Defibrillation success is associated with myocardial organization. Spatial coherence as a new method of quantifying the electrical organization of the heart

Evolution of activation patterns during long-duration ventricular fibrillation in pigs

Quantitative analysis has demonstrated five temporal stages of activation during the first 10 min of ventricular fibrillation (VF) in dogs. To determine whether these stages exist in another species, we applied the same analysis to the first 10 min of VF recorded in vivo from two 504-electrode arrays, one each on left anterior and posterior ventricular epicardium in six anesthetized pigs. The following descriptors were continuously quantified: 1) number of wavefronts, 2) wavefront fractionations, 3) wavefront collisions, 4) repeatability, 5) multiplicity index, 6) wavefront conduction velocity, 7) activation rate, 8) mean area activated by the wavefronts, 9) negative peak rate of voltage change, 10) incidence of breakthrough/foci, 11) incidence of block, and 12) incidence of reentry. Cluster analysis of these descriptors divided VF into four stages (stages i-iv). The values of most descriptors increased during stage i (1-22 s after VF induction), changed quickly to values indicating greater organization during stage ii (23-39 s), decreased steadily during stage iii (40-187 s), and remained relatively unchanged during stage iv (188-600 s). The epicardium still activated during stage iv instead of becoming silent as in dogs. In conclusion, during the first 10 min, VF activation can be divided into four stages in pigs instead of five stages as in dogs. Following a 16-s period during the first minute of VF when activation became more organized, all parameters exhibited progressive decreased organization. Further studies are warranted to determine whether these changes, particularly the increased organization of stage ii, have clinical consequences, such as alteration in defibrillation efficacy.

Therapeutic hypothermia (30 degrees C) enhances arrhythmogenic substrates, including spatially discordant alternans, and facilitates pacing-induced ventricular fibrillation in isolated rabbit hearts

BACKGROUND

Therapeutic hypothermia (TH, 30 degrees C) protects the brain from hypoxic injury. However, TH may potentiate the occurrence of lethal ventricular fibrillation (VF), although the mechanism remains unclear. The present study explored the hypothesis that TH enhances wavebreaks during VF and S(1) pacing, facilitates pacing-induced spatially discordant alternans (SDA), and increases the vulnerability of pacing-induced VF.

METHODS AND RESULTS

Using an optical mapping system, epicardial activations of VF were studied in 7 Langendorff-perfused isolated rabbit hearts at baseline (37 degrees C), TH (30 degrees C), and rewarming (37 degrees C). Action potential duration (APD)/conduction velocity (CV) restitution and APD alternans (n=6 hearts) were determined by S(1) pacing at these 3 stages. During TH, there was a higher percentage of VF duration containing epicardial repetitive activities (spatiotemporal periodicity) (P<0.001). However, TH increased phase singularity number (wavebreaks) during VF (P<0.05) and S(1) pacing (P<0.05). TH resulted in earlier onset of APD alternans (P<0.001), which was predominantly SDA (P<0.05), and increased pacing-induced VF episodes (P<0.05). TH also decreased CV, shortened wavelength, and enhanced APD dispersion and the spatial heterogeneity of CV restitution.

CONCLUSIONS

TH (30 degrees C) increased the vulnerability of pacing-induced VF by (1)facilitating wavebreaks during VF and S(1) pacing, and (2)enhancing proarrhythmic electrophysiological parameters, including promoting earlier onset of APD alternans (predominantly SDA) during S(1) pacing.

Post-shock synchronized pacing in isolated rabbit left ventricle: evaluation of a novel defibrillation strategy

INTRODUCTION

A failed near-threshold defibrillation shock is followed by an isoelectric window (IEW) and rapid repetitive responses that reinitiate ventricular fibrillation (VF). We hypothesized that properly timed (synchronized) postshock pacing stimuli (SyncP) may capture the recovered tissues during the repetitive responses and prevent postshock reinitiation of VF, resulting in improved defibrillation efficacy.

METHODS AND RESULTS

We explored the effect of postshock SyncP on defibrillation efficacy in isolated rabbit hearts (n = 12). Optical recording-guided real-time detection and electrical stimulation (5 mA) of recovered tissues in anterior/posterior left ventricle (LV) were performed following IEW. The IEW duration was found to be 69 +/- 13 ms. With the same shock strength, successful and failed defibrillation episodes were associated with 50% and 15% of the myocardium, respectively, captured by the SyncP (P < 0.001). Electrical stimulation from the posterior LV resulted in 75% of episodes capturing myocardium, as compared with anterior LV stimulation (55%; P < 0.01) and higher successful defibrillation rate (14%, posterior vs. 3%, anterior LV). The overall success in terminating VF by postshock SyncP was approximately 10%. The causes for failed myocardium capture by postshock SyncP included lack of IEW after low-strength shock (42.9%), incorrect locations of reference site (25.7%) and pacing electrodes (17.9%), and others, such as wave breakthroughs (13.5%).

CONCLUSION

Postshock SyncP was feasible and the larger the myocardium captured area, the more likely was the successful defibrillation. Postshock SyncP delivered to the posterior LV was more effective than anterior LV to terminate VF.

Discovery of gradient pattern in dominant frequency maps during fibrillation: implication of rotor drift and epicardial conduction velocity changes

Dominant frequency (DF) maps for mapping epicardial activations of ventricular fibrillation (VF) have been studied mainly using fast Fourier transform (FFT). Small and discrete DF domains exhibited in these DF maps have undermined the hypothesis of mother rotor for VF maintenance. We applied continuous Fourier transform (CFT) to generate high-precision DF maps and studied characteristics of these high-precision DF maps. Optical epicardial activations were recorded in isolated rabbit hearts (n=10). Continuous Fourier transform of 1-second segments was performed in VF (n=188) and ventricular tachycardia (n=189) at 0.1 Hz precisions. Banded gradient patterns of gradual change in DF values were observed in 136 of 188 VF segments, but not in ventricular tachycardia. These gradients were not observed when FFT was used. Gradients were observed along the conduction path of reentrant-like waves with decreasing DF values along the path. Spectra in the gradients did not exhibit bimodal spectra as is usually observed in traditional DF domain boundaries. Time-space plots revealed clear association between gradient pattern and epicardial conduction velocity changes. Prior simulation studies predicted a gradient in activation rate during rotor drift. This gradient pattern has been observed for the first time experimentally by only using CFT, but not FFT. High-precision DF videos indicated the existence of gradient movement from one spatial location to another, smoothly instead of randomly disappearing from one location and appearing in another. The discovery of associated pseudoconduction velocity changes, and gradient patterns might suggest that dominant rotor (mother rotor) drifting plays a maintenance role only detectable by CFT and not FFT.

Waveform analysis of ventricular fibrillation to predict defibrillation

PURPOSE OF REVIEW

Ventricular fibrillation occurs during many cases of cardiac arrest and is treated with rescue shocks. Coarse ventricular fibrillation occurs earlier after the onset of cardiac arrest and is more likely to be converted to an organized rhythm with pulses by rescue shocks. Less organized or fine ventricular fibrillation occurs later, has less power concentrated within narrow frequency bands and lower amplitude, and is less likely to be converted to an organized rhythm by rescue shocks. Quantitative analysis of the ventricular fibrillation waveform may distinguish coarse ventricular fibrillation from fine ventricular fibrillation, allowing more appropriate delivery of rescue shocks.

RECENT FINDINGS

A variety of studies in animals and humans indicate that there is underlying structure within the ventricular fibrillation waveform. Highly organized or coarse ventricular fibrillation is characterized by large power contributions from a few component frequencies and higher amplitude. Amplitude, decomposition into power spectra, or probability-based, nonlinear measures all can quantify the organization of human ventricular fibrillation waveforms. Clinical data have accumulated that these quantitative measures, or combinations of these measures, can predict the likelihood of rescue shock success, restoration of circulation, and survival to hospital discharge.

SUMMARY

Many quantitative ventricular fibrillation measures could be implemented in current generations of monitors/defibrillators to assist the timing of rescue shocks during clinical care. Emerging data suggest that a period of chest compressions or reperfusion can increase the likelihood of successful defibrillation. Therefore, waveform-based prediction of defibrillation success could reduce the delivery of failed rescue shocks.

Evolution of activation patterns during long-duration ventricular fibrillation in dogs

Although resuscitation for sudden cardiac arrest attempts are frequently not instituted for several minutes after the onset of ventricular fibrillation (VF), previous mapping studies have examined only the first 40 s of VF or have involved isolated perfused hearts that did not become ischemic during VF. We applied quantitative pattern analysis to mapping data throughout the first 10 min of VF acquired from a 21 x 24 unipolar electrode array located on the ventricular epicardium of six open-chest dogs. The following twelve descriptors were continuously quantified: 1) number of wavefronts, 2) incidence of reentry, 3) wavefront propagation velocity, 4) incidence of breakthrough/focus, 5) incidence of block, 6) mean area activated by the wavefronts, 7) wavefront fractionations, 8) wavefront collisions, 9) multiplicity index, 10) repeatability, 11) negative peak rate of voltage change, and 12) peak frequency of activation. Cluster analysis of these descriptors divided VF into five stages (stages i-v). The values of most descriptors (except block and breakthrough incidence) increased during stage i (1-11 s after VF induction) and maintained high values with rapid dynamic fluctuations during stage ii (12-62 s). Descriptors changed quickly to values indicating greater organization during stage iii (63-86 s), decreased steadily during stage iv (87-310 s), and approached zero during stage v (311-600 s). There was a high incidence of reentry just before, during, and after stage iii. In conclusion, during the first 10 min, VF can be divided into five stages according to the evolution of electrophysiological characteristics. All of the parameters show a rapid deterioration during VF, except for a temporary reversal approximately 1 min after induction when activation briefly became more organized. Thus a quantitative description of activation does not uniformly decrease as VF progresses, but undergo rapid changes and exhibit a brief interval of increased organization after approximately 1 min of VF. Further studies are warranted to determine whether these changes, particularly the increased organization of stage iii, have clinical consequences, such as an alteration in defibrillation efficacy.

Fiber orientation and cell-cell coupling influence ventricular fibrillation dynamics

Cell Coupling Influences VF Dynamics.

INTRODUCTION

The structure of ventricular fibrillation (VF) is influenced by regional differences in action potential durations and perhaps restitution kinetics and fiber anisotropy. The spatial organization of VF was investigated by measuring the cross-correlation (CC) and mutual information (MI) of membrane potential (Vm) oscillations recorded from multiple sites.

METHODS AND RESULTS

Rabbit hearts (n = 6) were retrogradely perfused and stained with di-4-ANEPPS, and VF was elicited by burst pacing. Vm oscillations were recorded optically from multiple locations on the epicardium using a 16 x 16 photodiode array or a 72 x 78 CCD camera. The spatial organization of VF was investigated by calculating the maximum CC (CCmax) and MI (MImax) that can be obtained between any two sites. CCmax and MImax were extended to all pixels and served as indices of the similarities between Vm transients at a reference pixel and all other pixels on the map. We found that maps of CCmax and MImax did not contain discrete regions with high CC or MI. However, CCmax and MImax decreased monotonically with increasing distance between any arbitrarily chosen reference pixel and all other pixels. In VF, maps of CCmax and MImax revealed elliptical gradients of CC and MI that were closely aligned with fiber orientation, with major axis at 127 degrees +/- 8 degrees on the left ventricles.

CONCLUSION

CC and MI analysis in fibrillation provides new evidence that anisotropy of fiber orientation and cell-cell coupling have a direct influence on VF dynamics.

Scaling structure of electrocardiographic waveform during prolonged ventricular fibrillation in swine

Ventricular fibrillation (VF) is the most common arrhythmia causing sudden cardiac death. However, the likelihood of successful defibrillation declines with increasing duration of VF. Because the morphology of the electrocardiogram (ECG) waveform during VF also changes with time, this study examined a new measure that describes the VF waveform and distinguishes between early and late VF. Surface ECG recordings were digitized at 200 samples/s from nine swine with induced VF. A new measure called the scaling exponent was calculated by examining the power-law relationship between the summation of amplitudes of a 1,024-point (5.12 second) waveform segment and the time scale of measurement. The scaling exponent is a local estimate of the fractal dimension of the ECG waveform. A consistent power-law relationship was observed for measurement time scales of 0.005-0.040 seconds. Calculation of the scaling exponent produced similar results between subjects, and distinguished early VF (< 4-minute duration) from late VF (> or = 4-minute duration). The scaling exponent was dependent on the order of the data, supporting the hypothesis that the surface ECG during VF is a deterministic rather than a random signal. The waveform of VF results from the interaction of multiple fronts of depolarization within the heart, and may be described using the tools of nonlinear dynamics. As a quantitative descriptor of waveform structure, the scaling exponent characterizes the time dependent organization of VF.

Coherence between body surface ECG leads and intracardiac signals increases during the first 10 s of ventricular fibrillation in the human heart

Ventricular fibrillation (VF) in the human heart is not well understood. The aim of this study was to measure changes in the phase relationship between the body surface ECG and intracardiac electrograms recorded during the first 10 s of human VF. We studied 11 episodes of VF and measured the coherence of (a) ECG lead I and ECG lead V1, (b) ECG lead V1 and the right ventricular apex (RVA) electrogram, and (c) ECG lead V1 and the smoothed RVA electrogram. Each coherence measurement was the average of the magnitude squared coherence function in the range 0-60 Hz, and measurements were made 1, 3, 5, 7 and 9 s after the onset of VF. Overall, the mean (SD) coherence was 31(6)% between ECG leads I and V1, 17(3)% between ECG lead V1 and the RVA electrogram, and 20(4)% between ECG lead V1 and the smoothed RVA electrogram. All three measurements of coherence increased significantly between 1 and 9 s with mean (SD) rates of 0.97(1.01)% s(-1), 0.8(1.18)% s(-1) and 0.82(1.19)% s(-1) respectively. These results show that propagation in human VF becomes more organized during the first 10 s of VF. This may be an optimal window for defibrillation.

Evolution of the organization of epicardial activation patterns during ventricular fibrillation

INTRODUCTION

This study quantified how the organization of epicardial activation changes during the first 40 seconds of ventricular fibrillation (VF).

METHODS AND RESULTS

Unipolar potentials were mapped from a 504 (24 x 21) electrode array (2-mm interelectrode spacing) on the anterior right ventricle (RV) and left ventricle (LV) epicardium. The array covered approximately 20% of the epicardial surface. In each of seven pigs, six episodes of VF were induced by premature stimulation. One-half second epochs of VF were analyzed, starting 0, 10, 20, 30, and 40 seconds post induction and using novel pattern analysis algorithms. Eight parameters were quantified: (1) the number of wavefronts; (2) the epicardial area activated by wavefronts; (3) the fraction of wavefronts arising from epicardial breakthrough or from a focus; (4) the fraction of wavefronts terminated by conduction block; (5) the multiplicity index (number of distinct activation pathways in the rhythm); (6) the repeatability index (number of times activation pathways are traversed); (7) the activation rate; and (8) the wavefront propagation velocity. The results showed that VF patterns were less organized at 10 than at 0 seconds, with more, smaller wavefronts traversing a larger variety of pathways for fewer repetitions. VF activation patterns then gradually reorganized up to 40 seconds, but by a different mechanism: the spatial size of subpatterns grew, but the dynamics otherwise appeared unchanged. During both transitions, both activation rate and propagation velocity slowed monotonically.

CONCLUSION

Thus, changes in organization during VF can occur by multiple mechanisms.