Electrophysiologic observations on ventricular tachyarrhythmias following reperfusion

Expression of skeletal muscle sodium channel (Nav1.4) or connexin32 prevents reperfusion arrhythmias in murine heart

AIMS

acute myocardial ischaemia induces a decrease in resting membrane potential [which leads to reduction of action potential (AP) V(max)] and intracellular acidification (which closes gap junctions). Both contribute to conduction slowing. We hypothesized that ventricular expression of the skeletal muscle Na(+) channel, Nav1.4 (which activates fully at low membrane potentials), or connexin32 (Cx32, which is less pH-sensitive than connexin43) would support conduction and be antiarrhythmic. We tested this hypothesis in a murine model of ischaemia and reperfusion arrhythmias.

METHODS AND RESULTS

empty adenovirus (Sham) or adenoviral constructs expressing either SkM1 (gene encoding Nav1.4) or Cx32 genes were injected into the left ventricular wall. Four days later, ventricular tachycardia (VT) occurred during reperfusion following a 5 min coronary occlusion. In Nav1.4- and Cx32-expressing mice, VT incidence and duration were lower than in Sham (P < 0.05). In vitro multisite microelectrode mapping was performed in the superfused right ventricular wall. To simulate ischaemic conditions, [K(+)] in solution was increased to 10 mmol/L and/or pH was decreased to 6.0. Western blots revealed Cx32 and Nav1.4 expression in both ventricles. Nav1.4 APs showed higher V(max) and conduction velocity (CV) than Shams at normal and elevated [K(+)]. Exposure of tissue to acid solution reduced intracellular pH to 6.4. There was no difference in CV between Sham and Cx32 groups in control solution. Acid solution slowed CV in Sham (P < 0.05) but not in Cx32.

CONCLUSION

Nav1.4 or Cx32 expression preserved normal conduction in murine hearts and decreased the incidence of reperfusion VT.

Cardioprotective and antiarrhythmic effect of U50,488H in ischemia/reperfusion rat heart

The objective of this study was to investigate the protective effect of U50,488H, a selective kappa-opioid receptor agonist, in the ischemia/reperfusion (I/R) rat and to delineate the underlying mechanism. Rat heart I/R injury was induced by occluding the left anterior descending coronary artery for 45 min and restoring perfusion for 120 min. U50,488H or vehicle was intravenously injected before ischemia. Electrocardiogram, heart rate (HR), arterial blood pressure (ABP), left ventricular pressure (LVP), systolic function (+dp/dtmax), and diastolic function (-dp/dtmax) were monitored in the course of the experiment. Myocardial infarction size was evaluated. Plasma concentrations of cardiac troponin T (cTnT), creatine kinase (CK), and lactate dehydrogenase (LDH) were measured. Single rat ventricular myocyte was obtained by enzymatic dissociation method. The potassium currents (IK) of isolated ventricular myocytes were recorded with the whole-cell configuration of the patch-clamp technique. Compared with the sham control group, no significant change was found in HR, while ABP, LVP and +/-dp/dtmax were significantly reduced in the I/R group. Administration of U50,488H significantly lowered HR in both control and I/R groups. Compared with the vehicle-treated I/R group, administration of U50,488H had no significant effect on I/R-induced reduction in ABP, LVP, and +/-dp/dtmax. However, this treatment significantly reduced the myocardial infarction size, and markedly decreased the contents of plasma cTnT, CK and LDH. During ischemia and reperfusion, the incidence of ventricular arrhythmia in U50,488H-treated rats was significantly reduced. These effects were independent of the bradycardia induced by U50,488H, as the reducing infarct size and antiarrhythmic effect of U50,488H were still observed in animals in which heart rate was kept constant by electrical pacing. U50,488H and BRL-52537 still produced an antiarrhythmic effect when the rat heart was subjected to a shorter ischemic period of 10 min occlusion of coronary artery, which produced no infarction. IK of the myocytes were inhibited by U50,488H in a dose-dependent manner in normal and hypoxic rat ventricular myocytes. However, the effects of U50,488H on IK did not show any significant difference in normal and hypoxic myocytes. The above-described effects of U50,488H were totally blocked by nor-Binaltorphimine, a selective kappa-opioid receptor antagonist. The results suggest that kappa-opioid agonist U50,488H exerts its direct cardioprotective and antiarrhythmic effects against I/R via kappa-opioid receptor, which participates in the regulation of potassium channels in normal and hypoxic ventricular myocytes.

Non-dipolar content of the T-wave as a measure of repolarization inhomogeneity in ST-elevation myocardial infarction

The non-dipolar content of the T-wave, i.e. the component of the signal, which cannot be explained by a dipolar model, has been suggested as a measure of the local repolarization inhomogeneity. Our purpose was to study the non-dipolar content of the T-wave during the initial course of ST-elevation myocardial infarction (STEMI), when local repolarization inhomogeneity presumably is markedly increased. Twelve-lead ECG was semicontinuously collected in 211 patients with STEMI, treated with a thrombolytic agent. The T-wave was processed by principal component analysis. The absolute and relative T-wave residues were used as measures of the non-dipolar content. The median values for each hour and for the entire monitoring time were computed. Changes in the parameters were closer studied in two windows, 0-10 respectively, 11-24 h after start of ECG-monitoring. The median of the absolute T-wave residue during the entire monitoring period was 25 000 units in the STEMI-group and 13 500 units in the comparison group. The median for hour 1 was 36 500 units and 28 800 units for hour 2. The decrease was greater in patients with >or=50% resolution of the ST-elevation at 60 min. The moment of change, identified by cumulative sum-method, showed no correlation to the time for 50% ST-resolution. We conclude, that patients with thrombolysed STEMI have an increased non-dipolar content of the T-wave. Resolution of the ST-elevation is associated with a decrease. The increased non-dipolar content reflects a property of the repolarization phase, which is related to but separated from the ST-elevation.

Effects of [5-(2-methoxy-5-fluorophenyl)furan-2-ylcarbonyl]guanidine (KR-32560), a novel sodium/hydrogen exchanger-1 inhibitor, on myocardial infarct size and ventricular arrhythmias in a rat model of ischemia/reperfusion heart injury

The cardioprotective effects of the novel sodium/hydrogen exchanger-1 (NHE-1) inhibitor KR-32560 {[5-(2-methoxy-5-fluorophenyl)furan-2-ylcarbonyl]guanidine} were studied in an anesthetized rat model of 30-min ischemia / 2.5-h reperfusion heart injury. KR-32560 (0.01 - 1 microM) dose-dependently inhibited NHE-1-mediated rabbit platelet swelling induced by intracellular acidification. KR-32560 at 0.1 and 1.0 mg/kg (i.v. bolus, given 10 min before ischemia) reduced infarct size from 65.9% (control) to 49.7% and 32.7%, respectively, while reducing the extension of myocardial injury (mm(3)/g of left heart weight) from 405.1 (control) to 302.9 and 185.4, respectively (all P<0.05 vs control). KR-32560 dose-dependently reduced the total number of ventricular premature beats (VPBs) during ischemia from 510.2 (control) to 353.8 and 134.2 beats (all P<0.05, n = 6), while reducing ventricular tachycardia (VT) incidence from 49.3 (control) to 26.8 and 4.3 and VT duration from 249.2 s (control) to 150.5 and 26.7 s (all P<0.05, n = 6). KR-32560 dose-dependently reduced ventricular fibrillation (VF) incidence from 19.0 (control) to 9.2 and 1.2 and VF duration from 88.0 s to 34.5 and 2.8 s (all P<0.05, n = 6). KR-32560 also exerted similar effects on reperfusion arrhythmias, except for VPBs. These results indicate that KR-32560 may exert significant cardioprotective effects in ischemia/reperfusion heart injury.

Cardioprotective effects of [5-(2-methyl-5-fluorophenyl)furan-2-ylcarbonyl]guanidine (KR-32568) in an anesthetized rat model of ischemia and reperfusion heart injury

The effects of a novel sodium/hydrogen exchanger-1 (NHE-1) inhibitor, KR-32568, were studied in an anesthetized rat model of 30 min ischemia/2.5 h reperfusion heart injury. KR-32568 dose-dependently inhibited NHE-1-mediated rabbit platelet swelling induced by intracellular acidification. In our anesthetized rat model, KR-32568 reduced infarct size from 67 (control) to 43 and 24% at 0.1 and 1.0 mg/kg (i.v. bolus, given 10 min before ischemia), respectively. KR-32568 at the same doses also significantly reduced the total number of ventricular premature beats during ischemia/reperfusion from 530 (control) to 266 and 115 beats, ventricular tachycardia (VT) incidence from 51 (control) to 21 and 8, VT duration from 238 s (control) to 63 and 33 s, ventricular fibrillation (VF) incidence from 17 (control) to 8 and 0, and VF duration from 85 s to 18 and 1 s. These results indicate that KR-32568 may exert potent cardioprotective effects in rats via inhibition of sodium/hydrogen exchanger-1.

Protective effects of a plant histaminase in myocardial ischaemia and reperfusion injury in vivo

Grass pea seedling histaminase (a copper-diamine oxidase) was found to exert a significant cardioprotection against post-ischaemic reperfusion damage. Electrocardiogram (ECG) recordings from the rats subjected in vivo to ischaemia and reperfusion showed ventricular tachycardia (VT) and ventricular fibrillations (VF) occurring in 9 out of 12 untreated rats whereas no ventricular arrhythmias were found under histaminase (80U/kg body weight) treatment (n=16 rats). Computer-assisted morphometry of the ischaemic reperfused hearts stained with nitroblue tetrazolium showed the extension of damaged myocardium (area at risk and infarct size) significantly reduced in rats treated with histaminase, in comparison with the non-treated rats, whereas no protection was found with the semicarbazide inactivated histaminase. Biochemical markers of ischaemia-reperfusion myocardial tissue damage: malonyldialdehyde (MDA), tissue calcium concentration, myeloperoxidase (MPO), and apoptosis indicator caspase-3 were significantly elevated in untreated post-ischaemic reperfused rats, but significantly reduced under histaminase protection. In conclusion, plant histaminase appears to protect hearts from ischaemia-reperfusion injury by more than one mechanism, essentially involving histamine oxidation, and possibly as reactive oxygen species scavenger, presenting good perspectives for a novel therapeutic approach in treatment of ischaemic heart pathology.

Protective effects of M40403, a selective superoxide dismutase mimetic, in myocardial ischaemia and reperfusion injury in vivo

1. Myocardial injury caused by ischaemia and reperfusion comes from multiple pathogenic events, including endothelial damage, neutrophil extravasation into tissue, mast cell activation, and peroxidation of cell membrane lipids. These events are followed by myocardial cell alterations resulting eventually in cell necrosis. An enhanced formation of reactive oxygen species is widely accepted as a stimulus for tissue destruction and cardiac failure. 2. In this study, we have investigated the cardioprotective effects of M40403 in myocardial ischaemia-reperfusion injury. M40403 is a low molecular weight, synthetic manganese containing superoxide dismutase mimetic (SODm) that selectively removes superoxide anion. Ischaemia was induced in rat hearts in vivo by ligating the left anterior descending coronary artery. Thirty minutes after the induction of ischaemia, the ligature was removed and reperfusion allowed to occur for at least 60 min. M40403 (0.1-1 mg kg(-1)) was given intravenously 15 min before ischaemia. 3. The results obtained in this study showed that M40403 significantly reduced the extent of myocardial damage, mast cell degranulation and the incidence of ventricular arrhythmias. Furthermore, M40403 significantly attenuated, in a dose-dependent manner, neutrophil infiltration in the myocardium as well as the associated induction of lipid peroxidation. Calcium overload seen post-reperfusion of the ischaemic myocardium was also reduced by M40403. 4. Immunohistochemical analysis for nitrotyrosine revealed a positive staining in cardiac tissue taken after reperfusion: this was attenuated by M40403. Moreover reperfused cardiac tissue sections showed positive staining for P-selectin and for anti-intercellular adhesion molecule (ICAM-1) in the vascular endothelial cells. M40403 treatment markedly reduced the intensity and degree of P-selectin and ICAM-1 in these tissues. No staining for nitrotyrosine, P-selectin or ICAM-1 was found in cardiac tissue taken at the end of the ischaemic period. 5. Overall, M40403 treatment reduced the morphological signs of myocardial cell injury and significantly improved survival. 6. Taken together, these results clearly indicate that M40403 treatment exerts a protective effect against ischaemia-reperfusion-induced myocardial injury, supporting a key role for superoxide anion in reperfusion injuries. This suggests that synthetic enzymes of SOD such as M40403, offer a novel therapeutic approach for the treatment of ischaemic heart disease where superoxide anion plays a dominant role.

A fast Fourier transform analysis of coronary reperfusion-induced ventricular fibrillation and the modification by dibutyryl cyclic AMP in a cat model

To investigate the effect of dibutyryl cyclic AMP (dbcAMP) on ventricular fibrillation after coronary reperfusion, the proximal portion of the anterior descending branch of left coronary artery was reperfused 20 min after ligation in 24 cats. McFee X Y Z electrocardiograms were recorded and ventricular fibrillation was analyzed using a fast Fourier transform analysis (FFT). Ventricular fibrillation occurred in 20 of 24 cases. Sixty seconds after the occurrence of ventricular fibrillation, an intracardiac infusion of dbcAMP was administered. Nine of the 20 were defibrillated and converted to sinus rhythm or junctional rhythm after the administration of dbcAMP. The amplitude and frequency of the main power spectrum of the ventricular fibrillation waves were analyzed by FFT before and after the infusion of saline or dbcAMP. In the saline group there was no significant change in FFT. However, in the dbcAMP group, the amplitude increased significantly from 0.036 +/- 0.015 (MV--2) to 0.054 +/- 0.013 (MV--2) (p < 0.01) and the frequency decreased significantly from 4.22 +/- 1.37 (Hz) to 1.33 +/- 0.91 (Hz) (p < 0.01). Those results indicate that dbcAMP increased the amplitude and decreased the frequency of the main power spectrum of ventricular fibrillation analyzed by FFT. These distinctive changes in FFT analysis were associated with defibrillation in 9 of 20 cases.

Defibrotide has antiischemic activity in perfused rabbit hearts, preventing tissue Ca++ overloading

Defibrotide (D), a polydeoxyribonucleotide obtained from mammalian lungs, reduced the ischemic contracture due to low perfusion (0.2 ml/min) of the isovolumic left heart of the rabbit and abolished the irregularity of the rhythm of the heart, thereby restoring the cardiomechanical activity upon reperfusion (20 ml/min). D stimulated the release of PG-like material. Indomethacin infusion completely prevented both the antiischemic activity of D and its ability to increase the generation of prostaglandins in the rabbit heart. Measurement by atomic absorption spectroscopy of calcium content in ischemic heart tissue and its mitochondrial fraction indicated that the ischemic procedure significantly increased tissue calcium content in both. D, Prostacyclin (PGI2) and Nifedipine protected the heart from ischemic ventricular contracture and prevented accumulation of calcium in the heart. The effect of D on preventing Ca++ overload was completely abolished by indomethacin infusion. The results indicate that the beneficial effects of Defibrotide in experimental ischemia are primarily due to a release of Prostaglandin E2 (PGE2) and PGI2, which in turn may inhibit the detrimental effects of calcium overload in myocytes and mitochondria.

[Arrhythmia as an indicator for reperfusion following acute myocardial infarct?]

For the purposes of the European double blind and randomized study 27 patients with acute myocardial infarction underwent thrombolysis with rt-PA (60 mg over 90 minutes i.v.) or placebo. To evaluate whether arrhythmias, especially ventricular arrhythmias indicate coronary reperfusion after thrombolysis a 24 hour Holter monitoring was performed from the beginning of the rt-PA or placebo infusion. Typical reperfusion arrhythmias were thought to be idioventricular rhythms (rate less than 110/min), ventricular tachycardia (rate greater than 110/min) or bradycardic rhythm disturbances (rate less than 50/min). The effect of thrombolysis on reperfusion of the infarct related artery was evaluated 90 minutes after the infusion by coronary angiography. After 90 minutes of rt-PA or placebo infusion in 16/16 patients treated with rt-PA and 2/11 patients, who received placebo, was the infarct artery patent. 16/18 patients with a patent artery presented a total of 105 arrhythmic events. 47% of the arrhythmias obviously due to reperfusion were classified as idioventricular rhythms. In contrast only 3/9 patients with an occluded infarct artery presented 25 arrhythmic events. The time of occurrence was not different during the running rt-PA infusion compared to placebo. The following interval up to 24 hours showed no difference in incidence and type of the arrhythmias. No relationship was found between reperfusion arrhythmias and salvage of myocardium during 90 minutes of rt-PA or placebo infusion.

Reperfusion-induced arrhythmias in the conscious rat: a comparative study with three calcium antagonists

The effects of three calcium antagonists (diltiazem, verapamil, and nifedipine) on reperfusion-induced arrhythmias were compared in a conscious rat preparation with coronary artery occlusion and implanted electrocardiogram limb electrodes. Upon reperfusion after a 5-min period of occlusion, all (15/15) untreated control rats exhibited immediate ventricular tachycardia, which rapidly deteriorated to ventricular fibrillation; 87% (13/15) of the rats died as a consequence of these rhythm disturbances. In the groups treated with calcium antagonists, each drug (diltiazem, verapamil, or nifedipine) was given as an intravenous bolus 10 min prior to coronary occlusion (n = 12 in each group). The incidence of ventricular fibrillation was significantly reduced by all three calcium antagonists and this antifibrillatory effect resulted in a significantly lower mortality in all drug-treated groups. With diltiazem (0.5 and 2.0 mg/kg) mortality fell from 87 to 42% (P less than 0.05) and 35% (P less than 0.01), respectively; with verapamil (0.5 and 5.0 mg/kg) it fell to 25% (P less than 0.01) and 0% (P less than 0.001); and with nifedipine (5.0 and 50 micrograms/kg), it fell to 25% (P less than 0.01) and 8% (P less than 0.001). At a dose of 5.0 mg/kg, verapamil caused a large reduction in heart rate both prior to and during coronary occlusion and reperfusion; however, with other doses and drugs no significant changes in heart rate were observed. ST segment elevation during the 5-min ischemic period was reduced by pretreatment with all drugs. In conclusion, in the conscious rat, pretreatment with diltiazem, verapamil, or nifedipine affords some protection against reperfusion-induced arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias in the assessment of coronary artery reperfusion following thrombolytic therapy

Arrhythmias are used as markers of coronary reperfusion after administration of thrombolytic agents. We studied the effects of coronary recanalization on the development of arrhythmias in patients receiving thrombolytic agents during the early hours of acute myocardial infarction. Acute cardiac catheterization, assessing perfusion of the infarction-related artery and identifying the arrhythmias, was performed within eight hours of onset of symptoms. Fifty-six of 67 patients (84 percent) studied had total occlusion of the infarction-related artery, 25 of whom had restoration of coronary flow during the 90 minutes after initiation of therapy; 31 had no evidence of reperfusion. Eleven patients had subtotal vessel occlusion that did not change appreciably during therapy, and 20 patients (30 percent) had transient arrhythmias. There were no significant differences in the frequency of arrhythmias: 36 percent of reperfused patients, 19 percent of nonreperfused, and 45 percent of subtotal occlusion patients. Only bradyarrhythmia was significantly related to the restoration of flow of the right coronary artery. Other rhythm disturbances, including accelerated idioventricular rhythm, did not correlate with a change in the perfusion status of the vessel. Bradycardia may be a useful marker for right coronary artery reperfusion. Arrhythmias in general are not specific for coronary reperfusion and should not be used as event markers.

Ventricular fibrillation complicating acute myocardial infarction. Two distinct clinical and electrocardiographic features

Two distinct electrocardiographic patterns of ventricular fibrillation (VF) complicating acute myocardial infarction (AMI) were observed in 34 patients during the first 24 hours from initial symptoms. Type 1 (seven patients) was characterized by fast disorganized ventricular activity, small voltage, and no clear identifiable QRS complexes (fine VF). Type 2 (27 patients) was defined as multiform QRS configuration (greater than 300/min) with marked changes in the amplitude (polymorphous VF). Type 1 rhythm was seen mostly during the hyperacute ischemic phase, probably associated with total coronary vessel occlusion; type 2 was observed when Q waves were already present in the electrocardiogram.

Defibrotide, an antithrombotic substance which prevents myocardial contracture in ischemic rabbit heart

Defibrotide, a polydeoxyribonucleotide obtained from mammalian lungs, reduced in a dose-dependent fashion the ischemic contracture due to low perfusion (0.2 ml/min) of isovolumic left heart of rabbit and abolished the irregular rhythm of the heart, thereby restoring the cardiomechanical activity upon reperfusion (20 ml/min). Defibrotide stimulated the release of PG-like material from the heart in a dose-dependent manner without modifying the basal contractility. Both PGE2 and PGI2 (10 ng/ml) have an antiischemic activity on this preparation as shown by the partial reduction of the ischemic contracture and by the improvement of heart contractility upon reperfusion. Indomethacin infusion (1 microgram/ml) completely removed both the antiischemic activity of Defibrotide (400 micrograms/ml) and its ability to increase the generation of prostaglandins in the rabbit heart. These results suggest that Defibrotide has a beneficial influence on ischemic rabbit heart through an increase in prostaglandin synthesis. However other mechanisms not necessarily related to prostaglandin generation, such as a direct effect on membrane function deactivation and mitochondrial Ca2+ overload, should be considered in explaining the antiischemic activity of Defibrotide in the rabbit heart.

MM-CK subtypes diagnose reperfusion early after myocardial infarction

Isoelectric focusing (IEF) was used to analyze the serum MM-CK isoenzyme subtypes in 16 patients receiving streptokinase (SK) for attempted coronary thrombolysis early after acute myocardial infarction. Twelve patients had revascularization documented by serial coronary angiograms (Group I); in four patients, angiography documented no such reperfusion (Group II). The data also were compared with a previously reported group of 8 patients who did not receive streptokinase (Group III). Total and MB-CK activity, as well as the MM-CK isoenzyme subtypes MM3-CK, MM2-CK, and MM1-CK tended to rise earlier and peak earlier in Group I compared with Group II; serum MM3-CK, the predominant subtype in myocardium, however, definitely peaked earlier in Group I (8.65 +/- 2.07 hr) compared with Group II (18.50 +/- 6.67 hr) (p less than 0.001). Soon after its release from myocardium, MM3-CK is converted in the serum to MM2-CK and eventually to MM1-CK; thus, the MM3-CK:MM1-CK ratio amplifies the time course of subtype conversion. The MM3-CK:MM1-CK activity ratio peaked earlier in Group I (5.51 +/- 0.97 H) compared to Group II (10.74 +/- 3.28 hr) (p less than 0.01), and peaked even earlier than MM3-CK (p less than 0.007) in both Groups I and II. Thus, the time course of the MM3-CK:MM1-CK ratio separates those patients who reperfuse when early SK is used after acute myocardial infarction from those who do not, and does it significantly earlier than the other enzymatic parameters of cellular necrosis, total CK, and MB-CK.

Reperfusion arrhythmias during coronary reperfusion therapy in man. Clinical and angiographic correlations

We hypothesized that patients suffering acute myocardial infarction who have reperfusion arrhythmias (RPA) during intracoronary streptokinase infusion (ICSK) would have different clinical and angiographic characteristics and a larger infarction size than those who achieved reperfusion without RPA. Of 35 patients who received intracoronary streptokinase, 27 had successful reperfusion documented by angiography. Successful reperfusion was accompanied by RPA in eight patients and no RPA in 19 patients. RPA included episodes of ventricular tachycardia in one, idioventricular rhythm in four, junctional bradycardia in one, or AV block in two patients which occurred at the time of reperfusion. Myocardial infarction size was calculated using creatine kinase-MB (CK-MB) isoenzyme time activity curves using standard methods. The mean CK-MB g equivalents (eq) for those with RPA was 71 +/- 25 (+/- 1 SD) and for those with no RPA was 45 +/- 24 (p less than .04). In patients with RPA, ejection fraction rose 5 +/- 14 percentage points before discharge, but fell 10 +/- 13 points in those with RPA (p less than .03). There was no difference between groups in total dose of streptokinase, final degree of stenosis of the affected vessel, reocclusion rate, or time from onset of symptoms to reperfusion. We conclude that patients suffering acute myocardial infarction who have RPA during ICSK in most cases have a larger infarction site or a more "stunned myocardium," as indicated by greater CK-MB release and fall in ejection fraction which is not due to increased time of ischemia.

Ventricular fibrillation

Ventricular fibrillation is the most common mechanism of sudden unexpected cardiac death in persons with asymptomatic or symptomatic coronary artery disease. The electrophysiologic mechanisms reviewed in this article include: automaticity of pacemaker fibers, transformation of nonpacemaker into pacemaker fibers, "injury" currents and reentry. Some of the conditions facilitating ventricular fibrillation include bradycardia, long QT syndrome, electrocution, electrolyte imbalance, drugs, sympathetic stimulation and myocardial ischemia. Electrophysiologic studies during acute myocardial ischemia suggest that the earliest activity at the onset of arrhythmia may originate at the sites of the surviving Purkinje fibers or at the epicardial rim. Reentrant arrhythmias arising in ischemic myocardium are attributed to nonhomogeneous distribution of local hyperkalemia and acidosis.

Determinants of reperfusion cardiac electrical activity after cold cardioplegic arrest during coronary bypass surgery

In a prospective study of 99 patients with coronary artery disease, reperfusion of the heart after a period of ischemia (protected by contemporary techniques of myocardial preservation) resulted in spontaneous resumption of cardiac electrical activity in 53%, spontaneous defibrillation in 10%, reperfusion ventricular fibrillation (VF) in 32% and indeterminate rhythm in 5%. In hearts spontaneously developing rhythms excluding VF (as opposed to hearts requiring direct-current shock), factors significantly associated were a higher plasma potassium concentration (5.2 vs 4.8 mEq/liter), shorter reperfusion time (1 vs 4 minutes), higher plasma magnesium concentration (1.36 vs 1.25 mg/dl) and a lower myocardial temperature (27 vs 32 degrees C). The duration of ischemia, arterial blood gas levels, plasma catecholamine levels, plasma ionized calcium levels, volume of cardioplegia and mean arterial pressure did not relate to occurrence of spontaneous episodes. However, VF developed in 39 of 52 patients (75%) with spontaneous resumption of electrical activity. This event was associated with lower myocardial temperature. Thus, direct-current shocks were ultimately required in 77 of the 99 patients (78%). Although certain thermal, biochemical and hemodynamic variables facilitate spontaneous resumption of cardiac rhythm, the development of VF may negate the potential benefit of this event in the prevention of myocardial damage from direct-current defibrillation.

Anti-arrhythmic effects of prazosin and propranolol during coronary artery occlusion and re-perfusion in dogs and pigs

Open-chest dogs and pigs anaesthetized with pentobarbitone were used to evaluate the anti-arrhythmic effect of prazosin and propranolol during a 30 min period of occlusion of the left anterior descending coronary artery followed by 15 min of re-perfusion. In dogs, both prazosin and propranolol reduced the incidence of ventricular premature depolarizations and ventricular tachycardia during the occlusion period. During the 45 min period of occlusion and re-perfusion, the incidence of ventricular fibrillation was significantly reduced in the prazosin-treated and propranolol-treated dogs. In pigs prazosin reduced the incidence of ventricular premature depolarizations during occlusion and propranolol reduced the incidence of both ventricular premature depolarizations and ventricular tachycardia during occlusion, but the incidence of ventricular fibrillation was not significantly reduced in the prazosin- and propranolol-treated pigs. Prazosin reduced arterial pressure and propranolol lowered heart rate in both dogs and pigs, but a comparison of mean arterial pressure and heart rate in animals surviving and those not surviving the 30 min of coronary artery occlusion and 15 min of re-perfusion showed no significant difference.