Ectopic right atrial rhythms: experimental and clinical data

[Clinical development of the automatic implantable defibrillator over 35 years: A success story]

After 12 years of development and experimental evaluation, the first automatic implantable cardioverter-defibrillator (ICD) was implanted in man on February 4, 1980. This overview describes the technical and functional developments over 35 years from a simple shock-box, weighing 292 g, to the sophisticated 80 g device of today, delivering graded therapy to sustained ventricular arrhythmias and biventricular stimulation to treat heart failure. Finally, a special tribute is given to Michel Mirowski, one of the inventors of the ICD, as scientist and physician dedicated to patient care.

Alterations in subsidiary pacemaker function after prolonged subsidiary pacemaker dominance in the canine right atrium

In vivo and in vitro techniques were used to study the functional characteristics of subsidiary atrial pacemaker activity 4 to 11 months after surgical excision of the sinoatrial node region of the dog heart. Characteristics of this long-term subsidiary atrial pacemaker activity were compared with those of sinoatrial node and short-term subsidiary atrial pacemaker activities. Extracellular bipolar electrodes were used to estimate the site of earliest activation and monitor spontaneous rate. Under both in vivo and in vitro conditions, long-term pacemaker activity was located in the same region of the inferior right atrium as was short-term pacemaker activity. Under in vitro conditions, long-term activity was characterized by a reduced sensitivity to acetylcholine and overdrive pacing and by a lack of dependence on beta-adrenergic stimulation compared with short-term activity. Furthermore, long-term pacemaker activity was more sensitive to acetylcholine and less sensitive to norepinephrine (greater than 10(-7) M) compared with sinoatrial node activity. It is concluded that the subsidiary atrial pacemakers that emerge soon after removal of the sinoatrial node are the same as those pacemakers that ultimately assume long-term control of the heart. In addition, after subsidiary atrial pacemakers assume dominant pacemaker function, their dependence on norepinephrine and their response to acetylcholine and overdrive pacing are reduced. These changes facilitate a more stable regulation of atrial pacemaker rhythm and, thereby, make subsidiary atrial pacemaker function more like that of the sinoatrial node.

Sir Thomas Lewis redivivus: from pebbles in a quiet pond to autonomic storms

Images

Functional characteristics of sinoatrial and subsidiary pacemaker activity in the canine right atrium

A canine in vitro right atrial preparation was developed to study the functional characteristics of subsidiary atrial pacemaker (SAP) activity and to compare them with those of sinoatrial node (SAN) activity. Extracellular bipolar electrodes were used to estimate the site of earliest activation and monitor spontaneous rate. Ligation of the SAN artery at the midportion of the sulcus terminalis suppressed SAN activity and usually (73.5%) elicited SAP activity in a well-defined region of the inferior atrium. SAP activity in this region required a "threshold" concentration of norepinephrine (10(-8) M) in the Tyrode's perfusate. In response to all concentrations of norepinephrine tested, SAN activity attained a greater maximum spontaneous rate than SAP activity. Cholinergic stimulation with acetylcholine or eserine elicited a greater negative chronotropic response from SAP than SAN activity. Overdrive pacing suppressed SAP activity to a significantly greater extent than SAN activity. We conclude that this in vitro preparation can be useful for studying the pharmacology and electrophysiology of subsidiary atrial pacemakers that emerge after suppression of SAN activity. In contrast to SAN activity, SAP activity requires norepinephrine and is more sensitive than SAN activity to acetylcholine and overdrive pacing. Consequently, after loss of SAN function, autonomic modulation of SAP activity may result in atrial dysrhythmias and prolonged periods of overdrive suppression.

Experimental studies on sick sinus syndrome: relationship of extent of right atrial lesions to subsidiary pacemaker shift and its function

An area where the sinus node was located in 36 dogs was defined as the "SN-area." Five to 7 days after cauterization of the SN-area, a subsidiary pacemaker remained in the SN-area in seven (group S) and shifted to outside the SN-area in 14 dogs (group E). The SN-area in group S had escaped complete destruction, but that in group E was destroyed completely. Heart rate in group S and group E was 154.0 +/- 27.1 and 107.6 +/- 16.8 beats/min (p less than 0.001), respectively. Maximum duration of asystole after overdrive (maxDAO) in group S and group E was 656.7 +/- 260.2 and 2470.2 +/- 2271.6 msec (p less than 0.01), respectively. Propranolol (0.2 mg/kg intravenously) decreased heart rate in group S and group E to 88.3 +/- 7.9 and 71.7 +/- 8.7% (p less than 0.001), and prolonged maxDAO to 140.1 +/- 28.1 and 492.7 +/- 591.4% (p less than 0.025), respectively. It is concluded that the rate and stability of subsidiary pacemakers after cauterization of the sinus node have a close relationship with their location in the right atrium, which is dependent on the extent of lesions in the SN-area. Sympathetic tone played a significant role in maintaining these functions in group E.

Use of P wave morphology for inferring pacemaker localization along the sulcus terminalis in the dog

P wave morphology in leads II and III, recorded at high gain and sweep speed, was correlated to the initial site of activation over the anatomical SA node and at sites more distal on the sulcus terminalis. Pacemaker localization was inferred from the initial site of activation of seventeen bipolar recording sites on the sulcus terminalis, interatrial septum and left atrium in anesthetized, open chest dogs. Positive P waves were observed with activation originating from the rostral to the caudal sulcus terminalis. However, different initial sites of activation produced P waves with distinct morphological characteristics. Pacemaker localization nearest the rostral SA node produced upright bifid P waves which exhibited a small initial positive deflection forming a plateau on the ascending limb. Recovery to baseline was generally smooth. A middle SA nodal pacemaker produced P waves similar to that of a rostral pacemaker, but the amplitude was higher and a notch appeared halfway during recovery to baseline. The distinguishing features of the P wave with activation originating at the caudal SA node were a bifid initial deflection and multiple notching at the peak of the P wave and during recovery to baseline. Activation originating at the upper and middle third of the sulcus terminalis distal to the anatomical SA node produced P waves whose initial deflection was negative. The peaks of these P waves were notched. Pacemaker localization in the vicinity of the lower sulcus opposite the coronary sinus produced P waves in leads II and III which were very low amplitude appearing as oscillations in the baseline. Thus, a positive P wave occurs in lead II and III not only during sinus rhythm, i.e., activation originating from the vicinity of the anatomical SA node, but also from non-SA nodal sulcus sites. Furthermore, the morphology of the P wave may be used to infer pacemaker localization within the SA node and at other sites along the sulcus terminalis in the supine open or closed chest dog.

Fine structure of cells and their histologic organization within internodal pathways of the heart: clinical and electrocardiographic implications

The fine structure of the normal internodal pathways was studied in 1 human and 2 canine hearts and correlated with histologic observations on more than 100 human and 10 canine hearts. From the electron microscopic studies six different kinds of myocardial cells were classified from two locations: the Eustachian ridge (posterior internodal pathway) and the Bachmann bundle (anterior internodal pathway). Five of the six kinds of cells (working myocardial cells, Purkinje-like cells, either broad or slender transitional cells and P cells, all previously described) were present in both locations. A sixth cell, pleomorphic and dark in appearance, with a special intertwined relation to P cells, is newly designated as an ameboid cell. It was found solely in the Eustachian ridge. In the same area a rare direct contact between a nerve and a myocardial cell was observed. The importance of these different kinds of cells, their respective cell connections, and their topographic locations inside the internodal pathways are discussed relative to certain functions such as rapid conduction and subsidiary pacemaking. The possible influence of these factors on clinical electrocardiographic changes is considered.

P waves during ectopic atrial rhythms in man: a study utilizing atrial pacing with fixed electrodes

Threshold bipolar pacing was performed from one of 12 selected atrial sites with temporary implanted electrodes in 69 patients following open-heart surgery in order to study P wave polarity and morphology and the P-R interval during paced ectopic atrial rhythms. A negative P wave was recorded in lead I only with pacing the left atrium and only when pacing near the left pulmonary veins. A positive bifid P wave in V1 was recorded only with left atrial pacing and only when pacing was near the inferior pulmonary veins and coronary sinus. P wave polarity and morphology were otherwise of no use in localization of the origin of the impulse in these studies. The pacing stimulus to P wave interval was found to vary between 10 and 54 msec, making the duration of the P-R interval an unreliable indicator of the site of origin of the paced impulse. Although the relation of these paced rhythms to spontaneously occurring ectopic rhythms is unclear, the previously published criteria for localizing ectopic atrial rhythms are again demonstrated to be unreliable. P wave polarity and morphology and the P-R interval are of limited value in ascertaining the origin of ectopic atrial rhythms in man.