Altered ventricular stretch contributes to initiation of cardiac memory

Mechanisms of stretch-induced electro-anatomical remodeling and atrial arrhythmogenesis

Atrial fibrillation (AF) is the most common cardiac rhythm disorder, often occurring in the setting of atrial distension and elevated myocardialstretch. While various mechano-electrochemical signal transduction pathways have been linked to AF development and progression, the underlying molecular mechanisms remain poorly understood, hampering AF therapies. In this review, we describe different aspects of stretch-induced electro-anatomical remodeling as seen in animal models and in patients with AF. Specifically, we focus on cellular and molecular mechanisms that are responsible for mechano-electrochemical signal transduction and the development of ectopic beats triggering AF from pulmonary veins, the most common source of paroxysmal AF. Furthermore, we describe structural changes caused by stretch occurring before and shortly after the onset of AF as well as during AF progression, contributing to longstanding forms of AF. We also propose mechanical stretch as a new dimension to the concept "AF begets AF", in addition to underlying diseases. Finally, we discuss the mechanisms of these electro-anatomical alterations in a search for potential therapeutic strategies and the development of novel antiarrhythmic drugs targeted at the components of mechano-electrochemical signal transduction not only in cardiac myocytes, but also in cardiac non-myocyte cells.

Arrhythmogenic Effects of Cardiac Memory

Cardiac memory is the term used to describe an interesting electrocardiographic phenomenon. Whenever a QRS complex is wide and abnormal, such as during ventricular pacing, the T waves will also be abnormal and will point to the opposite direction of the wide QRS. If the QRS then normalizes, such as after cessation of ventricular pacing, the T waves will normalize as well, but at a later stage. The period of cardiac memory is the phase between the sudden normalization of the QRS and the eventual and gradual return of the T waves to their baseline morphology. Cardiac memory is assumed to be an innocent electrocardiographic curiosity. However, during cardiac memory, reduction of repolarizing potassium currents increases left ventricular repolarization gradients. Therefore, when cardiac memory occurs in patients who already have a prolonged QT interval (for whatever reason), it can lead to a frank long QT syndrome with QT-related ventricular arrhythmias (torsades de pointes). These arrhythmogenic effects of cardiac memory are not generally appreciated and are reviewed here for the first time.

Synchronization of repolarization after cardiac resynchronization therapy: a combined clinical and modeling study

Introduction

The changes in ventricular repolarization after cardiac resynchronization therapy (CRT) are poorly understood. This knowledge gap is addressed using a multimodality approach including electrocardiographic and echocardiographic measurements in patients and using patient‐specific computational modeling.

Methods

In 33 patients electrocardiographic and echocardiographic measurements were performed before and at various intervals after CRT, both during CRT‐ON and temporary CRT‐OFF. T‐wave area was calculated from vectorcardiograms, and reconstructed from the 12‐lead electrocardiography (ECG). Computer simulations were performed using a patient‐specific eikonal model of cardiac activation with spatially varying action potential duration (APD) and repolarization rate, fit to a patient's ECG.

Results

During CRT‐ON T‐wave area diminished within a day and remained stable thereafter, whereas QT‐interval did not change significantly. During CRT‐OFF T‐wave area doubled within 5 days of CRT, while QT‐interval and peak‐to‐end T‐wave interval hardly changed. Left ventricular (LV) ejection fraction only increased significantly increased after 1 month of CRT. Computer simulations indicated that the increase in T‐wave area during CRT‐OFF can be explained by changes in APD following chronic CRT that are opposite to the change in CRT‐induced activation time. These APD changes were associated with a reduction in LV dispersion in repolarization during chronic CRT.

Conclusion

T‐wave area during CRT‐OFF is a sensitive marker for adaptations in ventricular repolarization during chronic CRT that may include a reduction in LV dispersion of repolarization.

The heart remembers what the mind forgets

Background: Cardiac memory, also known as the Chatterjee phenomenon, is a poorly understood, under-recognized but important and benign cause of T-wave inversions. After a period of abnormal ventricular activation, such as ventricular pacing, intermittent left bundle branch block or pre-excitation, the heart 'remembers' and mirrors its repolarization in the direction of the previous QRS. It usually manifests as T-wave inversions that can linger up to weeks after the provocative event.Case summary: An 87-year-old man with extensive cardiovascular history and risk factors presented to the emergency department with shortness of breath and chest pain. An ECG taken on admission revealed deep widespread T wave inversions. Serial high sensitive cardiac troponin (hs-cTn) however remained negative (<10 ng/ml) with a negative D-dimer. Upon reviewing previous ECGs and the medical history, the patient was diagnosed with cardiac memory, which required no further treatment.Conclusion: Cardiac memory should be considered in any patient with a ventricular pacemaker that presents with narrow QRS rhythm and T-wave changes suggestive of ischemia. Although it remains a diagnosis of exclusion, recognizing this important clinical entity can prevent unnecessary admissions, expensive diagnostic tests and invasive procedures.

Characteristics of Cardiac Memory in Patients with Implanted Cardioverter-defibrillators: The Cardiac Memory with Implantable Cardioverter-defibrillator (CAMI) Study

This study sought to determine factors associated with cardiac memory (CM) in patients with implantable cardioverter-defibrillators (ICDs). Patients with structural heart disease [n = 20; mean age: 72.6 ± 11.6 years; 80% male; mean left ventricular ejection fraction (LVEF): 31.7 ± 7.6%; history of myocardial infarction in 75% and nonsustained ventricular tachycardia (NSVT) in 85%] and preserved atrioventricular conduction received dual-chamber ICDs for primary (80%) or secondary (20%) prevention. Standard 12-lead electrocardiograms were recorded in AAI and DDD modes before and after seven days of right ventricular (RV) pacing in DDD mode with a short atrioventricular delay. The direction (azimuth and elevation) and magnitude of spatial QRS, T, and spatial ventricular gradient vectors were measured before and after seven days of RV pacing. CM was quantified as the degree of alignment between QRS_DDD-7 and T_AAI-7 vectors (QRS_DDD-7 –T_AAI-7 angle). Circular statistics and mixed models with a random slope and intercept were adjusted for changes in cardiac activation, LVEF, known risk factors, and the use of medications known to affect CM occurring on days 1 through 7. The QRS_DDD-7–T_AAI-7 angle strongly correlated (circular r = −0.972; p < 0.0001) with a T_AAI-7–T_DDD-7 angle. In the mixed models, CM-T azimuth changes [+132° (95% confidence interval (CI): 80°–184°); p < 0.0001] were counteracted by the history of MI [−180° (95% CI: −320° to −40°); p = 0.011] and female sex [−162° (95% CI: −268° to −55°); p = 0.003]. A CM-T area increase [+15 (95% CI: 6–24) mV*ms; p < 0.0001] was amplified by NSVT history [+27 (95% CI: 4–46) mV*ms; p = 0.007]. These findings suggest that preexistent electrical remodeling affects CM in response to RV pacing, that CM exhibits saturation behavior, and that women reach CM saturation more easily than men.

Cardiac Mechano-Electric Coupling: Acute Effects of Mechanical Stimulation on Heart Rate and Rhythm

The heart is vital for biological function in almost all chordates, including humans. It beats continually throughout our life, supplying the body with oxygen and nutrients while removing waste products. If it stops, so does life. The heartbeat involves precise coordination of the activity of billions of individual cells, as well as their swift and well-coordinated adaption to changes in physiological demand. Much of the vital control of cardiac function occurs at the level of individual cardiac muscle cells, including acute beat-by-beat feedback from the local mechanical environment to electrical activity (as opposed to longer term changes in gene expression and functional or structural remodeling). This process is known as mechano-electric coupling (MEC). In the current review, we present evidence for, and implications of, MEC in health and disease in human; summarize our understanding of MEC effects gained from whole animal, organ, tissue, and cell studies; identify potential molecular mediators of MEC responses; and demonstrate the power of computational modeling in developing a more comprehensive understanding of ‟what makes the heart tick.ˮ.

Surface ECG criteria can discriminate post-septal pacing cardiac memory from ischemic T wave inversions

Cardiac memory (CM) refers to transient T wave changes that appear after cessation of a period of abnormal ventricular activation, such as right ventricular (RV) pacing. ECG criteria for differentiating post-pacing CM from ischemia-induced T wave changes were previously published only for apical, but not for septal RV pacing.

AIM

To find ECG criteria for discriminating post-septal pacing CM from ischemic T wave inversions.

METHODS

ECGs were analyzed in 2 groups: CM (n = 23) and ischemia (n = 26). CM was induced by 2 weeks of DDD pacing with a short AV delay. Ischemic patients were grouped by culprit vessel: left anterior descending (LAD), circumflex (Cx), right coronary artery (RCA).

RESULTS

CM was visible on the ECG after 1 week of ventricular pacing, started to disappear in <1 week after pacing cessation and was completely reversible within 4 weeks of pacing cessation. T wave axis differed between CM (75.8 ± 18.5°) and Cx (-25.2 ± 25.5°, p < 0.01) and RCA (-18.3 ± 18.9°, p < 0.01) groups, but not compared to LAD group (96.4 ± 65.0°, p = 0.17). The combination of (1) positive T wave in aVF; and (2) (i) T wave amplitude in aVF ≥ the absolute value of the most negative precordial T wave, or (ii) positive T wave in V5 and positive or isoelectric T wave in lead I identified CM from all ischemia with a sensitivity of 91% and a specificity of 92%.

CONCLUSION

ECG criteria can discriminate post-septal RV pacing CM from ischemic changes with high sensitivity and specificity.

Cardiac Memory: A Case Report and Review of the Literature

BACKGROUND

A variety of clinical syndromes can cause T-wave inversion (TWI), ranging from life-threatening events to benign conditions. One benign cause of TWI is cardiac memory, which is characterized by the transient inversion of T-waves following abnormal activation of the ventricles, commonly due to intermittent left bundle branch block (LBBB), tachydysrhythmias, electrical pacing, or ventricular pre-excitation.

CASE REPORT

A 72-year-old man presented to the emergency department with chest pain, nausea, vomiting, and headache. Upon arrival, his electrocardiogram (ECG) showed new-onset LBBB with appropriate secondary ST-T wave changes. A subsequent ECG showed disappearance of LBBB and newly inverted T-waves in precordial leads V1-V5, followed by a repeat ECG that again showed LBBB. Serial troponin testing was unremarkable. During hospitalization, echocardiogram and nuclear perfusion stress test were normal. The transient TWIs in this patient were believed to be due to cardiac memory. We performed a literature review and identified 39 published cases of cardiac memory. The most common etiology for cardiac memory was after cardiac pacemaker placement, followed by intermittent LBBB (as was seen in our patient), and post-tachydysrhythmia. Patient ages ranged from 21 to 88 years, with an equal number of cases reported in men and women. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cardiac memory is a poorly understood, rarely observed phenomenon that can occur in the setting of intermittent LBBB. Testing for acute cardiac ischemia and underlying coronary artery disease is still recommended, as the diagnosis of cardiac memory can only be made after negative workup.

Association between T-wave discordance and the development of heart failure in left bundle branch block patients: Results from the Copenhagen ECG study

BACKGROUND

In left bundle branch block (LBBB), discrepancies between depolarization and repolarization of the heart can be assessed by similar direction (concordant) or opposite direction (discordant) of the lateral T-waves compared to the direction of the QRS complex and by the QRS-T angle. We examined the association between discordant T-waves and high QRS-T angles for heart failure development in primary care LBBB patients.

METHODS

Between 2001 and 2011, we identified 2540 patients from primary care with LBBB without overt heart failure. We examined the development of heart failure in relation to two ECG measures: (1) LBBB as either discordant (two or three monophasic T-waves in the opposite direction of the QRS complex in leads I, V5 or V6) or concordant, and (2) the frontal plane QRS-T angle in quartile groups.

RESULTS

In total, 244 of 913 patients (26.7%) with discordant LBBB developed heart failure compared to 302 of 1627 patients (16.7%) with concordant LBBB. Multivariable Cox regression comparing discordant with concordant LBBB showed a hazard ratio (HR) of 2.58 (95% Confidence interval [CI] 1.71-3.89) for heart failure development within 30 days of follow-up and a HR of 1.45 (95%CI 1.19-1.77) after 30 days. For QRS-T angle, comparing the highest quartile (160°-180°) with the lowest quartile (0°-110°) we found a HR of 2.25 (95%CI 1.26-4.02) within 30 days and a HR of 1.67 (95%CI 1.25-2.23) after 30 days.

CONCLUSION

T-wave discordance in lateral ECG leads and a high QRS-T angle are associated with heart failure development in primary care LBBB patients.

Electrical remodelling in patients with iatrogenic left bundle branch block

Aims

Left bundle branch block (LBBB) is induced in approximately one-third of all transcatheter aortic valve implantation (TAVI) procedures. We investigated electrophysiological remodelling in patients with TAVI-induced LBBB.

Methods and results

This retrospective study comprises 107 patients with initially narrow QRS complex of whom 40 did not and 67 did develop persistent LBBB after TAVI. 12-lead electrocardiograms (ECGs) taken before TAVI, within 24 hours (‘acute’), and 1–12 months after TAVI (‘chronic’) were used to reconstruct vectorcardiograms. From these vectorcardiograms, QRS and T-wave area were calculated as comprehensive indices of depolarization and repolarization abnormalities, respectively. TAVI-induced LBBB resulted in significant acute depolarization and repolarization changes while further repolarization changes were observed with longer lasting LBBB. The amount of long-term repolarization changes (remodelling) was highly variable between patients. The change in T-wave area between acute and chronic LBBB ranged from +57% to − 77%. After dividing the LBBB cohort into tertiles based on the change in T-wave area, only baseline QRS area was larger in the tertile with no significant change in T-wave area. During longer lasting LBBB, the spatial vector gradient (SVG) changed orientation towards the direction of the QRS-vector, indicating that later-activated regions developed shorter action potential duration.

Conclusion

This study in patients with TAVI-induced LBBB shows that repolarization changes develop within months after onset of LBBB, and that these changes are highly variable between individual patients.

Small-Conductance Calcium-Activated Potassium Current Is Activated During Hypokalemia and Masks Short-Term Cardiac Memory Induced by Ventricular Pacing

BACKGROUND

Hypokalemia increases the vulnerability to ventricular fibrillation. We hypothesize that the apamin-sensitive small-conductance calcium-activated potassium current (IKAS) is activated during hypokalemia and that IKAS blockade is proarrhythmic.

METHODS AND RESULTS

Optical mapping was performed in 23 Langendorff-perfused rabbit ventricles with atrioventricular block and either right or left ventricular pacing during normokalemia or hypokalemia. Apamin prolonged the action potential duration (APD) measured to 80% repolarization (APD80) by 26 milliseconds (95% confidence interval [CI], 14-37) during normokalemia and by 54 milliseconds (95% CI, 40-68) during hypokalemia (P=0.01) at a 1000-millisecond pacing cycle length. In hypokalemic ventricles, apamin increased the maximal slope of APD restitution, the pacing cycle length threshold of APD alternans, the pacing cycle length for wave-break induction, and the area of spatially discordant APD alternans. Apamin significantly facilitated the induction of sustained ventricular fibrillation (from 3 of 9 hearts to 9 of 9 hearts; P=0.009). Short-term cardiac memory was assessed by the slope of APD80 versus activation time. The slope increased from 0.01 (95% CI, -0.09 to 0.12) at baseline to 0.34 (95% CI, 0.23-0.44) after apamin (P<0.001) during right ventricular pacing and from 0.07 (95% CI, -0.05 to 0.20) to 0.54 (95% CI, 0.06-1.03) after apamin infusion (P=0.045) during left ventricular pacing. Patch-clamp studies confirmed increased IKAS in isolated rabbit ventricular myocytes during hypokalemia (P=0.038).

CONCLUSIONS

Hypokalemia activates IKAS to shorten APD and maintain repolarization reserve at late activation sites during ventricular pacing. IKAS blockade prominently lengthens the APD at late activation sites and facilitates ventricular fibrillation induction.

Intermittent left bundle branch block: an overlooked cause of electrocardiographic changes that mimic high-grade stenosis of the left anterior descending coronary artery

CONTEXT

The electrocardiographic (ECG) pattern of high-grade stenosis of the left anterior descending coronary artery (LAD) is important clinically because of the high risk of myocardial infarction and cardiac death if the pattern is not recognized. Although the recognition of this pattern is currently widespread, false-positive ECG changes that mimic this pattern are infrequently reported.

OBJECTIVE

To demonstrate that ECG changes from intermittent left bundle branch block (LBBB) and cardiac memory can mimic anterior ischemia.

METHODS

Medical record review of cardiology patients in whom ECG tracings showed intermittent LBBB and anterior T-wave changes during normal QRS conduction. Patients were included if ECG changes suggestive of high-grade LAD stenosis in leads V2 and V3 met the following criteria: (1) the QRS conduction was essentially normal during periods of absent LBBB; (2) the ST segment took off from an isoelectric point or only slightly elevated from baseline; and (3) the ST segment sloped up gradually with an abrupt and sharp down stroke leading to terminal T-wave inversion. Additional criteria were little or no ST segment elevation, no loss of precordial R waves, and ECG changes suggestive of high-grade LAD stenosis demonstrated in precordial leads V2 and V3. All patients demonstrated intermittent LBBB, and patients were excluded if a ventricular pacemaker was present. The case series began in 2003 and continued until 2011.

RESULTS

Sixteen patients (3 male) with intermittent LBBB were identified with ST- and T-wave changes during normal ventricular conduction that matched the pattern described by Hein J.J. Wellens, MD. Of these patients, none had evidence of clinically substantial coronary artery disease. Eleven patients had stress testing with myocardial perfusion imaging, and 5 patients underwent cardiac catheterization. In 1 patient whose ECG pattern showed high-grade LAD stenosis but normal coronary arteries at catheterization, a stress test was later performed, which provoked LBBB. All other patients had spontaneous, intermittent periods of LBBB and normal conduction.

CONCLUSION

The ECG pattern of high-grade LAD stenosis has proven to be an important marker of high-risk patients with chest pain. This pattern may also be seen in patients with a right ventricular pacemaker on resumption of native QRS conduction. Intermittent LBBB is a less obvious cause of a similar ECG pattern that may mimic anterior ischemia due to high-grade stenosis.

The multiple electrocardiographic manifestations of ventricular repolarization memory

T wave “memory” is a peculiar variety of cardiac remodeling caused by a transient change in the course of ventricular depolarization (due to ventricular pacing, rate-dependent intraventricular block, ventricular preexcitation or tachyarrhythmias with wide QRS complexes). It is usually manifested by inverted T waves that appears when normal ventricular activation is restored. This phenomenon is cumulative and occurs earlier if the ventricular myocardium has previously been exposed to the same conditioning stimuli. In this article the different conditions giving rise to “classical” T wave memory development are reviewed and also “another” type of T wave memory is described. It is also shown that cardiac memory may induce not only negative (pseudo-primary) T waves but also a reversal of primary and pseudo-primary T waves leading to “normalization” of ventricular repolarization. The knowledge of these dissimilar consequences of T wave memory is essential to assess the characteristics of ventricular repolarization.

Mechano-electrical coupling as framework for understanding functional remodeling during LBBB and CRT

It is not understood why, after onset of left bundle-branch block (LBBB), acute worsening of cardiac function is followed by a further gradual deterioration of function, whereas most adverse cardiac events lead to compensatory adaptations. We investigated whether mechano-electrical coupling (MEC) can explain long-term remodeling with LBBB and cardiac resynchronization therapy (CRT). To this purpose, we used an integrative modeling approach relating local ventricular electrophysiology, calcium handling, and excitation-contraction coupling to global cardiovascular mechanics and hemodynamics. Each ventricular wall was composed of multiple mechanically and electrically coupled myocardial segments. MEC was incorporated by allowing adaptation of L-type Ca2+ current aiming at minimal dispersion of local external work, an approach that we previously applied to replicate T-wave memory in a synchronous heart after a period of asynchronous activation. LBBB instantaneously decreased left-ventricular stroke work and increased end-diastolic volume. During sustained LBBB, MEC reduced intraventricular dispersion of mechanical workload and repolarization. However, MEC-induced reduction in contractility in late-activated regions was larger than the contractility increase in early-activated regions, resulting in further decrease of stroke work and increase of end-diastolic volume. Upon the start of CRT, stroke work increased despite a wider dispersion of mechanical workload. During sustained CRT, MEC-induced reduction in dispersion of workload and repolarization coincided with a further reduction in end-diastolic volume. In conclusion, MEC may represent a useful framework for better understanding the long-term changes in cardiac electrophysiology and contraction following LBBB as well as CRT.

pH (low) insertion peptide (pHLIP) targets ischemic myocardium

The pH (low) insertion peptide (pHLIP) family enables targeting of cells in tissues with low extracellular pH. Here, we show that ischemic myocardium is targeted, potentially opening a new route to diagnosis and therapy. The experiments were performed using two murine ischemia models: regional ischemia induced by coronary artery occlusion and global low-flow ischemia in isolated hearts. In both models, pH-sensitive pHLIPs [wild type (WT) and Var7] or WT-pHLIP-coated liposomes bind ischemic but not normal regions of myocardium, whereas pH-insensitive, kVar7, and liposomes coated with PEG showed no preference. pHLIP did not influence either the mechanical or the electrical activity of ischemic myocardium. In contrast to other known targeting strategies, the pHLIP-based binding does not require severe myocardial damage. Thus, pHLIP could be used for delivery of pharmaceutical agents or imaging probes to the myocardial regions undergoing brief restrictions of blood supply that do not induce irreversible changes in myocytes.

Mechano-electrical feedback explains T-wave morphology and optimizes cardiac pump function: insight from a multi-scale model

In the ECG, T- and R-wave are concordant during normal sinus rhythm (SR), but discordant after a period of ventricular pacing (VP). Experiments showed that the latter phenomenon, called T-wave memory, is mediated by a mechanical stimulus. By means of a mathematical model, we investigated the hypothesis that slow acting mechano-electrical feedback (MEF) explains T-wave memory. In our model, electromechanical behavior of the left ventricle (LV) was simulated using a series of mechanically and electrically coupled segments. Each segment comprised ionic membrane currents, calcium handling, and excitation-contraction coupling. MEF was incorporated by locally adjusting conductivity of L-type calcium current (g(CaL)) to local external work. In our set-up, g(CaL) could vary up to 25%, 50%, 100% or unlimited amount around its default value. Four consecutive simulations were performed: normal SR (with MEF), acute VP, sustained VP (with MEF), and acutely restored SR. MEF led to T-wave concordance in normal SR and to discordant T-waves acutely after restoring SR. Simulated ECGs with a maximum of 25-50% adaptation closely resembled those during T-wave memory experiments in vivo and also provided the best compromise between optimal systolic and diastolic function. In conclusion, these simulation results indicate that slow acting MEF in the LV can explain a) the relatively small differences in systolic shortening and mechanical work during SR, b) the small dispersion in repolarization time, c) the concordant T-wave during SR, and d) T-wave memory. The physiological distribution in electrophysiological properties, reflected by the concordant T-wave, may serve to optimize cardiac pump function.

The zebrafish as a novel animal model to study the molecular mechanisms of mechano-electrical feedback in the heart

Altered mechanical loading of the heart leads to hypertrophy, decompensated heart failure and fatal arrhythmias. However, the molecular mechanisms that link mechanical and electrical dysfunction remain poorly understood. Growing evidence suggest that ventricular electrical remodeling (VER) is a process that can be induced by altered mechanical stress, creating persistent electrophysiological changes that predispose the heart to life-threatening arrhythmias. While VER is clearly a physiological property of the human heart, as evidenced by "T wave memory", it is also thought to occur in a variety of pathological states associated with altered ventricular activation such as bundle branch block, myocardial infarction, and cardiac pacing. Animal models that are currently being used for investigating stretch-induced VER have significant limitations. The zebrafish has recently emerged as an attractive animal model for studying cardiovascular disease and could overcome some of these limitations. Owing to its extensively sequenced genome, high conservation of gene function, and the comprehensive genetic resources that are available in this model, the zebrafish may provide new insights into the molecular mechanisms that drive detrimental electrical remodeling in response to stretch. Here, we have established a zebrafish model to study mechano-electrical feedback in the heart, which combines efficient genetic manipulation with high-precision stretch and high-resolution electrophysiology. In this model, only 90 min of ventricular stretch caused VER and recapitulated key features of VER found previously in the mammalian heart. Our data suggest that the zebrafish model is a powerful platform for investigating the molecular mechanisms underlying mechano-electrical feedback and VER in the heart.

Microtubules and angiotensin II receptors contribute to modulation of repolarization induced by ventricular pacing

BACKGROUND

Left ventricular pacing (LVP) in canine heart alters ventricular activation, leading to reduced transient outward potassium current (I(to)), loss of the epicardial action potential notch, and T-wave vector displacement. These repolarization changes, referred to as cardiac memory, are initiated by locally increased angiotensin II (AngII) levels. In HEK293 cells in which Kv4.3 and KChIP2, the channel subunits contributing to I(to), are overexpressed with the AngII receptor 1 (AT1R), AngII induces a decrease in I(to) as the result of internalization of a Kv4.3/KChIP2/AT1R macromolecular complex.

OBJECTIVE

To test the hypothesis that in canine heart in situ, 2h LVP-induced decreases in membrane KChIP2, AT1R, and I(to) are prevented by blocking subunit trafficking.

METHODS

We used standard electrophysiological, biophysical, and biochemical methods to study 4 groups of dogs: (1) Sham, (2) 2h LVP, (3) LVP + colchicine (microtubule-disrupting agent), and (4) LVP + losartan (AT1R blocker).

RESULTS

The T-wave vector displacement was significantly greater in LVP than in Sham and was inhibited by colchicine or losartan. Epicardial biopsies showed significant decreases in KChIP2 and AT1R proteins in the membrane fraction after LVP but not after sham treatment, and these decreases were prevented by colchicine or losartan. Colchicine but not losartan significantly reduced microtubular polymerization. In isolated ventricular myocytes, AngII-induced I(to) reduction and loss of action potential notch were blocked by colchicine.

CONCLUSIONS

LVP-induced reduction of KChIP2 in plasma light membranes depends on an AngII-mediated pathway and intact microtubular status. Loss of I(to) and the action potential notch appear to derive from AngII-initiated trafficking of channel subunits.

Repolarization changes underlying long-term cardiac memory due to right ventricular pacing: noninvasive mapping with electrocardiographic imaging

BACKGROUND

Cardiac memory refers to the observation that altered cardiac electrical activation results in repolarization changes that persist after the restoration of a normal activation pattern. Animal studies, however, have yielded disparate conclusions, both regarding the spatial pattern of repolarization changes in cardiac memory and the underlying mechanisms. The present study was undertaken to produce 3-dimensional images of the repolarization changes underlying long-term cardiac memory in humans.

METHODS AND RESULTS

Nine adult subjects with structurally normal hearts and dual-chamber pacemakers were enrolled in the study. Noninvasive electrocardiographic imaging was used before and after 1 month of ventricular pacing to reconstruct epicardial activation and repolarization patterns. Eight subjects exhibited cardiac memory in response to ventricular pacing. In all subjects, ventricular pacing resulted in a prolongation of the activation recovery interval (a surrogate for action potential duration) in the region close to the site of pacemaker-induced activation from 228.4±7.6 ms during sinus rhythm to 328.3±6.2 ms during cardiac memory. As a consequence, increases are observed in both apical-basal and right-left ventricular gradients of repolarization, resulting in a significant increase in the dispersion of repolarization.

CONCLUSIONS

These results demonstrate that electrical remodeling in response to ventricular pacing in human subjects results in action potential prolongation near the site of abnormal activation and a marked dispersion of repolarization. This dispersion of repolarization is potentially arrhythmogenic and, intriguingly, was less evident during continuous right ventricular pacing, suggesting the novel possibility that continuous right ventricular pacing at least partially suppresses pacemaker-induced cardiac memory.

Computational modeling of the human atrial anatomy and electrophysiology

This review article gives a comprehensive survey of the progress made in computational modeling of the human atria during the last 10 years. Modeling the anatomy has emerged from simple "peanut"-like structures to very detailed models including atrial wall and fiber direction. Electrophysiological models started with just two cellular models in 1998. Today, five models exist considering e.g. details of intracellular compartments and atrial heterogeneity. On the pathological side, modeling atrial remodeling and fibrotic tissue are the other important aspects. The bridge to data that are measured in the catheter laboratory and on the body surface (ECG) is under construction. Every measurement can be used either for model personalization or for validation. Potential clinical applications are briefly outlined and future research perspectives are suggested.

Modeling cardiac electromechanics and mechanoelectrical coupling in dyssynchronous and failing hearts: insight from adaptive computer models

Computer models have become more and more a research tool to obtain mechanistic insight in the effects of dyssynchrony and heart failure. Increasing computational power in combination with increasing amounts of experimental and clinical data enables the development of mathematical models that describe electrical and mechanical behavior of the heart. By combining models based on data at the molecular and cellular level with models that describe organ function, so-called multi-scale models are created that describe heart function at different length and time scales. In this review, we describe basic modules that can be identified in multi-scale models of cardiac electromechanics. These modules simulate ionic membrane currents, calcium handling, excitation-contraction coupling, action potential propagation, and cardiac mechanics and hemodynamics. In addition, we discuss adaptive modeling approaches that aim to address long-term effects of diseases and therapy on growth, changes in fiber orientation, ionic membrane currents, and calcium handling. Finally, we discuss the first developments in patient-specific modeling. While current models still have shortcomings, well-chosen applications show promising results on some ultimate goals: understanding mechanisms of dyssynchronous heart failure and tuning pacing strategy to a particular patient, even before starting the therapy.

Cardiac electrical remodeling in health and disease

Electrical remodeling of the heart takes place in response to both functional (altered electrical activation) and structural (including heart failure and myocardial infarction) stressors. These electrophysiological changes produce a substrate that is prone to malignant ventricular arrhythmias. Understanding the cellular and molecular mechanisms of electrical remodeling is important in elucidating potential therapeutic targets designed to alter maladaptive electrical remodeling. For example, altered patterns of electrical activation lead primarily to electrical remodeling, without significant structural remodeling. By contrast, secondary remodeling arises in response to a structural insult. In this article we review cardiac electrical remodeling (predominantly in the ventricle) with an emphasis on the mechanisms causing these adaptations. These mechanisms suggest novel therapeutic targets for the management or prevention of the most devastating manifestation of heart disease, sudden cardiac death (SCD).

Determinants of CREB degradation and KChIP2 gene transcription in cardiac memory

BACKGROUND

Left ventricular pacing (LVP) to induce cardiac memory (CM) in dogs results in a decreased transient outward K current (I(to)) and reduced mRNA and protein of the I(to) channel accessory subunit, KChIP2. The KChIP2 decrease is attributed to a decrease in its transcription factor, cyclic adenosine monophosphate response element binding protein (CREB).

OBJECTIVE

This study sought to determine the mechanisms responsible for the CREB decrease that is initiated by LVP.

METHODS

CM was quantified as T-wave vector displacement in 18 LVP dogs. In 5 dogs, angiotensin II receptor blocker, saralasin, was infused before and during pacing. In 3 dogs, proteasomal inhibitor, lactacystin, was injected into the left anterior descending artery before LVP. Epicardial biopsy samples were taken before and after LVP. Neonatal rat cardiomyocytes (NRCM) were incubated with H(2)O(2) (50 micromol/l) for 1 hour with or without lactacystin.

RESULTS

LVP significantly displaced the T-wave vector and was associated with increased lipid peroxidation and increased tissue angiotensin II levels. Saralasin prevented T-vector displacement and lipid peroxidation. CREB was significantly decreased after 2 hours of LVP and was comparably decreased in H(2)O(2)-treated NRCM. Lactacystin inhibited the CREB decrease in LVP dogs and H(2)O(2)-treated NRCM. LVP and H(2)O(2) both induced CREB ubiquitination, and the H(2)O(2)-induced CREB decrease was prevented by knocking down ubiquitin.

CONCLUSION

LVP initiates myocardial angiotensin II production and reactive oxygen species synthesis, leading to CREB ubiquitination and its proteasomal degradation. This sequence of events would explain the pacing-induced reduction in KChIP2, and contribute to altered repolarization and the T-wave changes of cardiac memory.

Reversal of primary and pseudo-primary T wave abnormalities by ventricular pacing. A novel manifestation of cardiac memory

AIMS

"Cardiac memory" refers to abnormal T waves (TW) appearing after transient periods of altered ventricular depolarization. The aim of the study was to test the hypothesis that in the presence of abnormal TW, short periods of tailored ventricular pacing (VP) can be followed by normalization of ventricular repolarization.

METHODS

Ten patients with normal TW (control group) and 18 patients with abnormal TW (study group) underwent 15 min of VP at a cycle length of 500 ms. In the control group, VP was performed from the right ventricular apex, and in the study group from right or left ventricular sites that resulted in paced QRS complexes of opposite polarity to that of the abnormal TW. Before and after VP, atrial pacing was maintained at a stable cycle length. Simultaneous 12-lead electrocardiography (ECG) was recorded before, during, and following VP to assess changes in TW polarity, amplitude, electrical axis, QTc interval, and QTc interval dispersion.

RESULTS

As expected, VP was followed by memory-induced changes in TW in eight of ten patients in the control group. Mean T wave axis shifted from +60 degrees + or - 21.2 degrees to +23.5 degrees + or - 50.7 degrees (p = 0.01) in the frontal plane. In the study group, complete or partial normalization of TW occurred in 17 of 18 patients. Mean T wave axis shifted from -23.7 degrees + or - 22.9 degrees to +19.7 degrees + or - 34.7 degrees (p < 0.0002) in the frontal plane when paced from right ventricular outflow tract. The QTc interval shortened after VP both in the control group (424 + or - 25 vs. 399 + or - 27 ms; p = 0.007) and in the study group (446 + or - 26 vs. 421 + or - 22 ms; p < 0.0002). No significant changes were found in QTc interval dispersion.

CONCLUSIONS

Transient changes in the sequence of ventricular activation may either induce or normalize abnormal TW. The background of preceding ventricular depolarization needs to be taken into account before determining the clinical significance of a given pattern of ventricular repolarization.

Why T waves change: a reminiscence and essay

The following article is a personal reflection on my study of a subject which has long interested me. The subject is the T wave, and especially the T wave changes occurring as a marker of cardiac memory. My interest evolved over coffees that Mauricio Rosenbaum and I used to share at the Hotel Algonquin during his frequent trips from Buenos Aires to New York. There is something about the Algonquin, whose scarred wooden tabletops carry the imprints of Robert Benchley, Dorothy Parker, and the 1920's New York literati, and there was something about Mauricio-clinician-scientist, friend, and raconteur extraordinaire-that made his repeated challenges to me to "look at cardiac memory before you begin losing your own" irresistible. So began my personal voyage into trying to understand the T wave. My guideposts were the experiments of Wilson and Finch,(1) the astute observations of a host of investigators who followed, and Mauricio's iconoclastic insights. The story is far from over...I doubt I'll see the end of it in my lifetime. But if the beauty of discovery is in the voyage, then it has been - for me - a memorable trip.

Pathophysiology and clinical implications of cardiac memory

Altering the pattern of activation of the ventricle causes remodeling of the mechanical and electrical properties of the myocardium. The electrical remodeling is evident on the surface electrocardiogram as significant change in T-wave polarity following altered activation; this phenomenon is ascribed to as "T-wave memory" or "cardiac memory." The electrophysiological remodeling following altered activation is characterized by distinct changes in regions proximal (early-activated) versus distal (late-activated) to the site of altered activation. The early-activated region exhibits marked attenuation of epicardial phase 1 notch due to reduced expression of the transient outward potassium current (I(to)). This is attributed to electrotonic changes during altered activation, and angiotensin-mediated regulation of Kv4.3 (the pore-forming alpha subunit responsible for I(to)). The late-activated region exhibits the most significant action potential prolongation due to markedly increased mechanical strain through a mechano-electrical feedback mechanism. Consequently, regionally heterogeneous action potential remodeling occurs following altered activation. This enhances regional repolarization gradients that underlie the electrophysiological basis for T-wave memory. Further, recent clinical studies highlight detrimental consequences of altered activation including worsening mechanical function and increased susceptibility to arrhythmias. Future studies to identify molecular mechanisms that link electrotonic and mechanical strain-induced changes to cellular electrophysiology will provide important insights into the role of altered activation in regulating cardiac repolarization and arrhythmogenesis.

Stretch-activated receptors mediate cardiac memory

BACKGROUND

Cardiac memory refers to long-lasting T-wave changes that follow an episode of altered ventricular activation sequence. Memory-induced alterations in repolarizing ion channel activity have been characterized. However, the mechanism by which changes in activation sequence produce these effects is unknown. We hypothesized that cardiac memory is mediated by the response of stretch-activated receptors (SARs) to a change in mechanical activation sequence.

METHODS

In anesthetized, closed-chest dogs, coronary sinus leads were used to pace the posterolateral left ventricle (LV) continuously for 1 hour at a rate of 120 bpm. The surface vectorcardiogram was used to quantify cardiac memory by measuring T-wave displacement after pacing. Streptomycin, which has been shown to block SARs, was given at a dose of 4 g intramuscularly 1 hour before experimental LV pacing sessions. T-wave displacement after control sessions of LV pacing in the absence of drug (n = 12) was compared to that produced by pacing after streptomycin administration (n = 10 sessions).

RESULTS

There was a distinct and consistent cardiac memory seen after 1 hour of LV pacing under control conditions, with T-wave displacement of 1.28 +/- 0.43 mV (P < 0.001 vs baseline). Pretreatment with streptomycin had no direct effect on the electrocardiogram or hemodynamics, but decreased pacing-induced T-wave displacement to 0.50 +/- 0.28 mV (P < 0.001 vs control sessions).

CONCLUSIONS

Streptomycin, a SAR blocker, dramatically attenuated the development of cardiac memory following epicardial pacing. These data suggest that SARs are a critical link between mechanical sequence of activation and regional modulation of action potential duration that is responsible for cardiac memory.

Vectorcardiographic determinants of cardiac memory during normal ventricular activation and continuous ventricular pacing

BACKGROUND

Cardiac memory (CM) refers to persistent T-wave changes on resumption of normal conduction after a period of abnormal ventricular activation. Traditionally, to observe CM, normal ventricular activation had to be restored, limiting the exploration of this phenomenon in clinical practice.

OBJECTIVE

This study sought to prove that CM can be detected during continuous aberrant activation and to establish factors affecting its magnitude using a vectorcardiographic technique.

METHODS

Sixteen nonpacemaker-dependent patients (11 male, age 72 +/- 8 years, mean +/- SD) undergoing pacemaker/internal cardioverter-defibrillator implantation were paced in DDD mode with a short atrioventricular (AV) delay for 7 days to induce CM. Electrocardiograms were acquired during AAI and DDD pacing at a constant rate before and after CM induction. Dower transform-derived vectorcardiograms were reconstructed and analyzed.

RESULTS

T vector during AAI pacing changed in both magnitude (baseline, 0.26 +/- 0.10 mV; Day 7, 0.39 +/- 0.13 mV, P < .01) and direction aligning with the paced QRS vector (baseline DDD QRS - AAI T angle 125 degrees +/- 36 degrees; Day 7, 39 degrees +/- 21 degrees, P < .01). During DDD pacing, there was no change in T-vector direction, but T amplitude decreased (baseline, 1.06 +/- 0.32 mV; Day 7, 0.71 +/- 0.26 mV, P < .01). CM measured as T-vector peak displacement (TPD) was identical in AAI and DDD mode (TPD 0.46 +/- .0.17 mV and 0.46 +/- 0.17 mV, respectively). Individual CM magnitude correlated with QRS/T-vector amplitude ratio during DDD pacing at baseline (r = 0.90).

CONCLUSION

CM can be reliably shown during continuous ventricular pacing, expanding its application to situations in which abnormal ventricular activation persists. Its magnitude is determined by the QRS/T-amplitude ratio of the ventricular paced beat.

Cardiac memory: a work in progress

Cardiac memory is a form of electrophysiological remodeling generally considered benign, although it shares transduction pathways with factors that may be pathological, such as angiotensin II and reactive oxygen species. When induced by electrical pacing, memory provides a window into the mechanisms engaged during cardiac device therapy. Emphasis is placed on the complexity of signaling processes occurring downstream to the simple intervention of cardiac pacing and the relationship of resultant ion channel changes to their expression in action potentials and body surface recordings.

Update on the pathophysiological basics of cardiac resynchronization therapy

Cardiac resynchronization therapy is an established treatment for patients with severe heart failure and ventricular conduction disturbance. Cardiac resynchronization therapy improves cardiac pump function and clinical status, and reduces morbidity and mortality. This electrical treatment for heart failure has also contributed enormously to the understanding of the pathophysiology of ventricular conduction disturbance. This article highlights the latest findings about the pathophysiology of ventricular conduction disturbance and pacing as well as that of resynchronization, with emphasis on the role of regional mechanical performance in triggering remodeling processes involved and on the selection of patients using mechanical dyssynchrony.