A system for in-vivo cardiac optical mapping

Cardiac Optical Mapping in Situ in Swine Models: A View of the Current Situation

Optical mapping is recognized as a promising tool for the registration of electrical activity in the heart. Most cardiac optical mapping experiments are performed in ex vivo isolated heart models. However, the electrophysiological properties of the heart are highly influenced by the autonomic nervous system as well as humoral regulation; therefore, in vivo investigations of heart activity in large animals are definitely preferred. Furthermore, such investigations can be considered the last step before clinical application. Recently, two comprehensive studies have examined optical mapping approaches for pig hearts in situ (in vivo), likely advancing the methodological capacity to perform complex electrophysiological investigations of the heart. Both studies had the same aim, i.e., to develop high-spatiotemporal-resolution optical mapping suitable for registration of electrical activity of pig heart in situ, but the methods chosen were different. In this brief review, we analyse and compare the results of recent studies and discuss their translational potential for in situ cardiac optical mapping applications in large animals. We focus on the modes of blood circulation that are employed, the use of different voltage-sensitive dyes and their loading procedures, and ways of eliminating contraction artefacts. Finally, we evaluate the possible scenarios for optical mapping (OM) application in large animals in situ and infer which scenario is optimal.

Cardiac optical mapping - State-of-the-art and future challenges

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Cardiac optical mapping is a fluorescent imaging method to study electrical behaviour and calcium handling in the heart.

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Optical mapping provides higher spatio-temporal resolution than electrode techniques, allowing unique insights into cardiac electrophysiology in health and disease from a variety of pre-clinical models.

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Both transmembrane voltage and intracellular calcium dynamics can be studied with the use of appropriate fluorescent dyes.

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Optical mapping has traditionally required the use of mechanical uncouplers, however computational and technical developments have lessened the requirement for these agents.

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Novel fluorescent dyes have been developed to optimise spectral properties, experimental timescales, biological compatibility and fluorescence output.

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The combination of these developments has made possible novel mapping experiments, including recent in vivo application of the technique.

Cardiac optical mapping utilises fluorescent dyes to directly image the electrical function of the heart at a high spatio-temporal resolution which far exceeds electrode techniques. It has therefore become an invaluable tool in cardiac electrophysiological research to map the propagation of heterogeneous electrical signals across the myocardium. In this review, we introduce the principles behind cardiac optical mapping and discuss some of the challenges and state of the art in the field. Key advancements discussed include newly developed fluorescent indicators, tools for the analysis of complex datasets, panoramic imaging systems and technical and computational approaches to realise optical mapping in freely beating hearts.

In vivo ratiometric optical mapping enables high-resolution cardiac electrophysiology in pig models

Aims

Cardiac optical mapping is the gold standard for measuring complex electrophysiology in ex vivo heart preparations. However, new methods for optical mapping in vivo have been elusive. We aimed at developing and validating an experimental method for performing in vivo cardiac optical mapping in pig models.

Methods and results

First, we characterized ex vivo the excitation-ratiometric properties during pacing and ventricular fibrillation (VF) of two near-infrared voltage-sensitive dyes (di-4-ANBDQBS/di-4-ANEQ(F)PTEA) optimized for imaging blood-perfused tissue (n = 7). Then, optical-fibre recordings in Langendorff-perfused hearts demonstrated that ratiometry permits the recording of optical action potentials (APs) with minimal motion artefacts during contraction (n = 7). Ratiometric optical mapping ex vivo also showed that optical AP duration (APD) and conduction velocity (CV) measurements can be accurately obtained to test drug effects. Secondly, we developed a percutaneous dye-loading protocol in vivo to perform high-resolution ratiometric optical mapping of VF dynamics (motion minimal) using a high-speed camera system positioned above the epicardial surface of the exposed heart (n = 11). During pacing (motion substantial) we recorded ratiometric optical signals and activation via a 2D fibre array in contact with the epicardial surface (n = 7). Optical APs in vivo under general anaesthesia showed significantly faster CV [120 (63–138) cm/s vs. 51 (41–64) cm/s; P = 0.032] and a statistical trend to longer APD₉₀ [242 (217–254) ms vs. 192 (182–233) ms; P = 0.095] compared with ex vivo measurements in the contracting heart. The average rate of signal-to-noise ratio (SNR) decay of di-4-ANEQ(F)PTEA in vivo was 0.0671 ± 0.0090 min⁻¹. However, reloading with di-4-ANEQ(F)PTEA fully recovered the initial SNR. Finally, toxicity studies (n = 12) showed that coronary dye injection did not generate systemic nor cardiac damage, although di-4-ANBDQBS injection induced transient hypotension, which was not observed with di-4-ANEQ(F)PTEA.

Conclusions

In vivo optical mapping using voltage ratiometry of near-infrared dyes enables high-resolution cardiac electrophysiology in translational pig models.

Optical mapping of the pig heart in situ under artificial blood circulation

The emergence of optical imaging has revolutionized the investigation of cardiac electrical activity and associated disorders in various cardiac pathologies. The electrical signals of the heart and the propagation pathways are crucial for elucidating the mechanisms of various cardiac pathological conditions, including arrhythmia. The synthesis of near-infrared voltage-sensitive dyes and the voltage sensitivity of the FDA-approved dye Cardiogreen have increased the importance of optical mapping (OM) as a prospective tool in clinical practice. We aimed to develop a method for the high-spatiotemporal-resolution OM of the large animal hearts in situ using di-4-ANBDQBS and Cardiogreen under patho/physiological conditions. OM was adapted to monitor cardiac electrical behaviour in an open-chest pig heart model with physiological or artificial blood circulation. We detail the methods and display the OM data obtained using di-4-ANBDQBS and Cardiogreen. Activation time, action potential duration, repolarization time and conduction velocity maps were constructed. The technique was applied to track cardiac electrical activity during regional ischaemia and arrhythmia. Our study is the first to apply high-spatiotemporal-resolution OM in the pig heart in situ to record cardiac electrical activity qualitatively under artificial blood perfusion. The use of an FDA-approved voltage-sensitive dye and artificial blood perfusion in a swine model, which is generally accepted as a valuable pre-clinical model, demonstrates the promise of OM for clinical application.

Translational Models of Arrhythmia Mechanisms and Susceptibility: Success and Challenges of Modeling Human Disease

We discuss large animal translational models of arrhythmia susceptibility and sudden cardiac death, focusing on important considerations when interpreting the data derived before applying them to human trials. The utility of large animal models of arrhythmia and the pros and cons of specific translational large animals used will be discussed, including the necessary tradeoffs between models designed to derive mechanisms vs. those to test therapies. Recent technical advancements which can be applied to large animal models of arrhythmias to better elucidate mechanistic insights will be introduced. Finally, some specific examples of past successes and challenges in translating the results of large animal models of arrhythmias to clinical trials and practice will be examined, and common themes regarding the success and failure of translating studies to therapy in man will be discussed.

Optical Mapping

Optical mapping of electrical activity in the heart is based on voltage-sensitive and lipophilic fluorescence dyes. Optical signals recorded from cardiac cells correlate well with their transmembrane potentials. High spatiotemporal resolution, wide field mapping, and high sensitivity to transmembrane potential enable detailed characterization of action potential initiation and propagation. Optical mapping is used to study complex patterns of excitation propagation, including propagation across the sinoatrial and atrioventricular nodes and during atrial and ventricular arrhythmias.Optical mapping is used to study the role of reentrant activity in atrial and ventricular fibrillation.

Validation and Trustworthiness of Multiscale Models of Cardiac Electrophysiology

Computational models of cardiac electrophysiology have a long history in basic science applications and device design and evaluation, but have significant potential for clinical applications in all areas of cardiovascular medicine, including functional imaging and mapping, drug safety evaluation, disease diagnosis, patient selection, and therapy optimisation or personalisation. For all stakeholders to be confident in model-based clinical decisions, cardiac electrophysiological (CEP) models must be demonstrated to be trustworthy and reliable. Credibility, that is, the belief in the predictive capability, of a computational model is primarily established by performing validation, in which model predictions are compared to experimental or clinical data. However, there are numerous challenges to performing validation for highly complex multi-scale physiological models such as CEP models. As a result, credibility of CEP model predictions is usually founded upon a wide range of distinct factors, including various types of validation results, underlying theory, evidence supporting model assumptions, evidence from model calibration, all at a variety of scales from ion channel to cell to organ. Consequently, it is often unclear, or a matter for debate, the extent to which a CEP model can be trusted for a given application. The aim of this article is to clarify potential rationale for the trustworthiness of CEP models by reviewing evidence that has been (or could be) presented to support their credibility. We specifically address the complexity and multi-scale nature of CEP models which makes traditional model evaluation difficult. In addition, we make explicit some of the credibility justification that we believe is implicitly embedded in the CEP modeling literature. Overall, we provide a fresh perspective to CEP model credibility, and build a depiction and categorisation of the wide-ranging body of credibility evidence for CEP models. This paper also represents a step toward the extension of model evaluation methodologies that are currently being developed by the medical device community, to physiological models.

Atrial fibrillation therapy now and in the future: drugs, biologicals, and ablation

Atrial fibrillation (AF) is a complex disease with multiple inter-relating causes culminating in rapid, seemingly disorganized atrial activation. Therapy targeting AF is rapidly changing and improving. The purpose of this review is to summarize current state-of-the-art diagnostic and therapeutic modalities for treatment of AF. The review focuses on reviewing treatment as it relates to the pathophysiological basis of disease and reviews preclinical and clinical evidence for potential new diagnostic and therapeutic modalities, including imaging, biomarkers, pharmacological therapy, and ablative strategies for AF. Current ablation and drug therapy approaches to treating AF are largely based on treating the arrhythmia once the substrate occurs and is more effective in paroxysmal AF rather than persistent or permanent AF. However, there is much research aimed at prevention strategies, targeting AF substrate, so-called upstream therapy. Improved diagnostics, using imaging, genetics, and biomarkers, are needed to better identify subtypes of AF based on underlying substrate/mechanism to allow more directed therapeutic approaches. In addition, novel antiarrhythmics with more atrial specific effects may reduce limiting proarrhythmic side effects. Advances in ablation therapy are aimed at improving technology to reduce procedure time and in mechanism-targeted approaches.

In situ optical mapping of voltage and calcium in the heart

Electroanatomic mapping the interrelation of intracardiac electrical activation with anatomic locations has become an important tool for clinical assessment of complex arrhythmias. Optical mapping of cardiac electrophysiology combines high spatiotemporal resolution of anatomy and physiological function with fast and simultaneous data acquisition. If applied to the clinical setting, this could improve both diagnostic potential and therapeutic efficacy of clinical arrhythmia interventions. The aim of this study was to explore this utility in vivo using a rat model. To this aim, we present a single-camera imaging and multiple light-emitting-diode illumination system that reduces economic and technical implementation hurdles to cardiac optical mapping. Combined with a red-shifted calcium dye and a new near-infrared voltage-sensitive dye, both suitable for use in blood-perfused tissue, we demonstrate the feasibility of in vivo multi-parametric imaging of the mammalian heart. Our approach combines recording of electrophysiologically-relevant parameters with observation of structural substrates and is adaptable, in principle, to trans-catheter percutaneous approaches.

Construction and validation of anisotropic and orthotropic ventricular geometries for quantitative predictive cardiac electrophysiology

Reaction-diffusion computational models of cardiac electrophysiology require both dynamic excitation models that reconstruct the action potentials of myocytes as well as datasets of cardiac geometry and architecture that provide the electrical diffusion tensor D, which determines how excitation spreads through the tissue. We illustrate an experimental pipeline we have developed in our laboratories for constructing and validating such datasets. The tensor D changes with location in the myocardium, and is determined by tissue architecture. Diffusion tensor magnetic resonance imaging (DT-MRI) provides three eigenvectors e(i) and eigenvalues λ(i) at each voxel throughout the tissue that can be used to reconstruct this architecture. The primary eigenvector e(1) is a histologically validated measure of myocyte orientation (responsible for anisotropic propagation). The secondary and tertiary eigenvectors (e(2) and e(3)) specify the directions of any orthotropic structure if λ(2) is significantly greater than λ(3)-this orthotropy has been identified with sheets or cleavage planes. For simulations, the components of D are scaled in the fibre and cross-fibre directions for anisotropic simulations (or fibre, sheet and sheet normal directions for orthotropic tissues) so that simulated conduction velocities match values from optical imaging or plunge electrode experiments. The simulated pattern of propagation of action potentials in the models is partially validated by optical recordings of spatio-temporal activity on the surfaces of hearts. We also describe several techniques that enhance components of the pipeline, or that allow the pipeline to be applied to different areas of research: Q ball imaging provides evidence for multi-modal orientation distributions within a fraction of voxels, infarcts can be identified by changes in the anisotropic structure-irregularity in myocyte orientation and a decrease in fractional anisotropy, clinical imaging provides human ventricular geometry and can identify ischaemic and infarcted regions, and simulations in human geometries examine the roles of anisotropic and orthotropic architecture in the initiation of arrhythmias.

Termination of equine atrial fibrillation by quinidine: an optical mapping study

OBJECTIVE

To perform the first optical mapping studies of equine atrium to assess the spatiotemporal dynamics of atrial fibrillation (AF) and of its termination by quinidine.

ANIMALS

Intact, perfused atrial preparations obtained from four horses with normal cardiovascular examinations.

MATERIALS AND METHODS

AF was induced by a rapid pacing protocol with or without acetylcholine perfusion, and optical mapping was used to determine spatial dominant frequency distributions, electrical activity maps, and single-pixel optical signals. Following induction of AF, quinidine gluconate was perfused into the preparation and these parameters were monitored during quinidine-induced termination of AF.

RESULTS

Equine AF develops in the context of spatial gradients in action potential duration (APD) and diastolic interval (DI) that produce alternans, conduction block, and Wenckebach conduction in different regions at fast pacing rates. Quinidine terminates AF and prevents subsequent reinduction by reducing the maximal frequency and increasing frequency homogeneity.

CONCLUSIONS

Heterogeneity of APD and DI promote alternans and conduction block at fast pacing rates in the equine atrium, predisposing to the development of AF. Quinidine terminates AF by reducing maximum frequency and increasing frequency homogeneity. Our results are consistent with the hypothesis that quinidine increases effective refractory period, thereby decreasing frequency.

Multiplicative optical tomography of cardiac electrical activity

Cardiac electrical activity can be mapped today through the response of voltage-sensitive dyes; but poor transparency of muscle tissue has enforced shallow-depth imaging. We present a three-dimensional (3D) reconstruction method for electrical activity deep inside the myocardial wall. Our approach is nonlinear and differs substantially from standard diffusive optical tomography. It does not require matrix inversion, data regularization or a priori information concerning the original object. Opposite sides of a slab-shaped preparation are scanned in parallel by detection and illumination points with a constant vector offset between illumination and detection axes (biaxial scanning). Scanning is performed in two perpendicular directions. In each direction, a pair of 2D images is obtained under offsets of opposite signs. These two pairs are the input for a multiplicative reconstruction algorithm, whose output is a 3D image. The overall procedure was successfully tested on computer-generated sources that include points, lines and hemispheres, patterned after actual electrophysiological excitations. The algorithm is computationally efficient and stable with respect to varying noise levels in the raw data.

Method for the three-dimensional localization of intramyocardial excitation centers using optical imaging

This study explores the possibility of localizing the excitation centers of electrical waves inside the heart wall using voltage-sensitive dyes (fluorescent or absorptive). In the present study, we propose a method for the 3-D localization of excitation centers from pairs of 2-D images obtained in two modes of observation: reflection and transillumination. Such images can be obtained using high-speed charge-coupled device (CCD) cameras and photodiode arrays with time resolution up to 0.5 ms. To test the method, we simulate optical signals produced by point sources and propagating ellipsoidal waves in 1-cm-thick slabs of myocardial tissue. Solutions of the optical diffusion equation are constructed by employing the method of images with Robin boundary conditions. The coordinates of point sources as well as of the centers of expanding waves can be accurately determined using the proposed algorithm. The method can be extended to depth estimations of the outer boundaries of the expanding wave. The depth estimates are based on ratios of spatially integrated images. The method shows high tolerance to noise and can give accurate results even at relatively low signal-to-noise ratios. In conclusion, we propose a novel and efficient algorithm for the localization of excitation centers in 3-D cardiac tissue.

Multichannel data acquisition system for mapping the electrical activity of the heart

BACKGROUND

Details of the electrical conduction pattern of the heart are revealed to the electrophysiologist when multichannel data are used for activation mapping. Commercial electronic systems are available for simultaneous acquisition of many surface electrograms; however, the cost of these systems may be prohibitive and they can be mostly inflexible for adaptation to other research projects. Furthermore, the hardware and software design is often proprietary. In this article we describe the in-house design and implementation of a 320-multichannel acquisition system for animal electrophysiologic research.

METHOD AND RESULTS

Several modules comprise this system. The multichannel data are first preprocessed by amplification, filtering, and analog multiplexing. An algorithm for automatic adjustment of signal gains is implemented to maximize the voltage resolution and minimize noise pickup. Signals are then digitized, and sequenced to order the multichannel data and to add markers required for analysis. The digital data are streamed to archival storage media. Additionally, the electrocardiogram (ECG), blood pressure, and stimulus channel signals are stored simultaneously. Selected signals are then displayed in real-time for measurement and analysis and as a check of the system integrity. Examples of multielectrode arrays and surface recordings are provided. Costs for building such a system are estimated.

CONCLUSIONS

Multichannel data acquisition systems that are designed and constructed in-house have several advantages over turnkey commercial systems, including the potential for considerable cost savings, flexibility in acquiring data, and the ability to subsequently add additional components.

Simulation of voltage-sensitive optical signals in three-dimensional slabs of cardiac tissue: application to transillumination and coaxial imaging methods

Voltage-sensitive dyes are an important tool in visualizing electrical activity in cardiac tissue. Until today, they have mainly been applied in cardiac electrophysiology to subsurface imaging. In the present study, we assess different imaging methods used in optical tomography with respect to their effectiveness in visualizing 3D cardiac activity. To achieve this goal, we simulate optical signals produced by excitation fronts initiated at different depths inside the myocardial wall and compare their properties for various imaging modes. Specifically, we consider scanning and broad-field illumination, including trans- and epi-illumination. We focus on the lateral optical resolution and signal intensity, as a function of the source depth. Optical diffusion theory is applied to derive a computationally efficient approximation of the point-spread function and to predict voltage-sensitive signals. Computations were performed both for fluorescent and absorptive voltage-sensitive dyes. Among all the above-mentioned methods, fluorescent coaxial scanning yields the best resolution (<2.5 mm) and gives the most information about the intramural cardiac activity.

Characteristics of a charged-coupled-device-based optical mapping system for the study of cardiac arrhythmias

We develop an optical fluorescent mapping system that is able to record the action potential wavefront propagation within cardiac tissue samples with high spatial and temporal resolutions. The system's main component, the fluorescence acquisition device (customized CCD camera), offers a high spatial resolution of 128 x 128 pixels, with 12-bit digitization and a frame rate of 490 frames/s. The system is designed and implemented to image an area of approximately 20 x 20 mm at its minimum object distance of 140 mm, corresponding to a spatial resolution of approximately 3 line pairs/mm. Experiments using this system with di-4-ANEPPS-stained canine cardiac tissues with stimulated action potentials through external electrodes result in successful mappings of the distribution and propagation of the action potential wavefronts, showing the system's sensitivity to the change in fluorescence intensity in regions of action potentials. These data demonstrate this optical mapping system as a powerful device in the study of cardiac arrhythmia mechanisms.

Synthesis of voltage-sensitive fluorescence signals from three-dimensional myocardial activation patterns

Voltage-sensitive fluorescent dyes are commonly used to measure cardiac electrical activity. Recent studies indicate, however, that optical action potentials (OAPs) recorded from the myocardial surface originate from a widely distributed volume beneath the surface and may contain useful information regarding intramural activation. The first step toward obtaining this information is to predict OAPs from known patterns of three-dimensional (3-D) electrical activity. To achieve this goal, we developed a two-stage model in which the output of a 3-D ionic model of electrical excitation serves as the input to an optical model of light scattering and absorption inside heart tissue. The two-stage model permits unique optical signatures to be obtained for given 3-D patterns of electrical activity for direct comparison with experimental data, thus yielding information about intramural electrical activity. To illustrate applications of the model, we simulated surface fluorescence signals produced by 3-D electrical activity during epicardial and endocardial pacing. We discovered that OAP upstroke morphology was highly sensitive to the transmural component of wave front velocity and could be used to predict wave front orientation with respect to the surface. These findings demonstrate the potential of the model for obtaining useful 3-D information about intramural propagation.

Optical mapping approaches to cardiac electrophysiological functions

Recently, optical methods for monitoring membrane potential with fast voltage-sensitive dyes have been introduced as a powerful tool for studying cardiac electrical functions. These methods offer two principal advantages over more conventional electrophysiological techniques. One is that optical recordings may be made from very small cells that are inaccessible to microelectrode impalement, and the other is that multiple sites/regions of a preparation can be monitored simultaneously to provide spatially resolved mapping of electrical activity. The former has made it possible to record spontaneous electrical activities in early embryonic precontractile hearts, and the latter has been applied for mapping of the propagation patterns of electrical activities in the cardiac tissue. In this article, optical studies of the electrophysiological function of the vertebrate heart are reviewed.

Visualizing excitation waves inside cardiac muscle using transillumination

Voltage-sensitive fluorescent dyes have become powerful tools for the visualization of excitation propagation in the heart. However, until recently they were used exclusively for surface recordings. Here we demonstrate the possibility of visualizing the electrical activity from inside cardiac muscle via fluorescence measurements in the transillumination mode (in which the light source and photodetector are on opposite sides of the preparation). This mode enables the detection of light escaping from layers deep within the tissue. Experiments were conducted in perfused (8 mm thick) slabs of sheep right ventricular wall stained with the voltage-sensitive dye di-4-ANEPPS. Although the amplitude and signal-to-noise ratio recorded in the transillumination mode were significantly smaller than those recorded in the epi-illumination mode, they were sufficient to reliably determine the activation sequence. Penetration depths (spatial decay constants) derived from measurements of light attenuation in cardiac muscle were 0.8 mm for excitation (520 +/- 30 nm) and 1.3 mm for emission wavelengths (640 +/- 50 nm). Estimates of emitted fluorescence based on these attenuation values in 8-mm-thick tissue suggest that 90% of the transillumination signal originates from a 4-mm-thick layer near the illuminated surface. A 69% fraction of the recorded signal originates from > or =1 mm below the surface. Transillumination recordings may be combined with endocardial and epicardial surface recordings to obtain information about three-dimensional propagation in the thickness of the myocardial wall. We show an example in which transillumination reveals an intramural reentry, undetectable in surface recordings.

Contact fluorescence imaging of reentry in monolayers of cultured neonatal rat ventricular myocytes

INTRODUCTION

We present a novel contact fluorescence imaging (CFI) approach to monitor transmembrane potentials in monolayers of cultured neonatal rat ventricular cells. We apply CFI to demonstrate, for the first time, long-term recordings as well as electrical induction and termination of reentrant activity in this in vitro model.

METHODS AND RESULTS

CFI was performed in confluent cell monolayers stained with di-8-ANEPPS. An anatomic obstacle (6 x 0.5 mm) was created in the center of the monolayers. Reentry was induced with a premature stimulus after pacing at 2 Hz (both via field stimulation). Seven sustained (>3 min) reentrant episodes, anchored to the anatomic obstacle, were observed in three monolayers. Field stimulation (30 V/cm) was applied to successfully terminate 6 of the 7 reentries. Analysis of reentrant activity showed similarities with anatomic reentry in tissue preparations, such as reduced conduction velocity around the core, variable conduction velocity along the reentrant pathway due to wavefront curvature effects, and field-induced activation at the obstacle borders leading to reentry termination (cardioversion).

CONCLUSION

This study demonstrates the feasibility of CFI for macroscopic optical mapping of transmembrane potentials in a single layer of cultured cells. Our results suggest that the monolayer cell culture model is an attractive complement to tissue models of reentry and cardioversion.

Progressive depolarization: a unified hypothesis for defibrillation and fibrillation induction by shocks

Experimental studies of defibrillation have burgeoned since the introduction of the upper limit of vulnerability (ULV) hypothesis for defibrillation. Much of this progress is due to the valuable work carried out in pursuit of this hypothesis. The ULV hypothesis presented a unified electrophysiologic scheme for linking the processes of defibrillation and shock-induced fibrillation. In addition to its scientific ramifications, this work also raised the possibility of simpler and safer means for clinical defibrillation threshold testing. Recent results from an optical mapping study of defibrillation suggest, however, that the experimental data supporting the ULV hypothesis could instead be interpreted in a manner consistent with traditional views of defibrillation such as the critical mass hypothesis. This review will describe the evidence calling for such a reinterpretation. In one regard the ULV hypothesis superseded the critical mass hypothesis by linking the defibrillation and shock-induced fibrillation processes. Therefore, this review also will discuss the rationale for developing a new defibrillation hypothesis. This new hypothesis, progressive depolarization, uses traditional defibrillation concepts to cover the same ground as the ULV hypothesis in mechanistically unifying defibrillation and shock-induced fibrillation. It does so in a manner consistent with experimental data supporting the ULV hypothesis but which also takes advantage of what has been learned from optical studies of defibrillation. This review will briefly describe how this new hypothesis relates to other contemporary viewpoints and related experimental results.