Annihilation, entrainment and modulation of ventricular parasystolic rhythms

Apparent disappearance of ventricular parasystole due to a marked difference between the long form and the short form of the ectopic cycles

Electrocardiograms were taken from a 44-year-old man with irregular ventricular parasystole in whom pure parasystolic cycles without any intervening nonectopic QRS complexes were found. When a sinus impulse fell late in the parasystolic cycle, it hastened occurrence of the next parasystolic discharge. This suggested that type I second degree entrance block occurred in the re-entrant pathway containing the parasystolic focus. When a sinus impulse fell early in the parasystolic cycle, it delayed occurrence of the next parasystolic discharge. This suggested that electrotonic modulation occurred in the parasystolic focus. As a result, the difference in length between the short form and the long form of the parasystolic cycle became markedly great. When the length of two adjacent sinus cycles ranged between the short and the long parasystolic cycle, manifest parasystolic QRS complexes disappeared for a long time. In true ventricular parasystole with pure ectopic cycles, such long disappearance has never been reported before.

Ventricular parasystolic couplets originating in the pathway between the ventricle and the parasystolic pacemaker: mechanism of "irregular" parasystole

This article explains the mechanism of "irregular" parasystole. Two theories have been suggested: "electrotonic modulation" and "type I second degree entrance block." This study attempts to clarify the mechanism of irregular parasystole in cases of true ventricular parasystole associated with ventricular parasystolic couplets. Cases associated with ventricular parasystolic couplets were selected from 37 clinical cases of true ventricular parasystole in which one or more pure parasystolic cycles with no intervening nonectopic QRS complexes were found. Of the 37 cases of true ventricular parasystole, ventricular parasystolic couplets were found in 4 cases. In none of the other 33 cases, ventricular parasystolic couplets were found. In all the cases coexisting with ventricular parasystolic couplets, the latter ectopic QRS complex of the couplet failed to reset the parasystolic rhythm. The above findings suggest that the latter ectopic QRS complex of the parasystolic couplet originated not in the parasystolic pacemaker but in the pathway between the ventricle and the parasystolic pacemaker. It seems that when a sinus impulse fell late in the parasystolic cycle, it passed through the site of second degree entrance block and that the parasystolic couplets originated from the reentrant pathway between the ventricle and the pacemaker. This strengthens our previous suggestion that the mechanism of irregular parasystole is governed by "type I second degree entrance block" and not by "electrotonic modulation."

Catheter ablation of atrioatrial conduction as a cure for atrial arrhythmia after orthotopic heart transplantation

OBJECTIVES

We present three patients in whom atrial arrhythmia was treated by ablation of electrical conduction across a surgical suture line.

BACKGROUND

Conduction across the suture line separating the donor and native right atria has recently been described after orthotopic heart transplantation.

METHODS

Mapping and pacing of both grafted and recipient right atrium was performed to assess the relation between both atria and its relevance to clinical arrhythmia, prior to successful radiofrequency at the site of electrical communication.

RESULTS

In cases 1 and 3, atrioatrial conduction was bidirectional. In both, two types of P waves were observed during sinus rhythm. In case 2, conduction from the recipient to the grafted atrium yielded a very particular surface ECG pattern of atrial extrasystole. The block being unidirectional, the recipient atrial sinus rhythm was not perturbed and behaved like an atrial parasystole. Ablation was performed during sinus rhythm in case 1, recipient right atrial pacing in case 2 and grafted right atrial pacing in case 3 at the site with the shortest conduction time to the other tissue. At the successful ablation site multiple component potentials were recorded. Respectively, 1, 4 and 2 radiofrequency pulses were followed by total atrioatrial conduction interruption. No tachycardia could be induced at the end of the procedure and late follow-up was event free.

CONCLUSIONS

The existence of arrhythmogenic atrioatrial conduction should be taken into account when evaluating atrial arrhythmias in the transplanted heart because it is potentially curable by radiofrequency catheter ablation.

Effect of standing on ventricular parasystole: shortening of the parasystolic cycle length

OBJECTIVE

To investigate the effect of standing on the parasystolic cycle length in cases of "true" ventricular parasystole.

METHODS

Parasystolic cycle length and sinus cycle length were measured during lying and standing in eight men with true ventricular parasystole. These cycle lengths were also measured after exercise in the lying position.

RESULTS

In all cases, parasystolic cycle length and sinus cycle length both shortened on standing, by a mean of 6.4% and 17.8%, respectively, compared to lying. In all cases, the rate of shortening of the parasystolic cycle length was less than that of the sinus cycle length. Parasystolic cycle length was prolonged after exercise, in contrast to a shortening of the sinus cycle length.

CONCLUSIONS

Influences on the parasystolic cycle length are not always in the same direction as on the sinus cycle length. This suggests that the effect of autonomic changes on parasystolic rhythm is not always parallel to that on sinus rhythm.

Nonlinear dynamics, chaos and complex cardiac arrhythmias

Periodic stimulation of a nonlinear cardiac oscillator in vitro gives rise to complex dynamics that is well described by one-dimensional finite difference equations. As stimulation parameters are varied, a large number of different phase locked and chaotic rhythms is observed. Similar rhythms can be observed in the intact human heart when there is interaction between two pacemaker sites. Simplified models are analysed, which show some correspondence to clinical observations.

Reverse effects of exercise on the sinus and parasystolic cycle lengths

Ventricular arrhythmias are the primary concern in the exercise laboratory. It has recently been suggested that in not a few cases, ventricular premature complexes are governed by modulated parasystole and not by ordinary extrasystolic rhythm. In many cases, however, it is difficult to differentiate between parasystole and ordinary extrasystoles. Few reports are available on the effect of exercise in cases of "true" parasystole. This study investigated the effect of exercise on the parasystolic cycle length 11 cases of true ventricular parasystole, in which one or more "pure" parasystolic cycles containing no intervening nonectopic QRS complexes were found. In all cases, in contrast to an acceleration of the sinus rate, a definite decrease in the parasystolic rate was found. In no case did complete suppression occur. These findings suggest that the effects of exercise on ordinary ventricular extrasystolic rhythm and on ventricular parasystole may be considerably different from each other.

Two cases of ventricular parasystole associated with ventricular tachycardia

In two patients, ventricular parasystole (VP) was associated with ventricular tachycardia (VT), and in one patient, catheter ablation was successful. In patient 1, with dilated cardiomyopathy, VP led to VT, which converted to ventricular fibrillation. In patient 2, VP led to symptomatic nonsustained polymorphic VT. The origin of parasystolic focus was determined by endocardial mapping, and a radiofrequency current was delivered to patient 2. Both VP and VT disappeared immediately, and no recurrence has been observed during a follow-up of 8 months. Catheter ablation to the parasystolic focus was effective and a relationship between VP and VT was strongly suggested.

Bradycardia- and tachycardia-dependent termination of ventricular bigeminy: mechanism of ventricular extrasystoles with fixed coupling

Fourteen men with intermittent ventricular bigeminy were selected for this study because coupling intervals of the extrasystoles were considerably long and usually fixed, and bradycardia-dependent (10 cases) and/or tachycardia-dependent (12 cases) termination of bigeminy occurred. In all cases, when the heart rate ranged between two certain values, ventricular bigeminy with fixed-coupled extrasystoles was sustained. In all cases showing bradycardia-dependent termination, bigeminy was suddenly terminated with no changes in coupling of the preceding extrasystoles when the heart rate was decreased below a certain lower value. In all cases showing tachycardia-dependent termination except one, when the heart rate increased beyond a certain higher value, coupling intervals gradually lengthened until bigeminy was terminated. These findings strongly suggest the possibility that, in a considerably large number of clinical cases, ventricular extrasystoles with fixed coupling are caused by longitudinal dissociation of conduction in the reentrant pathway of extrasystoles.

Differentiation between parasystole and extrasystoles. Influence of vagal stimulation on parasystolic impulse formation

Recently, it has been shown that when a sinus impulse falls late in the parasystolic cycle, it usually hastens the next ectopic discharge. Thus, in many cases, the classic criteria for the diagnosis of parasystole (ie, varying coupling intervals and constant shortest interectopic intervals) cannot be used. To differentiate between parasystole and extrasystoles in such cases, the influence of vagal stimulation on parasystolic impulse formation was investigated in seven cases of "true" parasystole in which one or more "pure" ectopic cycles without any intervening nonectopic QRS complexes were found spontaneously. In all cases pure ectopic cycles were found during sinus arrest caused by vagal stimulation; namely, none of the cases showed extreme prolongation of the parasystolic cycle. These results strongly suggest that instead of the classic criteria, vagal stimulation causing temporary sinus arrest is the optimal method for differentiation between parasystole and extrasystoles in cases without spontaneous pure ectopic cycles.

Atrioventricular electrotonic interaction in complete atrioventricular block: an experimental model using radiofrequency energy in the rabbit heart

Provided the conditions for electrotonic transmission exist, an automatic focus surrounded by a block zone may be externally modulated. The atrioventricular (AV) electrotonic interaction was studied in 16 perfused rabbit hearts with supra-Hisian complete AV block induced using low radiofrequency energy doses (2.5 watts; 10 seconds). In nine experiments the sinus node was preserved (group I), whereas in seven it was removed maintaining an AV nodal rhythm (group II). The V-V (ventricular cycle length) and V-A (coupling of the intervening atrial beat) in both groups, and also the A-A (atrial cycle length) and A-V (coupling of the intervening ventricular beat) intervals in group II, were measured beat by beat after current delivery. The phase response curves V-V versus V-A, and A-A versus A-V showed AV interaction in five experiments from group I, and in four from group II, as follows: (1) accelerating phase response curve, characterized by a pacemaker acceleration (V-V or A-A abbreviation) at a critical V-A or A-V coupling interval; maximum acceleration could be progressively (phase response curve without rapid cross-over) or briskly (phase response curve with rapid crossover) reached; from this point onwards acceleration decreased with a further increase in V-A or A-V coupling interval (acceleration slope). (2) Biphasic phase response curve, characterized by initial delaying and late accelerating phases. Maximum acceleration and the acceleration slope were both smaller in accelerating phase response curves without rapid cross-over. On reverting complete block in two experiments, a progressive increase in maximum acceleration and acceleration slope was observed.

CONCLUSIONS

(1) AV interaction in complete AV block can be manifested as accelerating or biphasic phase response curves; (2) transition from electrotonic interaction to conduction seems to be a continuum.

Antitachycardia devices: realities and promises

Nonpharmacologic therapy for ventricular arrhythmias has gained growing attention with the development of the implantable cardioverter-defibrillator. In addition, the reports of adverse effects of drug therapy from several studies, including the Cardiac Arrhythmia Suppression Trial (CAST), have supported the need for these devices. The development of new implantable cardioverter-defibrillators that have the capability of antitachycardia pacing, bradycardia pacing, cardioversion and defibrillation has enhanced their clinical utility. The currently available implantable cardioverter-defibrillators have been shown to significantly improve survival after sudden cardiac arrest in patients with life-threatening ventricular arrhythmias. Newer devices with expanded capabilities may reduce mortality even further. In this report the features of currently available antitachycardia devices and implantable cardioverter-defibrillators are reviewed and the features and current implant data on newer antitachycardia devices are discussed.

Evolution of rhythms during periodic stimulation of embryonic chick heart cell aggregates

During periodic stimulation of spontaneously beating chick heart cell aggregates, there is often an evolution of coupling patterns between the stimulator and the aggregate action potential. For example, at rapid stimulation frequencies, a rhythm that is initially 1:1 (stimulus frequency:aggregate frequency) can evolve to other rhythms such as 5:4 and 4:3. Time-dependent effects generated during periodic stimulation are characterized by three types of experiments to determine 1) the effect of periodic stimulation on the intrinsic cardiac beat rate (overdrive suppression), 2) the effect of periodic stimulation on the phase resetting properties of the aggregate, and 3) the time-dependent changes in the coupling patterns between the stimulator and the aggregate during periodic stimulation. The protocols involved variations in the duration and rate of periodic stimulation. A mathematical model is developed in the form of a two-dimensional finite difference equation based on the data from experiments 1 and 2. The model is used to predict the data generated by experiment 3. There is good correspondence with the experiments in that the theory reproduces complex transitions between various rhythms and displays irregular rhythms similar to those observed experimentally. These results have implications for the evolution of cardiac arrhythmias such as atrioventricular heart block and modulated parasystole.

Modulated parasystole complicating permanent ventricular pacing: the different influence of spontaneous and paced impulses upon the parasystolic rhythm

A case of modulated ventricular parasystole observed in a patient with a VVIM pacemaker is reported. Analysis reveals that the electronic influence (modulation) effected upon the parasystolic focus by the sinus impulses is different from that exerted by the paced impulses. Furthermore, fusion beats reflect an intermediate modulating effect according to the prevalence of the sinus or the paced wavefront.

Effects of supernormal capture on directly measured nonmodulated parasystolic cycles

Pacemaker capture during the supernormal period was seen in a case of modulated parasystole where ectopic cycles occurred without any interposed nonparasystolic beat. This contrasts with previous clinical reports, since, in the latter, the parasystolic cycle length could not be measured directly. As in experimental studies, supernormal modulation resulted in a triphasic phase response curve. Although less likely, similar electrocardiographic changes could be produced by a conceptually different phenomenon, namely full parasystolic resetting due to loss of protection occurring exclusively early in the cycle, combined with modulation in the other (late) parts of the cycle.

Influence of sinus impulses on the parasystolic cycle length

Recently, it has been shown that in most clinical cases of parasystole, the parasystolic rhythm is not completely independent of the sinus rhythm. In this study, to disclose the mechanism of such "irregular" parasystole, parasystolic cycles with an intervening sinus QRS complex (XSX) were compared with their immediately adjacent pure parasystolic cycles without any intervening nonparasystolic QRS complexes (XX) in 10 cases of ventricular parasystole. In eight cases, the XSX interval was equal to or nearly equal to the adjacent pure XX interval; in one, the XSX interval was shorter than the XX interval; and in only one, the XSX interval was longer than the XX interval. In six cases in which the XSX interval was almost equal to the XX interval, calculated XSX intervals with a later intervening sinus QRS complex were obtained from the differences between the XSSX interval (ie, interectopic interval with two intervening sinus QRS complexes) and its adjacent XX interval. In five of the six cases, the calculated XSX interval was shorter than the XX interval. These observations suggest that in most cases of parasystole, early intervening sinus impulses do not change the parasystolic cycle, whereas late intervening sinus impulses shorten the parasystolic cycle. This suggests the presence of type I second-degree entrance block as the mechanism of "irregular" parasystole.

A clinical study of the dynamics of parasystole

A mathematical model for pure parasystole and modulated parasystole leads to a number of quantitative predictions. The predictive power of the model is examined by confronting it with data obtained from a 16-year-old symptomatic male born with a ventricular septal defect that was surgically closed at 5 years of age. A diagnosis of ventricular parasystole and inducible ventricular tachycardia was made following a syncopal episode. The physiological variables required by the model to make specific predictions are the sinus and ectopic cycle lengths and the ventricular refractory period. From these three variables, a two-dimensional parameter space is constructed consisting of the ratio of the refractory period to the sinus cycle length and the ratio of the ectopic to sinus cycle length. For any set of parameters, predictions are made concerning the number of sinus beats between ectopic beats. The different behaviors exhibited in the electrocardiographic (ECG) data agree with theoretical predictions.

Implantable electrical devices in the management of tachyarrhythmias

Electrical therapy for tachyarrhythmias attempts to achieve one or more of three aims: a) prevention of tachycardia; (b) control of the hemodynamic effect of tachycardia; (c) termination of tachycardia. In practice, long term control of tachycardia in selected patients can be achieved with implantable devices which can automatically recognize and terminate tachycardias. Termination can be achieved with a number of pacing modalities. These pacing modalities are reviewed in this article and some guidelines to the choice of modality are given. Patients with supraventricular tachycardia are often more appropriately treated with drugs or surgery but some can be effectively treated with antitachycardia pacing. Some patients with ventricular tachycardia can be successfully treated with these devices but this group is at risk of tachycardia acceleration or degeneration in response to pacing. An implantable cardioverter-defibrillator should be used as a backup in these patients. Present generation devices now incorporate antitachycardia pacing, low energy cardioversion, and higher energy defibrillation in the same unit.

Implantable cardioverter-defibrillators (ICDs) 1989: how close are we to the ideal device?

Major technical advances over the last few years have led to significant improvements in implantable cardioverter-defibrillators. Tachycardias can be detected using a number of criteria which include rate, rate of onset, duration, and stability of tachycardia. A number of target tachyarrhythmias can be distinguished in the same patient and differentiated from sinus or other benign tachycardias. Different tachycardias can then be treated with different electrical therapies. Therapies now incorporated in the latest generation of implantable devices include comprehensive antitachycardia pacing techniques, low-energy cardioversion and high-energy cardioversion-defibrillation. Bradycardia support pacing is also incorporated. Improvements in the electrodes used for sensing tachycardia and delivering therapy have resulted in the first implants of devices without the need for thoracotomy. Improvements in capacitor technology have resulted in a gradual reduction in the size of devices in spite of their increasing sophistication. Further research is needed to evaluate different shock charges and waveforms. Tachycardia prevention by implanted devices is also a field of much current research. Thus, though not yet "ideal," the latest generation of implantable cardioverter-defibrillators represents an important therapeutic option in the treatment of ventricular tachyarrhythmias.

Concealed ventricular hexageminy

The authors report a case of concealed ventricular hexageminy in which, with a few exceptions, extrasystoles were separated by sinus beats conforming to the formula 6n - 1. Whenever an exception to this formula occurs, the intervening beats are not all of sinus origin, but include also a ventricular extrasystole that is different from those occurring in hexageminal distribution. The pattern is explained by a parasystolic rhythm modulated by sinus impulses, assuming a 3:1 ratio between the parasystolic cycle and the sinus cycle. Such a ratio would have to be associated with a trigeminal or concealed trigeminal distribution. There is, however, a 2:1 ectopic-ventricular block, leading to a change of the ectopic distributional pattern from the expected concealed trigeminy to that of the concealed hesageminy.

Ventricular tachycardia with alternating cycle lengths: self-entrainment of parasystolic rhythm?

A patient had ventricular tachycardia with cycle lengths consistently varying between 400 and 490 ms. Arrhythmias with a similar electrocardiographic pattern had been thought to result from the regular activity of an automatic pacemaker with either 3:2 exit block of the Wenckebach type or alternation in exit conduction times. However, the findings in our patient could also be explained by postulating the existence of modulated ventricular parasystole having 3:2 exit block or with alternating (short-long) exit conduction times. In either case, the action potentials elicited by the parasystole must have reached (with variable delays) the ventricular tissue beyond the zone of protection to produce electrotonic depolarizations which, in turn, were reflected back to the ectopic focus itself. This resulted in runs of 2:3 or 2:2 "self-entrainment" of the parasystolic pacemaker. Similar phenomena have been produced in biologic and mathematical models of modulated parasystole.

Concealed ventricular bigeminy with exceptions due to time-dependent modulation of an ectopic rhythm

This presentation reflects a case of atypical concealed bigeminy, where some interectopic intervals contain even numbers of sinus beats. Exceptions to the rule of concealed bigeminy only occur during slowing of the sinus node. The pattern is explained on the basis of modulated parasystole, by drawing a phase-response curve which explains all the interectopic intervals on the basis of the modulating effect exerted by the sinus impulses upon a parasystolic focus.

Modulation of atrioventricular junctional parasystole during atrial pacing

In this report we describe a case of a 68-year-old man with atrioventricular junctional parasystole in whom atrial pacing caused marked changes in the arrhythmic pattern. During atrial pacing at a cycle length of 960 ms, the duration of the ectopic cycle length was influenced by the interval between the parasystolic and nonparasystolic beat. A shorter interval from nonparasystolic to ectopic beat prolonged the ectopic cycle length and a longer one shortened it. Pacing at a cycle length of 900 ms completely suppressed the parasystole. Both of these changes are most likely due to modulation and entrainment of the parasystolic rhythm. During spontaneous variation of the sinus cycle length over 24 hours of ambulatory ECG recording, modulation could not be confirmed; however, there was parallel variation of the ectopic and sinus cycle lengths which suggests that both pacemakers were under the influence of the autonomic nervous system.

"Irregular" ventricular parasystole: the influence of sinus rhythm on a parasystolic focus

Fifteen cases of ventricular parasystole were analyzed to determine whether the interectopic intervals were regular, as expressed by long intervals being exact multiples of the short ones, or not. The regularity of the interectopic intervals was assessed by means of the variation index: the ratio of the maximal difference between various measurements of the parasystolic cycle length and the mean parasystolic cycle length. Three out of 15 cases had a variation index less than 5, and were classified as "regular parasystole." Twelve cases were associated with a variation index greater than 7.5, and were classified as "irregular parasystole." The cases of irregular parasystole were then analyzed to determine whether the variability of the interectopic intervals was casual or dependent on action of the sinus beats. A parasystolic resetting by critically timed sinus impulses (a form of intermittent parasystole) was evident in three cases. The irregularity in the remaining nine cases was due to modulation (viz., due to electrotonic influence exerted by the sinus beats on the parasystolic focus). In every case of modulated parasystole a phase-response curve was constructed, which enabled an analysis of all the interectopic intervals on the basis of a time-dependent effect exerted by the sinus impulses on an otherwise rhythmic parasystolic focus.

Phase resetting in a model of cardiac Purkinje fiber

The phase-resetting response of a model of spontaneously active cardiac Purkinje fiber is investigated. The effect on the interbeat interval of injecting a 20-ms duration depolarizing current pulse is studied as a function of the phase in the cycle at which the pulse is delivered. At low current amplitudes, a triphasic response is recorded as the pulse is advanced through the cycle. At intermediate current amplitudes, the response becomes quinquephasic, due to the presence of supernormal excitability. At high current amplitudes, a triphasic response is seen once more. At low stimulus amplitudes, type 1 phase resetting occurs; at medium amplitudes, a type could not be ascribed to the phase resetting because of the presence of effectively all-or-none depolarization; at high amplitudes, type 0 phase resetting occurs. The modeling results closely correspond with published experimental data; in particular type 1 and type 0 phase resetting are seen. Implications for the induction of ventricular arrhythmias are considered.

Distribution patterns of ventricular premature complexes at different heart rates

The relation between distribution patterns of ventricular premature complexes (VPCs) and heart rate in Holter recordings abundant in VPCs was analyzed using computer-assisted determination of the number of interectopic sinus beats at different heart rates. Within the complete 24-hour heart rate spectrum, zones were demonstrated that were characterized by manifest or concealed bigeminy or manifest or concealed trigeminy. Bigeminy zones were found in 26 and trigeminy zones in 21 of 42 patients. Bigeminy zones were found at a significantly lower heart rate, on the average, then trigeminy zones. In 10 patients both bigeminy and trigeminy zones were observed. Bigeminy and trigeminy zones probably correspond to the distribution patterns of VPCs predicted from modulation of a pacemaker and reflected reentry, both of which can be induced by electrotonically mediated impulses across a zone of impaired conduction in isolated bundles of Purkinje fibers. The bigeminy and trigeminy zones will correspond at least partly to the entrainment zones found during electrotonic modulation of parasystolic foci. The bigeminy zones will correspond to 2:1 entrainment and the trigeminy zones mainly to 3:1 entrainment.

A study of modulated ventricular parasystole by programmed stimulation

To analyze the phase-dependent sensitivity of the parasystolic pacemaker to nonparasystolic beats, 11 patients with modulated ventricular parasystole were studied using the ventricular extrastimulus method. The intrinsic parasystolic cycle lengths ranged from 1,100 to 1,800 ms. Premature stimuli altered the duration of the parasystolic cycle lengths by amounts that depended on timing of the test impulses within the parasystolic cycles. Premature impulses delivered during the first part of the parasystolic cycles prolonged the parasystolic cycle lengths to 107 to 151% of the intrinsic parasystolic cycle lengths and impulses applied during the second part abbreviated them to 70 to 81% of the intrinsic parasystolic cycle lengths. In 10 patients the accelerating effects were of greater magnitude than the decelerating effects. Transition from the accelerating to slowing phases was progressive or unstable in 9 patients and abrupt in 2. Changes induced by individual stimuli were short-lived and the parasystolic pacemakers returned immediately to their original rates. In 1 patient the biphasic sensitivity of parasystole to premature stimuli was shown to sustain for 21 days.

Concealed ventricular quadrigeminy linked to atrial quadrigeminy: a manifestation of modulated parasystole

Analysis of a long electrocardiographic recording including many atrial and ventricular extrasystoles shows that when atrial extrasystoles are in a quadrigeminal distribution, the ventricular extrasystoles also manifest a quadrigeminal distribution or reflect a distributional pattern of concealed quadrigeminy. Conversely, when atrial extrasystoles are other than in a quadrigeminal distribution, the ventricular extrasystoles do not occur in a quadrigeminal or concealed quadrigeminal distribution. This pattern is explained on the basis of modulated parasystole. A biphasic phase-response curve explains the observed phenomena on the basis of variations of the parasystolic cycle length due to the modulating effect of supraventricular beats.

Modulated ventricular parasystole as a mechanism for concealed bigeminy

Concealed extrasystolic ventricular bigeminy reflects a distributional pattern of ventricular extrasystoles where intervening sinus beats are always in odd numbers. This has been explained on bigeminal rhythm associated with exit block. This presentation reflects a modification of this concept in that the distributional pattern may be explained on the basis of complex concealed modulation of ventricular parasystole, the concealment being due to impulses falling within the refractory period rather than suffering true exit block.

Contribution of depolarized foci with variable conduction impairment to arrhythmogenesis in 1 day old infarcted canine cardiac tissue: an in vitro study

To assess the roles of entrance and exit block after canine myocardial infarction, single stage coronary artery ligations of canine circumflex coronary arteries were performed. After 1 day, atria and ventricles were paced using single stimuli and trains. After isolation, simultaneous microelectrode impalements were made in infarcted and uninfarcted tissue. Spontaneous foci, when identifiable, were always located in infarcted tissue. They could frequently be triggered by one or more driven beats, and their activity could often be terminated ("annihilated") by a properly timed beat. Foci with varying combinations of entrance and exit conduction impairment were observed. Variations in conduction characteristics altered the manifest arrhythmic pattern. With partial entrance block and intact exit conduction, foci could be electrotonically modulated and entrained into regular patterns. Activity that emerged from a focus with sufficient conduction delay could modulate the focus, and entrain it to discharge at a slower rate ("autoentrainment"). The results suggest that modulated parasystole may contribute to arrhythmogenesis after canine myocardial infarction and that variations in entrance and exit characteristics of depolarized foci may result in variable and complex arrhythmic patterns.

Supernormal modulation of ventricular parasystole: the triphasic phase-response curve

Modulation of ventricular parasystole by sinus beats has been shown both in vitro and in vivo to result in a classic biphasic phase-response curve. The first clinical presentation of 3 cases of supernormal modulation of ventricular parasystole resulting in a triphasic phase response curve is reported. Supernormal modulation reflects an unexpected early enhancement expedition of the ectopic ventricular impulses. An alternative explantation for the triphasic phase-response curve is the discharge and resetting of the parasystolic focus by critically timed sinus impulses.

Rate-dependent patterns of modulated ventricular parasystole

The effects of ventricular pacing on the arrangement of ventricular parasystolic beats were studied in 14 patients. By analyzing the effects of various pacing rates and modalities, it was found that both rate and pattern of manifest parasystolic beats were intimately related to the rate and coupling interval of the paced rhythm. Our findings indicate that fixed coupling of ectopic beats is not incompatible with parasystole; modulated parasystole may manifest as fixed rate classic parasystole; a parasystolic pacemaker can be entrained by a wide range of driving rates both above and below the intrinsic rate of the parasystole; and with different driving rates, these rate-dependent patterns can be observed in the same patient. Our observations suggest that spontaneous or drug-induced changes in the heart rate can lead to major alterations in the frequency and patterns of ventricular parasystole.

Entrainment of circus movement tachycardia utilizing an accessory pathway with long retrograde conduction times during ventricular and atrial stimulation

An unusual case is presented in which a circus movement tachycardia incorporating an accessory pathway with long retrograde conduction time was transiently entrained. Overdrive high right atrial stimulation produced entrainment without atrial fusion since collision of anterograde and retrograde impulses took place within the accessory pathway. Tachycardia termination occurred when, at a faster pacing rate, an atrial impulse that collided in the accessory pathway was blocked at the atrioventricular (AV) node. In contrast, the entrainment seen during right ventricular apical stimulation was characterized by the occurrence of both fusion and collision within the ventricles. The tachycardia was terminated when a pure paced impulse that collided in the normal pathway was blocked in a retrograde direction in the accessory pathway. These data indicate that: 1) transient entrainment of this arrhythmia (circus movement tachycardia) can be identified by the classical criteria used to diagnose it, provided that fusion and collision occur within the ventricles; and 2) the accessory pathway is the weak link for tachycardia termination only during ventricular pacing since the AV node is the weak link during atrial stimulation.

Concealment of manifest, and exposure of concealed, ventricular parasystole produced by isoproterenol

Few studies have dealt with the effects of isoproterenol on ventricular parasystole. Intravenous isoproterenol (2 to 4 micrograms/min) was administered to 11 nonmedicated patients with ventricular parasystole. At the onset of the drip infusion, 8 patients had continuous parasystole, 2 had intermittent parasystole, and 1 patient (in whom intermittent parasystole was documented 2 to 5 days earlier) showed no manifest parasystolic activity. In all patients, whose control parasystolic cycle length varied between 960 and 2,530 ms, isoproterenol caused a decrease of the parasystolic cycle lengths ranging from 12 to 36%. Therefore, isoproterenol produced a consistent increase of the parasystolic rate. In 4 patients, parasystolic activity ceased to be manifest when the concomitantly enhanced (by isoproterenol) sinus cycle lengths became shorter than 430 ms. This phenomenon reflected a tachycardia-dependent parasystolic concealment, presumably as a result of interference in the parasystolic-ventricular junction. In every case, the arrhythmia reappeared at its initial rate upon stopping the drip infusion. In no patient did parasystolic ventricular tachycardia develop. In the patient without manifest parasystolic beats, isoproterenol unmasked the intermittent parasystole that previously had been intrinsically manifest. The latter effect reflected a true exposure, or unmasking of a latent, rate-independent concealed, parasystolic focus.(ABSTRACT TRUNCATED AT 250 WORDS)