfaces of the heart, they may represent a more onerous substrate for the development of arrhythmias, and their quantitation may provide a valuable tool for evaluation of arrhythmia risk. Our data, derived from the arterially perfused canine left ventricular wedge preparation, suggest that transmural gradients of voltage during repolarization contribute importantly to the inscription of the T wave. The start of the T wave is caused by a more rapid decline of the plateau, or phase 2 of the epicardial action potential, creating a voltage gradient across the wall. The gradient increases as the epicardial action potential continues to repolarize, reaching a maximum with full repolarization of epicardium; this juncture marks the peak of the T wave. The next region to repolarize is endocardium, giving rise to the initial descending limb of the upright T wave. The last region to repolarize is the M region, contributing to the final segment of the T wave. Full repolarization of the M region marks the end of the T wave. The time interval between the peak and the end of the T wave therefore represents the transmural dispersion of repolarization. Conditions known to augment QTc dispersion, including acquired long QT syndrome (class IA or III antiarrhythmics) lead to augmentation of transmural dispersion of repolarization in the wedge, due to a preferential effect of the drugs to prolong the M cell action potential. Antiarrhythmic agents known to diminish QTc dispersion, such as amiodarone, also diminish transmural dispersion of repolarization in the wedge by causing a preferential prolongation of APD in epicardium and endocardium. While exaggerated transmural heterogeneity clearly can provide the substrate for reentry, a precipitating event in the form of a premature beat that penetrates the vulnerable window is usually required to initiate the reentrant arrhythmia. In long QT syndrome, the trigger is thought to be an early afterdepolarization (EAD)-induced triggered beat. The likelihood of developing EADs and triggered activity is increased when repolarizing forces are diminished, making for a slower and more gradual repolarization of phases 2 and 3 of the action potential, which translates into broad, low amplitude and sometimes bifurcated T waves in the electrocardiogram. Our findings suggest that regional differences in the duration of the M cell action potential may be the basis for QT dispersion measured at the body surface under normal and long QT conditions. The data indicate that the interval delimited by the peak and the end of the T wave represents an accurate measure of regional dispersion of repolarization across the ventricular wall and as such may be a valuable index for assessment of arrhythmic risk. The presence of low amplitude, broad and/or bifurcated T waves, particularly under conditions of long QT syndrome, is indicative of diminished repolarizing forces and may represent an independent variable of arrhythmic risk, forecasting the development of EAD-induced triggered beats that can precipitate torsade de pointes. Although the QT interval, QT dispersion, the T wave peak-to-end interval, and the width and amplitude of the T wave often change in parallel, they contain different information and should not be expected to be e

Reentrant waves and their elimination in a model of mammalian ventricular tissue

The vulnerability to reentrant wave propagation, its characteristics (period, meander, and stability), the effects of rotational transmural anisotropy, and the control of reentrant waves by small amplitude perturbations and large amplitude defibrillating shocks are investigated theoretically and numerically for models based on high order, stiff biophysically derived excitation equations.

Modulation of quinidine-induced arrhythmias by temperature in perfused rabbit heart

We used low temperature to slow ion channel kinetics and studied the electrophysiological effects of quinidine at different pacing rates in isolated rabbit hearts. Fifteen epicardial electrograms together with an endocardial monophasic action potential were recorded. Epicardial activation and local recovery times were measured. Arrhythmias together with the characteristics of their mode of induction and rate were analyzed by epicardial activation sequence mapping. In the presence of quinidine, arrhythmias consistent with both triggered activity and reentry were observed. At baseline, triggered activity was not inducible, even though at 25 degrees C the recovery time was greater than that in the presence of quinidine at 36 degrees C. Also, with quinidine, the incidence of triggered activity decreased at 30 and 25 degrees C. Therefore prolongation of the recovery time per se does not cause triggered activity. Quinidine's use-dependent effects on conduction and reverse use-dependent effects on recovery time were amplified by low temperatures. These findings can be understood in terms of the known temperature sensitivities of the kinetics of the membrane ion channels responsible for activation and recovery. The results demonstrate that temperature can be used as a tool to elucidate mechanisms of drug action.

Sympathetic innervation modulates repolarizing K+ currents in rat epicardial myocytes

During postnatal development, sympathetic innervation of the heart evolves, and repolarization accelerates. Our goal in this study was to test whether sympathetic innervation modulates the ion channels that regulate repolarization. We studied action potentials and repolarizing K+ currents in epicardial myocytes from rats in which sympathetic innervation was accelerated or delayed, respectively, by subcutaneous injection of nerve growth factor (NGF) or NGF antibody (Ab) for the first 15 days of life. A placebo group was included as well. Action potential duration (APD) to 90% repolarization was greater in the Ab (158 +/- 18 ms)-treated than the NGF (106 +/- 10 ms)-treated animals (P < 0.05); the APD at 90% repolarization for the placebo group was intermediate (125 +/- 30 ms). The transient outward (Ito) and inward rectifier (IK1) K+ currents were recorded in freshly dissociated cells using the whole cell patch-clamp technique. Ito was decreased in density at potentials positive to +40 mV in Ab-treated rats when compared with rats treated with NGF (P < 0.05). In addition, the inactivation curve of Ito in Ab-treated rats was shifted 13 mV positive to that of NGF-treated rats. IK1 also decreased in the Ab-treated group compared with the NGF group in the potential ranges of -100 to -90 mV (P < 0.05). However, the channel transcript abundance (RNA) in NGF-, Ab-, or placebo-treated rat hearts did not differ. Our results suggest that sympathetic innervation contributes to the developmental differences in K+ currents and APD postnatally in the rat.

Two forms of spiral-wave reentry in an ionic model of ischemic ventricular myocardium

It is well known that there is considerable spatial inhomogeneity in the electrical properties of heart muscle, and that the many interventions that increase this initial degree of inhomogeneity all make it easier to induce certain cardiac arrhythmias. We consider here the specific example of myocardial ischemia, which greatly increases the electrical heterogeneity of ventricular tissue, and often triggers life-threatening cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation. There is growing evidence that spiral-wave activity underlies these reentrant arrhythmias. We thus investigate whether spiral waves might be induced in a realistic model of inhomogeneous ventricular myocardium. We first modify the Luo and Rudy [Circ. Res. 68, 1501-1526 (1991)] ionic model of cardiac ventricular muscle so as to obtain maintained spiral-wave activity in a two-dimensional homogeneous sheet of ventricular muscle. Regional ischemia is simulated by raising the external potassium concentration ([K(+)](o)) from its nominal value of 5.4 mM in a subsection of the sheet, thus creating a localized inhomogeneity. Spiral-wave activity is induced using a pacing protocol in which the pacing frequency is gradually increased. When [K(+)](o) is sufficiently high in the abnormal area (e.g., 20 mM), there is complete block of propagation of the action potential into that area, resulting in a free end or wave break as the activation wave front encounters the abnormal area. As pacing continues, the free end of the activation wave front traveling in the normal area increasingly separates or detaches from the border between normal and abnormal tissue, eventually resulting in the formation of a maintained spiral wave, whose core lies entirely within an area of normal tissue lying outside of the abnormal area ("type I" spiral wave). At lower [K(+)](o) (e.g., 10.5 mM) in the abnormal area, there is no longer complete block of propagation into the abnormal area; instead, there is partial entrance block into the abnormal area, as well as exit block out of that area. In this case, a different kind of spiral wave (transient "type II" spiral wave) can be evoked, whose induction involves retrograde propagation of the action potential through the abnormal area. The number of turns made by the type II spiral wave depends on several factors, including the level of [K(+)](o) within the abnormal area and its physical size. If the pacing protocol is changed by adding two additional stimuli, a type I spiral wave is instead produced at [K(+)](o)=10.5 mM. When pacing is continued beyond this point, apparently aperiodic multiple spiral-wave activity is seen during pacing. We discuss the relevance of our results for arrythmogenesis in both the ischemic and nonischemic heart. (c) 1998 American Institute of Physics.

Hypoxia and hypothermia enhance spatial heterogeneities of repolarization in guinea pig hearts: analysis of spatial autocorrelation of optically recorded action potential durations

INTRODUCTION

Regional dispersions of repolarization (DOR) are arrhythmogenic perturbations that are closely associated with reentry. However, the characteristics of DOR have not been well defined or adequately analyzed because previous algorithms did not take into account spatial heterogeneities of action potential durations (APDs). Earlier simulations proposed that pathologic conditions enhance DOR by decreasing electrical coupling between cells, thereby unmasking differences in cellular repolarization between neighboring cells. Optical mapping indicated that gradients of APD and DOR are associated with fiber structure and are largely independent of activation. We developed an approach to quantitatively characterize APD gradients and DOR to determine how they are influenced by tissue anisotropy and cell coupling during diverse arrhythmogenic insults such as hypoxia and hypothermia.

METHODS AND RESULTS

Voltage-sensitive dyes were used to map APs from 124 sites on the epicardium of Langendorff-perfused guinea pig hearts during (1) cycles of hypoxia and reoxygenation and (2) after 30 minutes of hypothermia (32 degrees to 25 degrees C). We introduce an approach to quantitate DOR by analyzing two-dimensional spatial autocorrelation of APDs along directions perpendicular and parallel to the longitudinal axis of epicardial fibers. A spatial correlation length L was derived as a statistical measure of DOR. It corresponds to the distance over which APDs had comparable values, where L is inversely related to DOR. Hypoxia (30 min) caused a negligible decrease in longitudinal thetaL (from 0.530 +/- 0.138 to 0.478 +/- 0.052 m/sec) and transverse thetaT (from 0.225 +/- 0.034 to 0.204 +/- 0.021 m/sec) conduction velocities and did not alter thetaL/thetaT or activation patterns. In paced hearts (cycle length [CL] = 300 msec), hypoxia decreased APDs (123 +/- 18.2 to 46 +/- 0.6 msec; P < 0.001) within 10 to 15 minutes and enhanced DOR, as indicated by reductions of L from 1.8 +/- 0.9 to 1.1 +/- 0.5 mm (P < 0.005). Hypothermia caused marked reductions of thetaL (0.53 +/- 0.138 to 0.298 +/- 0.104 m/sec) and thetaT (0.225 +/- 0.034 to 0.138 +/- 0.027 m/sec), increased APDs (128 +/- 4.4 to 148 +/- 14.5 msec), and reduced L from 2.0 +/- 0.3 to 1.3 +/- 0.6 mm (P < 0.05). L decreased with increased time of hypoxia and recovered upon reoxygenation. Hypoxia and hypothermia reduced L measured along the longitudinal (L(L)) and transverse (L(T)) axes of cardiac fibers while the ratio of L(L)/L(T) remained constant.

CONCLUSION

Conventional indexes of DOR (i.e., APD "range" or "standard deviation," evaluated with extracellular electrodes) did not convey the spatial inhomogeneities of repolarization revealed by L. Spatial autocorrelation analysis provides a statistically significant measurement of DOR, which can take into account intrinsic heterogeneities of APDs and fiber orientation. The data show that hypoxia and hypothermia produce reductions of L, even though they have different effects on mean APD and conduction velocity. The preservation of a constant L(L)/L(T) ratio during hypoxia and hypothermia, despite large reductions in L, is consistent with a mechanism in which reduced cell-to-cell coupling unmasks intrinsic dispersions of APD and reduces L(L) and L(T) by the same factor. Thus, the spatial autocorrelation of APDs provides a sensitive index of DOR under normal and arrhythmogenic conditions. It incorporates the anisotropic nature of the myocardium and therefore is preferable to conventional indexes of DOR.

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.

Proarrhythmia with class III antiarrhythmic drugs: types, risks, and management

The nature of the proarrhythmic reactions induced by antiarrhythmic drugs is linked to the electrophysiologic effects of these agents. Torsades de pointes is the classic form of proarrhythmia observed during therapy with any drug that prolongs repolarization, for example, the class III agents. Its precise electrophysiologic mechanism is not fully elucidated, although the arrhythmia is generally considered to be due either to early afterdepolarization in the context of prolonged cardiac repolarization or to an increase in spatial or temporal dispersion of repolarization. Among the class III drugs the proarrhythmic risk appears to be lowest for amiodarone, probably due to its complex electrophysiologic profile that may create significant myocardial electrical homogeneity. In the case of d,l-sotalol, the incidence of torsades de pointes increases with dose and the baseline values of the QT interval. Where d-sotalol and other pure class III agents might fall into the varying spectrum of proarrhythmic potential remains unclear. That d-sotalol has been found to increase mortality in postinfarction patients with ventricular dysfunction (the Survival With Oral d-Sotalol [SWORD] trial) is a matter of considerable concern. It raises the possibility that such a phenomenon may be a common property of most, if not all, pure class III compounds. Accordingly, care must be taken to minimize the likelihood of proarrhythmia; in particular, therapy with a class III agent should only be initiated in the presence of a defined indication established on the basis of clinical trials. When class III antiarrhythmic drug-induced proarrhythmia occurs, immediate cessation of therapy with the responsible agent and correction of predisposing factors, such as electrolyte disorders or bradycardia, is mandatory. Intravenous administration of high-dose magnesium sulfate has been demonstrated to be effective in terminating and preventing new episodes of torsades de pointes. Temporary pacing may be necessary.

Tissue remodeling with micro-structurally based material laws

Cardiomyocytes and the extracellular collagen matrix which holds them together respond to changes in their mechanical environment by adapting their orientation, size and composition. We examine local mechanical feedback mechanisms affecting the fiber orientation, sheet orientation and passive fiber direction stiffness, using an axisymmetric finite element model of the left ventricle (LV), with material constitutive laws based on the fibrous-sheet microstructure of myocardium.

Repolarization alternans: techniques, mechanisms, and cardiac vulnerability

Sudden cardiac death continues to be the leading cause of mortality in developed countries. Electrical alternans of the ST segment and the T wave on the surface ECG as a noninvasive marker of patients at risk is a phenomenon that was initially observed early in this century and was seen then to be associated with cardiac rhythm disturbances. Substantial evidence indicates that T wave alternans (TWA) is related to myocardial ischemic as a harbinger of malignant ventricular arrhythmias because it reflects dispersion and heterogeneity of repolarization. Recent data have demonstrated a significant correlation between TWA and vulnerability to ventricular arrhythmias in individuals with or without organic heart disease, it also predicts the results of electrophysiological testing and arrhythmia-free survival in patients with a variety of cardiac diseases. This article reviews the historical background of TWA and discusses the early experimental and recent clinical evidence implying an integral link between TWA and ischemia-induced cardiac vulnerability.

Reproducible induction of "atypical" torsades de pointes by programmed electrical stimulation: a novel form of sotalol-induced proarrhythmia?

We present a patient with sotalol-induced polymorphic ventricular tachycardia that was seen only with programmed ventricular stimulation. Electrophysiologic studies performed prior to initiation of sotalol therapy revealed inducible monomorphic ventricular tachycardia. Possible underlying electrophysiologic mechanisms are discussed.

Repolarization abnormalities, arrhythmia and sudden death in canine tachycardia-induced cardiomyopathy

OBJECTIVES

This study sought to determine whether the canine model of tachycardia-induced heart failure (HF) is an effective model for sudden cardiac death (SCD) in HF.

BACKGROUND

Such a well established HF model that also exhibits arrhythmias and SCD, along with repolarization abnormalities that could trigger them, may facilitate the study of SCD in HF, which still eludes effective treatment.

METHODS

Twenty-five dogs were VVI-paced at 250 beats/min for 3 to 5 weeks. Electrocardiograms were obtained, and left ventricular endocardial monophasic action potentials (MAPs) were recorded at six sites at baseline and after HF. Weekly Holter recordings were made with pacing suspended for 24 h.

RESULTS

Six animals (24%) died suddenly, one with Holter-documented polymorphic ventricular tachycardia (VT). Holter recordings revealed an increased incidence of VT as HF progressed. Repolarization was significantly (p < 0.05) prolonged, as indexed by a corrected QT interval (mean [+/-SD] 311 +/- 25 to 338 +/- 25 ms) and MAP duration measured at 90% repolarization (MAPD90) (181 +/- 19 to 209 +/- 28 ms), and spatial MAPD90 dispersion rose by 40%. We further tested whether CsCl inhibition of repolarizing K+ currents, which are reportedly downregulated in HF, might preferentially prolong the MAPD90 in HF. With 1 mEq/kg body weight of CsCl, MAPD90 rose by 86 +/- 100 ms in dogs with HF versus only 28 +/- 16 ms in control animals (p = 0.002). Similar disparities in CsCl sensitivity were observed in myocytes isolated from normal and failing hearts.

CONCLUSIONS

Tachycardia-induced HF exhibits malignant arrhythmia and SCD, along with prolonged, heterogeneous repolarization and heightened sensitivity to CsCl at chamber and cellular levels. Thus, it appears to be a useful model for studying mechanisms and therapy of SCD in HF.

Modulation of the Electrophysiologic Actions of E-4031 and Dofetilide by Hyperkalemia and Acidosis in Rabbit Ventricular Myocytes

BACKGROUND: E-4031 and dofetilide are new class III antiarrhythmic agents that inhibit the rapid component of the delayed rectifier potassium channel (I(Kr)); however, the effectiveness of many antiarrhythmic drugs in ischemic conditions is uncertain. METHODS AND RESULTS: We modeled two components of ischemia, hyperkalemia (9.6 mM) and acidosis (pH 6.8), in voltage-clamped single rabbit ventricular myocytes to help determine the effect of ischemia on the action of these two drugs. In physiologic solution both E-4031 and dofetilide blocked I(Kr) and significantly reduced total outward current. In hyperkalemic solution, both E-4031 and dofetilide showed significantly reduced blockade of I(Kr), while in acidotic solution dofetilide showed significantly reduced blockade of I(Kr) and E-4031 showed a trend to reduced blockade. Neither drug significantly reduced total outward current in hyperkalemic or acidotic solutions. CONCLUSIONS: In these conditions, E-4031 and dofetilide demonstrate reduced blockade of I(Kr), resulting in loss of class III effect. Furthermore, the complete loss of blocking effect on total outward current during simulated ischemia suggests increases of other repolarizing currents also contribute to loss of class III effect.

Electrophysiology of Myocardial Cells in the Epicardial, Midmyocardial, and Endocardial Layers of the Ventricle

The recent discovery of multiple myocardial cell types in the ventricular wall of most species has prompted a reevaluation of several electrophysiologic and electrocardiographic findings. This review briefly presents the salient electrophysiologic features of myocardial cells in the epicardial, midmyocardial and endocardial regions of the ventricle. The epicardial action potential exhibits a prominent notch between phase 1 and phase 2 that results in a spike and dome configuration. The notch is smaller in midmyocardial cells and absent in endocardial cells. The action potential notch is due to the presence of a transient outward current (I(to)), which diminishes in amplitude from the epicardial to endocardial surfaces. Midmyocardial or "M cells" exhibit electrophysiologic features intermediate between those of myocardial and conducting cells. M cells differ from epicardial and endocardial cells primarily in their response to slowing of the stimulation rate. These cells display an exaggerated prolongation of action potential duration at moderate to slow rates of stimulation. The atypical response in M cells reflects decreased levels of the delayed rectifier K(+) current (I(K)) in this cell type (dV/dt) compared to epicardial or endocardial cells. These electrophysiologic distinctions contribute to differences in the responsiveness of the various cell types to pharmacologic agents and disease. Also, the dispersion of repolarization created between epicardium and endocardium in the early phases of the action potential, and between M cells and other ventricular layers during late repolarization, may explain the J wave and U wave of the electrocardiogram, respectively.

Comparison of proarrhythmogenic effects of two potassium channel openers, levcromakalim (BRL 38227) and nicorandil (RP 46417): a high-resolution mapping study on rabbit heart

This study was designed (a) to test and (b) to compare proarrhythmic effects of levcromakalim and nicorandil; and (c) determine the mechanism of arrhythmia initiation by using high-resolution ventricular epicardial mapping on 44 Langendorff-perfused rabbit hearts. Eighteen hearts were kept intact and received incremental doses (1-500 microM) of levcromakalim, nicorandil, and isosorbide dinitrate. In 26 hearts, a thin layer of epicardium was obtained after endocardial cryotechnique (frozen hearts). In intact hearts, isosorbide dinitrate did not produce any arrhythmia. In contrast, levcromakalim induced spontaneous ventricular fibrillation (VF) in all hearts at 50 microM, whereas only one VF occurred at 500 microM nicorandil. These three drugs produced a dose-dependent bradycardia in intact hearts. In frozen hearts, arrhythmias were induced by 5 microM levcromakalim and 50 microM nicorandil. Isosorbide dinitrate had no proarrhythmogenic effect. Epicardial mapping showed that most of induced ventricular tachycardias were based on reentry around an arc of functional conduction block. Ventricular conduction velocities did not change, but levcromakalim and nicorandil shortened ventricular effective refractory period. We conclude that (a) levcromakalim and nicorandil, used in toxic concentrations, have direct proarrhythmic effects; (b) nicorandil proarrhythmogenic effects are 10 times less marked than those of levcromakalim (arrhythmia is solely the result of the potassium channel opener property of nicorandil); and (c) most of ventricular tachycardias induced are based on reentry.

Electrocardiographic abnormalities in patients bitten by taipans (Oxyuranus scutellatus canni) and other elapid snakes in Papua New Guinea

Envenoming by a number of species of snake may affect the myocardium or cause electrocardiographic changes; several different mechanisms have been proposed. In a prospective study of snake bite in Papua New Guinea, electrocardiographic changes were observed in 36 of 69 patients (52%) envenomed by the taipan (Oxyuranus scutellatus), 2 of 6 (33%) envenomed by death adders (Acanthophis sp.) and one envenomed by the brown snake (Pseudonaja textilis). Septal T wave inversion and bradycardias, including atrioventricular block, were the commonest abnormalities. There was no haemodynamic deterioration. The cause of these changes is uncertain; only 2 of 24 patients (8.3%) with electrocardiographic changes had markedly elevated plasma concentrations of cardiac troponin T, a sensitive and specific marker of myocardial damage. This suggests that myocardial damage is uncommon following bites by these species. Electrocardiographic abnormalities are most likely to have been caused by a direct toxic effect of a venom component upon cardiac myocyte function; in taipan bites, taicatoxin, a calcium channel blocker, might be responsible.

Modeling triggered cardiac activity: an analysis of the interactions between potassium blockade, rhythm pauses, and cellular coupling

It is known that under certain conditions, a combination of potassium channel blockade, sympathetic nervous activity, and pauses in sinus rhythm can increase the occurrence of cardiac arrhythmias. Although the arrhythmogenic interactions of these three factors are not completely understood, it is believed that the associated arrhythmias may be initiated by afterpotentials via a process that we refer to as propagated triggered activity. Using a two-cell computational model of ventricular action potential kinetics, we simulate nonuniform potassium blockade, sympathetic nervous activity, and pauses in sinus rhythm under conditions of hypokalemia. Under these conditions, the two-cell model suggests that (1) the arrhythmogenic interactions of potassium blockade and sympathetic nervous activity are highly dependent on heart rate; (2) triggered activity induced by potassium blockade would most likely occur during a pause in sinus rhythm; (3) during a sufficiently large pause in sinus rhythm, potassium blockade can induce triggered activity at normal levels of sympathetic activity; and (4) potassium blockade can increase the probability of triggered activity only if heart rate falls within a critical range. We also show that during pauses in sinus rhythm, two-cell triggering interactions between potassium blockade and sympathetic activity closely parallel the parametric displacement of the dynamic instability underlying the afterpotentials. Our results indicate that the behavior of the triggering mechanism studied here is consistent with that of pause-induced arrhythmias.

Effects of long-term oral administration of amiodarone on the ventricular repolarization of rabbit hearts

The chronic effects of amiodarone on ventricular repolarization were investigated in Langendorff-perfused rabbit hearts in comparison with the acute effects of other Class III antiarrhythmic drugs. Forty to fifty electrograms were recorded through modified bipolar electrodes from the anterior to the lateral epicardial surface of the ventricles under His-bundle pacing (1.0 Hz). In control hearts, epicardial activation proceeded from the apex to the base. The interval from the initial sharp negative deflection of the QRS complex to the apex of the T-wave (Q-aT), which reflects the action potential duration (APD) at the recording site, was longest in the apex and shortest in the base. Therefore, repolarization proceeded from the base to the apex. In hearts treated with oral amiodarone (100 mg/kg, 4 weeks), Q-aT was uniformly prolonged by 14-16% throughout the entire mapped area, whereas the activation sequence was unaffected, and a normal Q-aT gradient was well preserved from the apex to the base. The spatial inhomogeneity of left ventricular repolarization was not enhanced by drug treatment. Acute application of sotalol (30 mumol/L), E-4031 (0.1 mumol/L) or MS-551 (1.0 mumol/L) caused a much greater Q-aT prolongation in the apex than in the base, resulting in a marked enhancement of the spatial inhomogeneity of repolarization. These findings suggest that the propensity of chronic amiodarone to induce torsade de pointes less often than other Class III agents may result at least in part from its favorable effect on the spatial homogeneity of ventricular repolarization.

T wave alternans in idiopathic long-QT syndrome: insight from body surface mapping

Body surface mapping was recorded during T wave alternans in two patients with idiopathic long QT syndrome. Eighty-seven lead ECGs of two consecutive beats during T wave alternans demonstrated that alternating changes in the morphology and polarity of the T wave existed mainly in the left frontal chest. The QRST isointegral maps of the same two consecutive beats showed alternation of a large negative area appearing mainly in the left frontal chest. These results indicate that T wave alternans in the two patients were related to alternate heterogeneous prolongation of the action potential duration in this region.