Effects of 2,3-butanedione monoxime on atrial-atrioventricular nodal conduction in isolated rabbit heart

Mapping Biological Current Densities With Ultrafast Acoustoelectric Imaging: Application to the Beating Rat Heart

Ultrafast acoustoelectric imaging (UAI) is a novel method for the mapping of biological current densities, which may improve the diagnosis and monitoring of cardiac activation diseases such as arrhythmias. This paper evaluates the feasibility of performing UAI in beating rat hearts. A previously described system based on a 256-channel ultrasound research platform fitted with a 5-MHz linear array was used for simultaneous UAI, ultrafast B-mode, and electrocardiogram (ECG) recordings. In this paper, rat hearts (n = 4) were retroperfused within a Langendorff isolated heart system. A pair of Ag/Cl electrodes were positioned on the epicardium to simultaneously record ECG and UAI signals for imaging frame rates of up to 1000 Hz and a mechanical index of 1.3. To account for the potential effect of motion on the UAI maps, acquisitions for n = 3 hearts were performed with and without suppression of the mechanical contraction using 2,3-butanedione monoxime. Current densities were detected for all four rats in the region of the atrio-ventricular node, with an average contrast-to-noise ratios of 12. The UAI signals' frequency matched the sinus rhythm, even without mechanical contraction, suggesting that the signals measured correspond to physiological electrical activation. UAI signals appeared at the apex and within the ventricular walls with a delay estimated at 29 ms. Finally, the signals from different electrode positions along the myocardium wall showed the possibility of mapping the electrical activation throughout the heart. These results show the potential of UAI for cardiac activation mapping in vivo and in real time.

Inhibition of sarcoplasmic reticulum Ca(2+)-ATPase decreases atrioventricular node-paced heart rate in rabbits

Recent data indicate that Ca(2+) cycling in isolated atrioventricular node (AVN) cells contributes to setting spontaneous rate. The aim of the present study was to extend this observation to the intact AVN in situ, by evaluating the effects of inhibiting sarcoplasmic reticulum Ca(2+) uptake with cyclopiazonic acid (CPA) on intact AVN spontaneous activity and its response to isoprenaline. A model of the AVN-paced heart was produced to investigate intact AVN automaticity, by surgical ablation of the sino-atrial node (SAN) in the rabbit Langendorff-perfused heart. Electrograms were recorded from a site close to the AVN (triangle of Koch), an atrial site above the AVN, the left atrium and right ventricle, enabling AVN pacing of the preparation to be confirmed. Before SAN ablation, the heart rate was 166.8 ± 5.4 beats min(-1). Ablation of the SAN was clearly indicated by a sudden and significant decrease of heart rate to 108.6 ± 9.6 beats min(-1) (P < 0.01, n = 10). Isoprenaline (100 nm) increased AVN rate to 187.8 ± 12.0 beats min(-1) after 1 min of application (P < 0.01, n = 10). Cyclopiazonic acid (10 and 30 μm) decreased AVN rate to 81.6 ± 4.8 (n = 9) and 77.4 ± 6.0 beats min(-1) (n = 7), respectively [P < 0.05, 10 or 30 μm CPA versus control (n = 10)] and also reduced the AVN rate increase in response to isoprenaline from 78.8 ± 10.0 to 46.8 ± 6.8 and 26.7 ± 5.3%, respectively (P < 0.01). These inhibitory effects of CPA on the intact AVN rate and its response to isoprenaline indicate that Ca(2+) cycling is important to the intact AVN spontaneous activity and its acceleration during sympathetic stimulation.

In vitro electrophysiological mapping of stem cells

The use of stem cells for cardiac regeneration is a revolutionary, emerging research area. For proper function as replacement tissue, stem cell-derived cardiomyocytes (SC-CMs) must electrically couple with the host cardiac tissue. Electrophysiological mapping techniques, including microelectrode array (MEA) and optical mapping, have been developed to study cardiomyocytes and cardiac cell monolayers, and these can be applied to study stem cells and SC-CMs. MEA recordings take extracellular measurements at numerous points across a small area of cell cultures and are used to assess electrical propagation during cell culture. Optical mapping uses fluorescent dyes to monitor electrophysiological changes in cells, most commonly transmembrane potential and intracellular calcium, and can be easily scaled to areas of different sizes. The materials and methods for MEA and optical mapping are presented here, together with detailed notes on their use, design, and fabrication. We also provide examples of voltage and calcium maps of mouse embryonic stem cell-derived cardiomyocytes (mESC-CMs), obtained in our laboratory using optical mapping techniques.

Autonomic control and innervation of the atrioventricular junctional pacemaker

BACKGROUND

The main physiologic function of the AV junction is control of timing between atrial and ventricular excitation. However, under pathologic conditions, the AV junction may become the pacemaker of the heart. Unlike the well-characterized sinoatrial node (SAN), autonomic control of the AV junctional pacemaker has not been studied.

OBJECTIVE

The purpose of this study was to characterize the autonomic control and innervation of the AV junctional pacemaker.

METHODS

The response of rabbit AV junctional pacemaker to autonomic stimulation was investigated using optical mapping, autonomic modulation via subthreshold stimulation (n = 12), and quantitative immunohistochemistry (n = 5), and the density of parasympathetic and sympathetic innervation in optically mapped preparations was quantified.

RESULTS

Subthreshold stimulation applied adjacent to the conduction system in the triangle of Koch autonomically modulates the junctional rate, and parasympathetic and sympathetic components can be separated with atropine and the beta-blocker nadolol. Subthreshold stimulation increased the rate maximally to 2.1 +/- 0.4 times when applied with atropine. Unlike the SAN pacemaker, which shifts significantly in response to autonomic stimulation, the AV junctional pacemaker remains stationary (most often in the inferior nodal extension), moving in only 5% of subthreshold stimulation trials. Staining with tyrosine hydroxylase and choline acetyltransferase revealed heterogeneous innervation within the AV junction.

CONCLUSION

AV junctional rhythm can be autonomically modulated with subthreshold stimulation to produce junctional rates of 145 +/- 16 bpm (cycle length 412 +/- 29 ms), similar to sinus rates in rabbit. Unlike the SAN, the anatomic location of the AV junctional pacemaker is stable during autonomic modulation.

Atrioventricular conduction with and without AV nodal delay: two pathways to the bundle of His in the rabbit heart

The electrophysiological properties of atrioventricular (AV) nodal dual pathways have traditionally been investigated with premature stimuli delivered with right atrial pacing. However, little is known about the functional characteristics of AV nodal inputs outside of this context. Superfused rabbit triangle of Koch preparations (n = 8) and Langendorff-perfused hearts (n = 10) were paced throughout the triangle of Koch and mapped electrically and optically for activation pattern, electrogram and optical action potential morphologies, stimulation thresholds, and stimulus-His (S-H) intervals. Optical mapping and changes in His electrogram morphology were used to confirm the activation pathway. Pacing stimuli >or=2 mm above the tricuspid valve caused fast-pathway activation of the AV node and His with a threshold of 2.4 +/- 1.6 mA. An area directly below the coronary sinus had high thresholds (8.6 +/- 1.4 mA) that also resulted in fast-pathway excitation (P < 0.001). S-H intervals (81 +/- 19 ms) for fast-pathway activation remained constant throughout the triangle of Koch, reflecting the AV delay. Stimuli applied <2 mm from the tricuspid valve resulted in slow pathway (SP) excitation or direct His excitation (4.4 +/- 2.2 mA threshold; P < 0.001 compared with fast pathway). For SP/His pacing, S-H intervals showed a strong dependence on the distance from the His electrode and were significantly lower than S-H intervals for fast-pathway activation. SP/His pacing also displayed characteristic changes in His electrogram morphology. In conclusion, optical maps and S-H intervals for SP/His activation suggest that AV conduction via SP bypasses the compact AV node via the lower nodal bundle, which may be utilized to achieve long-term ventricular synchronization.

A fiber-based ratiometric optical cardiac mapping channel using a diffraction grating and split detector

Optical fiber-based mapping systems are used to record the cardiac action potential (AP) throughout the myocardium. The optical AP contains a contraction-induced motion artifact (MA), which makes it difficult to accurately measure the action potential duration (APD). MA is removed by preventing contraction with electrical-mechanical uncoupling drugs, such as 2,3-butanedione monoxime (BDM). We designed a novel fiber-based ratiometric optical channel using a blue light emitting diode, a diffraction grating, and a split photodetector that can accurately measure the cardiac AP without the need for BDM. The channel was designed based on simulations using the optical design software ZEMAX. The channel has an electrical bandwidth of 150 Hz and an root mean-square dark noise of 742 muV. The channel successfully recorded the cardiac AP from the wall of five rabbit heart preparations without the use of BDM. After 20-point median filtering, the mean signal/noise ratio was 25.3 V/V. The APD measured from the base of a rabbit heart was 134 +/- 8.4 ms, compared to 137.6 +/- 3.3 ms from simultaneous microelectrode recordings. This difference was not statistically significant (p-value = 0.3). The quantity of MA removed was also measured using the motion ratio. The reduction in MA was significant (p-value = 0.0001). This fiber-based system is the first of its kind to enable optical APD measurements in the beating heart wall without the use of BDM.

Application of blebbistatin as an excitation-contraction uncoupler for electrophysiologic study of rat and rabbit hearts

BACKGROUND

Application of fluorescence imaging of cardiac electrical activity is limited by motion artifacts and/or side effects of currently available pharmacologic excitation-contraction uncoupling agents.

OBJECTIVES

The purpose of this study was to test whether blebbistatin, a recently discovered inhibitor of myosin II isoforms, can be used as an excitation-contraction uncoupler.

METHODS

The specificity and potency of blebbistatin were examined by assaying the effects of blebbistatin on the contraction and basic cardiac electrophysiologic parameters of Langendorff-perfused rabbit hearts, isolated rabbit right ventricle and right atrium, and single rat ventricular myocytes using conventional ECG, surface electrograms, microelectrode recordings, and optical imaging with voltage-sensitive and Ca(2+)-sensitive dyes. Action potential morphology, ECG parameters, cardiac conduction, and refractoriness were determined after perfusion with 0.1-10 microM blebbistatin.

RESULTS

Blebbistatin 5-10 microM completely eliminated contraction in all cardiac preparations but did not have any effect on electrical activity, including ECG parameters, atrial and ventricular effective refractory periods, and atrial and ventricular activation patterns. Blebbistatin 10 microM had no effects on action potential morphology in rabbit cardiac tissue. Blebbistatin inhibited single cellular contraction in a dose-dependent manner with half-maximal inhibitory concentration (IC(50)) = 0.43 microM, without altering the morphologies of intracellular calcium transients. The blebbistatin effect was completely reversible by simultaneous washout and photobleaching by ultraviolet light

CONCLUSION

Blebbistatin is a promising novel selective excitation-contraction uncoupler that can be used for optical imaging of cardiac tissues.

Cardiac conduction through engineered tissue

In children, interruption of cardiac atrioventricular (AV) electrical conduction can result from congenital defects, surgical interventions, and maternal autoimmune diseases during pregnancy. Complete AV conduction block is typically treated by implanting an electronic pacemaker device, although long-term pacing therapy in pediatric patients has significant complications. As a first step toward developing a substitute treatment, we implanted engineered tissue constructs in rat hearts to create an alternative AV conduction pathway. We found that skeletal muscle-derived cells in the constructs exhibited sustained electrical coupling through persistent expression and function of gap junction proteins. Using fluorescence in situ hybridization and polymerase chain reaction analyses, myogenic cells in the constructs were shown to survive in the AV groove of implanted hearts for the duration of the animal's natural life. Perfusion of hearts with fluorescently labeled lec-tin demonstrated that implanted tissues became vascularized and immunostaining verified the presence of proteins important in electromechanical integration of myogenic cells with surrounding re-cipient rat cardiomyocytes. Finally, using optical mapping and electrophysiological analyses, we provide evidence of permanent AV conduction through the implant in one-third of recipient animals. Our experiments provide a proof-of-principle that engineered tissue constructs can function as an electrical conduit and, ultimately, may offer a substitute treatment to conventional pacing therapy.

Possible involvement of ATP-purinoceptor signalling in the intercellular synchronization of intracellular Ca2+ oscillation in cultured cardiac myocytes

Isolated and cultured neonatal cardiac myocytes contract spontaneously and cyclically. The contraction rhythms of two isolated cardiac myocytes, each of which beats at different frequencies at first, become synchronized after the establishment of mutual contacts, suggesting that mutual entrainment occurs due to electrical and/or mechanical interactions between two myocytes. The intracellular concentration of free Ca(2+) also changes rhythmically in association with the rhythmic contraction of myocytes (Ca(2+) oscillation), and such a Ca(2+) oscillation was also synchronized among cultured cardiac myocytes. In this study, we investigated whether intercellular communication other than via gap junctions was involved in the intercellular synchronization of intracellular Ca(2+) oscillation in spontaneously beating cultured cardiac myocytes. Treatment with either blockers of gap junction channels or an un-coupler of E-C coupling did not affect the intercellular synchronization of Ca(2+) oscillation. In contrast, treatment with a blocker of P2 purinoceptors resulted in the asynchronization of Ca(2+) oscillatory rhythms among cardiac myocytes. The present study suggested that the extracellular ATP-purinoceptor system was responsible for the intercellular synchronization of Ca(2+) oscillation among cardiac myocytes.

Postganglionic nerve stimulation induces temporal inhibition of excitability in rabbit sinoatrial node

Vagal stimulation results in complex changes of pacemaker excitability in the sinoatrial node (SAN). To investigate the vagal effects in the rabbit SAN, we used optical mapping, which is the only technology that allows resolving simultaneous changes in the activation pattern and action potentials morphologies. With the use of immunolabeling, we identified the SAN as a neurofilament 160-positive but connexin 43-negative region ( n = 5). Normal excitation originated in the SAN center with a cycle length (CL) of 405 ± 14 ms ( n = 14), spread anisotropically along the crista terminalis (CT), and failed to conduct toward the septum. Postganglionic nerve stimulation (PNS, 400–800 ms) reduced CL by 74 ± 7% transiently and shifted the leading pacemaker inferiorly (78%) or superiorly (22%) from the SAN center by 2–10 mm. In the intercaval region between the SAN center and the septal block zone, PNS produced an 8 ± 1-mm2 region of transient hyperpolarization and inexcitability. The first spontaneous or paced excitation following PNS could not enter this region for 500–1,500 ms. Immunolabeling revealed that the PNS-induced inexcitable region is located between the SAN center and the block zone and has a 2.5-fold higher density of choline acetyltransferase than CT but is threefold lower than the SAN center. The fact that the inexcitability region does not coincide with the most innervated area indicates that the properties of the myocytes themselves, as well as intercellular coupling, must play a role in the inexcitability induction. Optically mapping revealed that PNS resulted in transient loss of pacemaker cell excitability and unidirectional entrance conduction block in the periphery of SAN.

Rotigaptide (ZP123) improves atrial conduction slowing in chronic volume overload-induced dilated atria

Chronic atrial dilation is associated with atrial conduction velocity slowing and an increased risk of developing atrial tachyarrhythmias. Rotigaptide (ZP123) is a selective gap junction modifier that increases cardiac gap junctional intercellular communication. We hypothesised that rotigaptide treatment would increase atrial conduction velocity and reduce the inducibility to atrial tachyarrhythmias in a model of chronic volume overload induced chronic atrial dilatation characterized by atrial conduction velocity slowing. Chronic volume overload was created in Japanese white rabbits by arterio-venous shunt formation. Atrial conduction velocity and atrial tachyarrhythmias inducibility were examined in Langendorff-perfused chronic volume overload hearts (n=12) using high-resolution optical mapping before and after treatment with rotigaptide. Moreover, expression levels of atrial gap junction proteins (connexin40 and connexin43) were examined in chronic volume overload hearts (n=6) and compared to sham-operated controls (n=6). Rotigaptide treatment significantly increased atrial conduction velocity in chronic volume overload hearts, however, rotigaptide did not decrease susceptibility to the induction of atrial tachyarrhythmias. Protein expressions of Cx40 and Cx43 were decreased by 32% and 72% (P<0.01), respectively, in chromic volume overload atria compared to control. To conclude, rotigaptide increased atrial conduction velocity in a rabbit model of chromic volume overload induced atrial conduction velocity slowing. The demonstrated effect of rotigaptide on atrial conduction velocity did not prevent atrial tachyarrhythmias inducibility. Whether rotigaptide may possess antiarrhythmic efficacy in other models of atrial fibrillation remains to be determined.

The Gurvich waveform has lower defibrillation threshold than the rectilinear waveform and the truncated exponential waveform in the rabbit heart

Implantable cardioverter defibrillator studies have established the superiority of biphasic waveforms over monophasic waveforms. However, external defibrillator studies of biphasic waveforms are not as widespread. Our objective was to compare the defibrillation efficacy of clinically used biphasic waveforms, i.e., truncated exponential, rectilinear, and quasi-sinusoidal (Gurvich) waveforms in a fibrillating heart model. Langendorff-perfused rabbit hearts (n = 10) were stained with a voltage-sensitive fluorescent dye, Di-4-ANEPPS. Transmembrane action potentials were optically mapped from the anterior epicardium. We found that the Gurvich waveform was significantly superior (p < 0.05) to the rectilinear and truncated exponential waveforms. The defibrillation thresholds (mean +/- SE) were as follows: Gurvich, 0.25 +/- 0.01 J; rectilinear-1, 0.34 +/- 0.01 J; rectilinear-2, 0.33 +/- 0.01 J; and truncated exponential, 0.32 +/- 0.02 J. Using optically recorded transmembrane responses, we determined the shock-response transfer function, which allowed us to predict the cellular response to waveforms at high accuracy. The passive parallel resistor-capacitor model (RC-model) predicted polarization superiority of the Gurvich waveform in the myocardium with a membrane time constant (taum) of less than 2 ms. The finding of a lower defibrillation threshold with the Gurvich waveform in an in vitro model of external defibrillation suggests that the Gurvich waveform may be important for future external defibrillator designs.

Role of Calcium Cycling Versus Restitution in the Mechanism of Repolarization Alternans

T-wave alternans, a powerful marker of arrhythmic events, results from alternation in action potential duration (APD). The underlying cellular mechanism of APD alternans is unknown but has been attributed to either intracellular calcium (Ca 2+ ) cycling or membrane ionic currents, manifested by a steep slope of cellular APD restitution. To address these mechanisms, high-resolution optical mapping techniques were used to measure action potentials and Ca 2+ transients simultaneously from hundreds of epicardial sites in the guinea pig model of pacing-induced T-wave alternans (n=7). The pacing rates (ie, alternans threshold) at which T-wave (369±11 bpm), APD (369±21 bpm), and Ca 2+ (371±29 bpm) alternans first appeared were comparable. Importantly, the site of origin of APD alternans and Ca 2+ alternans consistently occurred together near the base of the left ventricle, not where APD restitution was steepest. In addition, APD and Ca 2+ alternans were remarkably similar both spatially and temporally during discordant alternans. In conclusion, the mechanism underlying T-wave alternans in the intact heart is more closely associated with intracellular Ca 2+ cycling rather than APD restitution.

The electrophysiological and mechanical effects of 2,3-butane-dione monoxime and cytochalasin-D in the Langendorff perfused rabbit heart

Procedures that reduce contraction are used to facilitate optical measurements of membrane potential, but it is unclear to what extent they affect the excitability of the heart. This study has examined the electrophysiological consequences of a range of extracellular [Ca2+] (0.7-2.5 mmol l(-1)), 2,3-butane-dione monoxime (BDM; 1-20 mmol l(-1)) and cytochalasin-D (Cyto-D; 1-5 micromol l(-1)).

METHODS

Monophasic action potentials (MAPs) were recorded from the basal epicardial surface of the left ventricle of isolated rabbit hearts. Conduction delay (CD) and time to 90% repolarisation of the monophasic action potential (MAPD90) were measured. The effects of BDM and Cyto-D on restitution were studied at a [Ca2+] of 1.9 mmol l(-1). Restitution curves for MAPD90 were generated using a standard S1-S2 protocol.

RESULTS

All manoeuvres decreased left ventricular developed pressure (LVDP): 0.7 mmol l(-1) Ca2+ to 74.0 +/- 6.1%, 20 mmol l(-1) BDM to 4.5 +/- 1.0%, and 5 micromol l(-1) Cyto-D to 12.8 +/- 3.5% of control value. CD decreased from a control value (33.3 +/- 1.0 ms, n= 16) to 93.0 +/- 2.2% in 0.7 mmol l(-1) Ca2+, but increased to 133.7 +/- 10.5% in 20 mmol l(-1) BDM and 127.4 +/- 10.6% in 5 micromol l(-1) Cyto-D. At 350 ms pacing cycle length, MAPD90 (control = 119.6 +/- 1.7 ms n= 16) was prolonged by reduced extracellular [Ca2+]. BDM had no effects on MAPD90 at control pacing rates. Cyto-D caused a significant prolongation (to 115.0 +/- 3.0% of control, n= 6) at the highest concentration studied (5 micromol l(-1)). Both BDM (20 mmol l(-1)) and Cyto-D (3 micromol l(-1)) flattened the restitution curves but neither agent altered maximum MAPD90.

CONCLUSIONS

Extracellular [Ca2+] of 1.9 mmol l(-1) in conjunction with a moderate dose of Cyto-D (3 micromol l(-1)) reduced contractility with minimal effects on action potential duration and conduction at a fixed pacing cycle length. However, both BDM and Cyto-D had pronounced effects on electrical restitution.

Site of origin and molecular substrate of atrioventricular junctional rhythm in the rabbit heart

During failure of the sinoatrial node, the heart can be driven by an atrioventricular (AV) junctional pacemaker. The position of the leading pacemaker site during AV junctional rhythm is debated. In this study, we present evidence from high-resolution fluorescent imaging of electrical activity in rabbit isolated atrioventricular node (AVN) preparations that, in the majority of cases (11 out of 14), the AV junctional rhythm originates in the region extending from the AVN toward the coronary sinus along the tricuspid valve (posterior nodal extension, PNE). Histological and immunohistochemical investigation showed that the PNE has the same morphology and unique pattern of expression of neurofilament160 (NF160) and connexins (Cx40, Cx43, and Cx45) as the AVN itself. Block of the pacemaker current, If, by 2 mmol/L Cs+ increased the AV junctional rhythm cycle length from 611+/-84 to 949+/-120 ms (mean+/-SD, n=6, P<0.001). Immunohistochemical investigation showed that the principal If channel protein, HCN4, is abundant in the PNE. As well as the AV junctional rhythm, the PNE described in this study may also be involved in the slow pathway of conduction into the AVN as well as AVN reentry, and the predominant lack of expression of Cx43 as well as the presence of Cx45 in the PNE shown could help explain its slow conduction.

Transmural heterogeneity of calcium handling in canine

Spatial heterogeneity of the action potential and its influence on arrhythmia vulnerability is known. However, heterogeneity of intracellular calcium handling and, in particular, its effect on the electrophysiological substrate is less clear. Using optical mapping techniques, calcium transients and action potentials were recorded simultaneously from ventricular sites across the transmural wall of the arterially perfused canine left ventricular wedge preparation during steady-state baseline pacing and rapid pacing. During baseline pacing, the decay of intracellular calcium to diastolic levels and calcium transient duration were slower (70%, P<0.005) and longer (20%, P<0.005), respectively, closer to the endocardial surface compared with the epicardial surface. Tissue samples isolated from the left ventricular wall demonstrate that sarcoplasmic reticulum Ca2+ ATPase (SERCA2a) expression was significantly less in the subendocardial and midmyocardial layers compared with the subepicardial layer. In contrast, no significant difference in the transmural expression of Na+-Ca2+ exchanger was observed. During rapid pacing, calcium transient alternans and increased levels of diastolic intracellular calcium were significantly greater (P<0.01) closer to the endocardium (101%+/-62% and 41%+/-15%, respectively) compared with the epicardium (12%+/-7% and 12%+/-14%, respectively). In conclusion, cells closer to the endocardium exhibit a slower decay of intracellular calcium compared with cells near the epicardium, which may be due in part to reduced expression of SERCA2a. As a possible consequence, calcium transient alternans and increased diastolic levels of intracellular calcium may occur preferentially closer to the endocardial surface.

Cx43 and dual-pathway electrophysiology of the atrioventricular node and atrioventricular nodal reentry

Fluorescent imaging has revealed that posterior nodal extensions provide the anatomical substrate for the dual-pathway electrophysiology of the atrioventricular (AV) node during normal conduction and reentry. The reentry can be intranodal, or as well as the posterior nodal extensions, it can involve an endocardial layer of atrial/atrial-nodal (A/AN) cells as part of the AV nodal reentry (AVNR) circuit. Using fluorescent imaging with a voltage-sensitive dye and immunolabeling of Cx43, we mapped the electrical activity and structural substrate in 3 types of AVNR induced by premature atrial stimulation in 8 rabbit hearts. In 6 cases, the AVNR pathway involved (1) a fast pathway (FP), (2) the A/AN layer, and (3) a slow pathway (SP). In 4 cases, reentry took the path (1) SP, (2) A/AN layer, and (3) FP. In 2 cases, reentry was intranodal, propagating between the 2 posterior nodal extensions. Immunolabeling revealed that the FP and SP are formed by Cx43-expressing bundles surrounded by tissue without Cx43. Cx43-expressing posterior nodal extensions are the substrate of AVNR during both intranodal and extranodal reentry.

Autonomic blockade unmasks maturational differences in rate-dependent atrioventricular nodal conduction and facilitation in the mouse

INTRODUCTION

In large animals, rate-dependent AV nodal (AVN) properties of conduction are modulated by autonomic inputs. In this study, we investigated whether the properties of AVN conduction and facilitation are altered by autonomic blockade in the mouse and whether this effect is age dependent.

METHODS AND RESULTS

Young (age 4-6 weeks; n = 11) and adult (age 8-9 months; n = 11) female mice underwent in vivo electrophysiologic testing, before and after autonomic blockade. After autonomic blockade, the adult mice had significantly longer AVN effective refractory period (AVNERP; 67 +/- 14 msec vs 56 +/- 4 msec, P = 0.05) and functional refractory period (AVNFRP; 81 +/- 10 msec vs 72 +/- 4 msec, P = 0.05). With autonomic blockade, the increase from baseline of AVN Wenckebach cycle length (deltaAVW; 1.8 +/- 8.1 msec vs 8.8 +/- 3.3 msec, P = 0.04), as well as of AVNERP (deltaAVNERP; 3.5 +/- 3.5 msec vs 21.4 +/- 12.6 msec, P = 0.002) and AVNFRP (deltaAVNFRP; 2.3 +/- 3.2 msec vs 12.8 +/- 9.0 msec, P = 0.008), was significantly larger in adult than in young mice. Compared with young mice, adult mice were less likely to exhibit AVN facilitation (44% vs 90%, P = 0.03) and had smaller maximal shortening of AVN conduction times after the "test beat" for any coupling of the "facilitating beat" (4 +/- 4 msec vs 7 +/- 3 msec, P = 0.05).

CONCLUSION

Complete autonomic blockade significantly increases AVN conduction times and refractory periods in adult but not in young mice. Adult mice also exhibit less AVN facilitation. Our results confirm that, like in larger animals, rate-dependent murine AVN properties of conduction are under autonomic regulation. Adult mice have higher sympathetic AVN inputs at baseline, leading to slower conduction after autonomic blockade.

Optical mapping technique applied to biventricular pacing: potential mechanisms of ventricular arrhythmias occurrence

Although it has been suggested that multisite ventricular pacing alleviates heart failure by restoring ventricular electrical synchronization, the respective roles of voltage output, interventricular delay, and pacing sites in the development of ventricular arrhythmias occurrence have not been studied during biventricular pacing or LV pacing. Voltage-sensitive dye was used in eight ischemic Langerdorff-perfused guinea pig hearts to measure ventricular activation times and examine conduction patterns during multisite pacing from three RV and four LV sites. The hearts were stained with di-4-ANEPPS and mapped with a 16 x 16 photodiode array at a resolution of 625 microns per diode. Isochronal maps of RV and LV activation were plotted. Ischemia was produced by gradually halving the perfusion output over 5 minutes. Pacing the RV apex and the base of the LV anterior wall was associated with the most homogeneous and rapid activation pattern (28 +/- 9 vs 41 +/- 12 ms with the other configurations, P < 0.01), and no inducible arrhythmia. In six hearts, ventricular tachycardia could be induced when pacing from the right and left free walls with 20 ms of interventricular delay, at six times the pacing threshold output. In four hearts, simultaneous RV and LV pacing at high voltage output induced ventricular fibrillation with complex three-dimensional propagation patterns, independently of the pacing sites. During biventricular pacing with ischemia, pacing at high voltage output with a long interventricular delay is likely to induce ventricular arrhythmias, particularly when left and right pacing results in a conduction pattern orthogonal to the ventricular myocardial fibers orientation.

Reprogramming of gene expression in cultured cardiomyocytes and in explanted hearts by the myosin ATPase inhibitor butanedione monoxime

BACKGROUND

Butanedione monoxime (BDM) is a reversible myosin ATPase inhibitor. Its use in transplantation medicine may be of benefit in the preservation of hearts. As little is known about its ability to prevent stress and metabolic deregulation, we wanted to investigate the genomic response in cultured cardiomyocytes and explanted, preserved hearts at the transcriptional level.

METHODS

We thus investigated the gene expression of the transcription factors GATA-4, Nkx2.5, MEF-2c, and Oct-1 and of the downstream target genes atrial and brain natriuretic peptide, alpha- and beta-myosin heavy chain, alpha-cardiac actin, and alpha-skeletal actin. Additionally, lactate dehydrogenase and creatine kinase enzyme activities were measured as markers for membrane integrity and metabolic deregulation of cardiomyocytes.

RESULTS

In untreated cardiomyocyte cultures, expression of GATA-4 and Nkx2.5 was increased 7- and 4-fold, 72 hr after isolation, but the gene expression of MEF-2c and Oct-1 was reduced to 10% and 70%, at day 3 in culture. We show atrial natriuretic peptide and brain natriuretic peptide gene expression to be maximal 24 and 72 hr after isolation, the level being 3- and 2-fold, when compared with freshly isolated cells. The gene expression of alpha- and beta-myosin heavy chain was reduced to approximately 30% at day 3 in culture and similar observations were made for alpha-cardiac and alpha-skeletal actin, which declined to approximately 20% and 10% of control values, 72 hr after isolation. BDM prevented at the transcriptional level enhanced expression of markers for stress and metabolic deregulation, and the activities of lactate dehydrogenase and creatine kinase were highly significantly reduced. Similar results were obtained when explanted hearts were stored in BDM-containing organ preservation solution.

CONCLUSIONS

Preservation of metabolic function in donor organs is of critical importance in transplantation medicine, and we show gene markers for stress and metabolic deregulation in cultures of cardiomyocytes and explanted hearts to be significantly reduced by BDM. Reprogramming of gene expression of nuclear transcription factors and downstream target genes may prolong the acceptable storage time between explantation and transplantation.

Fluorescent imaging of a dual-pathway atrioventricular-nodal conduction system

A dual-pathway theory to explain atrioventricular-nodal (AVN) reentry has been proposed previously. However, the exact anatomical and functional correlates of the fast pathway (FP) and slow pathway (SP) have not yet been elucidated. We used optical mapping to reconstruct patterns of activation during retrograde conduction through the AVN and during AVN reentry in the triangles of Koch of 12 rabbits. Reentry was inducible by a premature stimulation of the bundle of His in 6 preparations (50%). A functional FP and SP appear to be anatomically correlated with posterior and posterolateral extensions of the AVN, which were recently described. Retrograde breakthrough points in 6 noninducible preparations were clustered near the apex of the triangle of Koch (FP), whereas 6 inducible preparations had either cycle length-dependent FP and SP exits (n=3) or only SP exits located near the coronary sinus orifice. The shift of breakthrough points from FP to SP during progressive shortening of the coupling interval was accompanied by a discontinuity in the conduction curve. We observed a transmural reentrant circuit involving the AVN, FP, SP, and the superficial endocardial layer of atrial and transitional cells. The presence of a functional SP during retrograde conduction was associated with inducibility of AVN reentry. The full text of this article is available at http://www.circresaha.org.

Reversal of repolarization gradient does not reverse the chirality of shock-induced reentry in the rabbit heart

INTRODUCTION

Two hypotheses have been proposed to explain the mechanisms of vulnerability and related failure of defibrillation therapy: the cross-field-induced critical point hypothesis and the virtual electrode-induced phase singularity hypothesis. These two hypotheses predict the opposite effect of preshock repolarization on the chirality (direction of rotation) of shock-induced reentry. The former suggests its reversal upon reversal of repolarization, whereas the latter suggests its preservation. The aim of this study was to determine, by reversing the repolarization sequence, which of the mechanisms is responsible for internal shock-induced arrhythmia in the Langendorff-perfused rabbit heart.

METHODS AND RESULTS

We used high-resolution optical mapping to assess the chirality of postshock reentry in 11 hearts. Hearts were paced at a coupling interval of 300 msec at various sites around the field of view (13.5 x 13.5 to 16.5 x 16.5 mm). Cathodal monophasic implantable cardioverter defibrillator shocks (-100 V, 8 msec) were applied during the T wave from a 10-mm coil electrode placed into the right ventricular cavity. We used 3.5 +/- 0.8 different pacing sites per heart. Change in direction of repolarization did not result in change of chirality. Chirality was constant in all 11 hearts despite the complete reversal of activation and repolarization patterns. However, the position of resulting vortices depended on transmembrane polarization gradient inverted delta Vm and amplitude of negative polarization Vm (deexcitation). Stronger gradients and deexcitation produced earlier epicardial break excitation (P = 0.04 and P < 0.0001, respectively).

CONCLUSION

Virtual electrode-induced phase singularity mechanism underlies internal shock-induced arrhythmia in this model.

Direct evidence of the role of virtual electrode-induced phase singularity in success and failure of defibrillation

INTRODUCTION

We recently demonstrated that virtual electrode-induced phase singularity is responsible for arrhythmogenesis during T wave shocks and explains the upper and lower limits of vulnerability. Furthermore, we suggested that the same mechanism might be responsible for defibrillation failure. The aim of this study was to experimentally support this hypothesis.

METHODS AND RESULTS

We used the voltage-sensitive dye di-4-ANEPPS and fast imaging to assess electrical activity in Langendorff-perfused rabbit hearts. Ventricular arrhythmias were induced by monophasic shocks applied during T wave. Three types of defibrillation shocks (n = 79) were delivered from an intravenous right ventricular electrode: monophasic (8 msec), optimal biphasic (8/8 msec, 2/1 leading-edge voltage ratio), and nonoptimal biphasic (8/8 msec, 1/1 leading-edge voltage ratio). We found that a monophasic shock extinguished arrhythmic pattern of electrical activity via a virtual electrode polarization effect. However, the virtual electrode polarization was likely to produce phase singularities, leading to another arrhythmia and defibrillation failure. Nonoptimal biphasic shocks produced similar effects. Optimal biphasic shocks were successful because the first phase of the shock erased the arrhythmia via the virtual electrodes effect, whereas the second phase canceled the virtual electrodes, eliminating the substrate for phase singularities and arrhythmia resulting from them.

CONCLUSION

Our data provide the first experimental support of the hypothesis implicating virtual electrode-induced phase singularity in defibrillation failure in the Langendorff-perfused rabbit heart. Optimal biphasic shock has a higher defibrillation efficacy because it does not produce virtual electrode-induced phase singularities.

Regional differences in arrhythmogenic aftereffects of high intensity DC stimulation in the ventricles

Regional differences of the aftereffects of high intensity DC stimulation were investigated in isolated rabbit hearts stained with a voltage-sensitive dye (di-4-ANEPPS). Optical action potential signals were recorded from the epicardial surface of the right and left ventricular free wall (RVep, LVep) and from the right endocardial surface of the interventricular septum (IVS). Ten-millisecond monophasic DC stimulation (S2, 20-120 V) was applied to the signal recording spots during the early plateau phase of the action potential induced by basic stimuli (S1, 2.5 Hz). There was a linear relationship between S2 voltage and the S2 field intensity (FI). S2 caused postshock additional depolarization, giving rise to a prolongation of the shocked action potential. With S2 > or = 40 V (FI > or = approximately 20 V/cm), terminal repolarization of action potential was inhibited, and subsequent postshock S1 action potentials for 1-5 minutes were characterized by a decrease in the maximum diastolic potential and a decrease in the amplitude and a slowing of their upstroke phase. The higher the S2 voltage, the larger the aftereffects. The changes in postshock action potential configuration in RVep were significantly greater than those observed in LVep and IVS when compared at the same levels of S2 intensity. In RVep, 12 of 20 shocks of 120 V resulted in a prolonged refractoriness to S1 (> 1 s), and the arrest was often followed by oscillation of membrane potential. Ventricular tachycardia or fibrillation ensued from the oscillation in five cases. No such long arrest or serious arrhythmias were elicited in LVep and IVS. These results suggest that RVep is more susceptible than LVep and IVS for arrhythmogenic aftereffects of high intensity DC stimulation.

Virtual electrode-induced reexcitation: A mechanism of defibrillation

Mechanisms of defibrillation remain poorly understood. Defibrillation success depends on the elimination of fibrillation without shock-induced arrhythmogenesis. We optically mapped selected epicardial regions of rabbit hearts (n=20) during shocks applied with the use of implantable defibrillator electrodes during the refractory period. Monophasic shocks resulted in virtual electrode polarization (VEP). Positive values of VEP resulted in a prolongation of the action potential duration, whereas negative polarization shortened the action potential duration, resulting in partial or complete recovery of the excitability. After a shock, new propagated wavefronts emerged at the boundary between the 2 regions and reexcited negatively polarized regions. Conduction velocity and maximum action potential upstroke rate of rise dV/dt (max) of shock-induced activation depended on the transmembrane potential at the end of the shock. Linear regression analysis showed that dV/dt(max) of postshock activation reached 50% of that of normal action potential at a V(m) value of -56.7+/-0.6 mV postshock voltage (n=9257). Less negative potentials resulted in slow conduction and blocks, whereas more negative potentials resulted in faster conduction. Although wavebreaks were produced in either condition, they degenerated into arrhythmias only when conduction was slow. Shock-induced VEP is essential in extinguishing fibrillation but can reinduce arrhythmias by producing excitable gaps. Reexcitation of these gaps through progressive increase in shock strength may provide the basis for the lower and upper limits of vulnerability. The former may correspond to the origination of slow wavefronts of reexcitation and phase singularities. The latter corresponds to fast conduction during which wavebreaks no longer produce sustained arrhythmias.

Shock-induced figure-of-eight reentry in the isolated rabbit heart

The patterns of transmembrane potential on the whole heart during and immediately after fibrillation-inducing shocks are unknown. To study arrhythmia induction, we recorded transmembrane activity from the anterior and posterior epicardial surface of the isolated rabbit heart simultaneously using 2 charge-coupled device cameras (32,512 pixels, 480 frames/second). Isolated hearts were paced from the apex at a cycle length of 250 ms. Two shock coils positioned inside the right ventricle (-) and atop the left atrium (+) delivered shocks at 3 strengths (0.75, 1.5, and 2.25 A) and 6 coupling intervals (130 to 230 ms). The patterns of depolarization and repolarization were similar, as is evident in the uniformity of action potential duration at 75% repolarization (131.4¿8.3 ms). At short coupling intervals (<180 ms), shocks hyperpolarized a large portion of the ventricles and produced a pair of counterrotating waves, one on each side of the heart. The first beat after the shock was reentrant in 90% of short coupling interval episodes. At long coupling intervals (>180 ms), increasingly stronger shocks depolarized an increasingly larger portion of the heart. The first beat after the shock was reentrant in 18% of long coupling interval episodes. Arrhythmias were most often induced at short coupling intervals (98%) than at long coupling intervals (35%). The effect and outcome of the shock were related to the refractory state of the heart at the time of the shock. Hyperpolarization occurred at short coupling intervals, whereas depolarization occurred at long coupling intervals. Consistent with the "critical point" hypothesis, increasing shock strength and coupling interval moved the location where reentry formed (away from the shock electrode and pacing electrode, respectively).

Spatial changes in the transmembrane potential during extracellular electric stimulation

The purpose of this study was to determine the spatial changes in the transmembrane potential caused by extracellular electric field stimulation. The transmembrane potential was recorded in 10 guinea pig papillary muscles in a tissue bath using a double-barrel microelectrode. After 20 S1 stimuli, a 10-ms square wave S2 shock field with a 30-ms S1-S2 coupling interval was given via patch shock electrodes 1 cm on either side of the tissue during the action potential plateau. Two shock strengths (2.1+/-0.2 and 6.5+/-0.6 V/cm) were tested with both shock polarities. The recording site was moved across the tissue along fibers with either 200 micrometer (macroscopic group [n=5], 12 consecutive recording sites over a 2. 2-mm tissue length in each muscle) or 20 micrometer (microscopic group [n=5], 21 consecutive recording sites over a 0.4-mm tissue length in each muscle) between adjacent recording sites. In the macroscopic group, the portion of the tissue toward the anode was hyperpolarized, whereas the portion toward the cathode was depolarized, with 1 zero-potential crossing from hyperpolarization to depolarization present near the center of the tissue. In the microscopic group, only 1 zero-potential crossing was observed in the center region of the tissue, whereas, away from the center, only hyperpolarization was observed toward the anode and depolarization toward the cathode. Although these results are consistent with predictions from field stimulation of continuous representations of myocardial structure, ie, the bidomain and cable equation models, they are not consistent with the prediction of depolarization-hyperpolarization oscillation from representations based on cellular-level resistive discontinuities associated with gap junctions, ie, the sawtooth model.

Electrical conduction between the right atrium and the left atrium via the musculature of the coronary sinus

BACKGROUND

The purpose of this study was to determine whether the coronary sinus (CS) musculature has electrical connections to the right atrium (RA) and left atrium (LA) and forms an RA-LA connection.

METHODS AND RESULTS

Six excised dog hearts were perfused in a Langendorff preparation. A 20-electrode catheter (2-4-2-mm spacing center to center) was placed along the CS. Excision of the pulmonary veins provided access to the LA, and a second 20-electrode catheter was placed along the LA endocardium opposite the CS catheter. An incision opened the CS longitudinally, and microelectrodes were inserted into the CS musculature and adjacent LA myocardium. Continuous CS musculature was visible along a 35+/-9-mm length of the CS beginning at the ostium. During lateral LA pacing, CS electrodes recorded double potentials, a rounded, low-frequency potential followed by a sharp potential. The rounded initial potential propagated in the lateral-to-septal direction and represented "far-field" LA activation (timing coincided with adjacent LA potentials and with action potentials recorded from microelectrodes in adjacent LA cells). The sharp potential represented CS activation (timing coincided with action potentials recorded from CS musculature). A distal LA-CS connection (earliest sharp potential in the CS during lateral LA pacing) was located 26+/-7 mm from the ostium. During RA pacing posterior to the CS ostium, CS electrodes recorded septal-to-lateral activation of the high-frequency potential, with slightly later activation of the rounded potential (LA activation). Incisions surrounding the CS ostium isolating the ostium from the RA had no effect on the CS musculature and LA potentials during RA pacing within the isolated segment containing the CS ostium. RA pacing outside the isolated segment delayed activation of the CS musculature until after LA activation, confirming that the RA-CS connection was located in the region of the CS ostium as well as confirming the presence of the LA-CS connection.

CONCLUSIONS

In canine hearts, the CS musculature is electrically connected to the RA and the LA and forms an RA-LA connection.

Virtual electrode effects in transvenous defibrillation-modulation by structure and interface: evidence from bidomain simulations and optical mapping

INTRODUCTION

Our goal in this combined modeling and experimental study was to gain insight into the transmembrane potential changes in defibrillation conditions, namely, when shocks are delivered by an implantable cardioverter defibrillator (ICD). Two hypotheses concerning the presence and characteristics of virtual electrode effects (VEE) during an ICD shock were tested numerically and experimentally: (H1) anisotropy-dependent VEE are induced over a considerable portion of the "bulk" myocardium; and (H2) surface (epicardial and endocardial) VEE are generated under special tissue bath conditions and are not fully anisotropy determined.

METHODS AND RESULTS

Optical mapping was performed on Langendorff-perfused rabbit hearts (n = 4) stained with di-4-ANEPPS. Monophasic shocks were applied during the plateau phase of an action potential through a 9-mm long distal electrode in the right or left ventricle and a 6-cm proximal electrode positioned 3 cm posteriorly to the heart. We modeled the experiment using an ellipsoidal bidomain heart with transmural fiber rotation, placed in a perfusing bath, and subjected to defibrillation shocks delivered by an electrode configuration as described. Our numerical simulations demonstrated VEE occupying a significant portion of the myocardium in the conditions of unequal anisotropy ratios for the intra- and extracellular domains. Statistically significant differences in epicardial polarization patterns were predicted numerically and confirmed experimentally when the interface conditions varied.

CONCLUSION

The present study concludes that VEE are present in transvenous defibrillation. They are shaped by the combined effect of cardiac tissue characteristics and interface conditions. Because of their size, VEE might contribute significantly to defibrillation outcome.

High-resolution, three-dimensional fluorescent imaging reveals multilayer conduction pattern in the atrioventricular node

BACKGROUND

The atrioventricular node (AVN) is the only normal electrical link between the upper and lower chambers of the heart. The AVN modulates transmission of impulses, thus coordinating the contraction of the atria and ventricles.

METHODS AND RESULTS

Structural and functional complexity, combined with the absence of adequate experimental techniques, has complicated attempts to directly evaluate the three-dimensional electrical activity of the AVN. Thus, despite a century of research by conventional electrophysiologic and histologic methods, even the existence of conduction through AVN is still debated.

CONCLUSIONS

Using a novel combination of microelectrode recordings and high resolution fluorescent imaging with voltage-sensitive dyes, we have for the first time clearly demonstrated three-dimensional conduction through the AVN.

Origin of heat-induced accelerated junctional rhythm

INTRODUCTION

The application of high-frequency current to the AV junctional area results in a temperature rise in the myocardium and may cause accelerated junctional rhythm (AJR). The aim of the study was to characterize heat-induced AJR in an in vitro animal model.

METHODS AND RESULTS

Studies were performed in isolated perfused pig and rabbit hearts. Using a small heating probe, we could induce AJR from a discrete area located in the middle of the triangle of Koch, which was smaller than the area from which RF energy application could elicit AJR. Histology showed that the heat-sensitive area was located over, or close to, the compact AV node. It did not correspond with the areas where double potentials were found or with the site(s) of earliest atrial activation during VA conduction. Microelectrode recordings revealed that AJR arose in nodal-type cells. Heat increased the slope of the phase 4 depolarization and shortened the action potential duration. Two types of AJR were observed: the first one was regular and the second one showed irregularity in the intervals. Interaction of multiple foci and the presence of conduction block between the foci and the His bundle caused the irregularity of the His-His intervals during the second type of AJR.

CONCLUSION

AJR observed during heat and RF application in the AV nodal area results from the effect of heat on AV nodal cells with underlying pacemaker activity. The heat-sensitive area is located over, or very close to, the compact AV node.

Relation of the atrial input sites to the dual atrioventricular nodal pathways: crossing of conduction curves generated with posterior and anterior pacing

INTRODUCTION

The usually accepted definition of the dual pathway electrophysiology requires the presence of conduction curves with a discontinuity ("jump"). However, AV nodal reentrant tachycardia has been observed in patients with "smooth" conduction curves, whereas discontinuity of the conduction curve does not guarantee induction of stable reentry. We hypothesize that the duality of AV nodal conduction can be revealed by careful choice of stimulation sites during the generation of AV nodal conduction curves.

METHODS AND RESULTS

In 21 rabbit heart atrial-AV nodal preparations, programmed electrical stimulation with S1-S2-S3 pacing protocol was applied either posteriorly at the crista terminalis input site (CrT) or anteriorly at the lower interatrial septum input site (IAS), or (in 8 preparations with surgically divided input sites) at both. We found that in intact preparations with "smooth" conduction curves, pacing at long coupling intervals produced shorter AV nodal conduction times from the IAS (56 +/- 9.8 msec vs 69 +/- 10.1 msec; P < 0.01). At short coupling intervals, in contrast, shorter conduction times were obtained from the CrT (173 +/- 21.8 msec vs 188 +/- 22.8 msec; P < 0.01). This resulted in a characteristic crossing of the superimposed IAS and CrT conduction curves. After division of the inputs, the IAS site had rapid conduction to the His bundle but a longer refractory period, whereas the CrT site had long conduction times and shorter refractory periods. Wavefronts entering the AV node from these two inputs can summate, resulting in improved conduction.

CONCLUSION

Pacing protocols designed to accentuate the asymmetry between the AV nodal inputs can help to reveal the functional difference between the dual pathways and thus to better assess the properties of AV nodal conduction.

Mechanism of atrioventricular nodal facilitation in rabbit heart: role of proximal AV node

The phenomenon of atrioventricular (AV) nodal "facilitation," described in traditional "black box"-functional studies, implies enhanced AV nodal dromotropic function. We investigated the role of atrial prematurities in the modulation of the nodal cellular responses in the mechanism of AV nodal facilitation. Atrial and His (H) bundle electrograms and microelectrode recordings from proximal AV nodal cells were analyzed in 15 superfused rabbit AV node preparations. The pacing protocol consisted of 30 basic beats (S1; coupling interval S1-S1 = 300 ms) followed by a facilitating prematurity (S2; coupling intervals S1-S2 of 300, 200, 150, and 130 ms) followed by the test beat (S3; coupling interval S2-S3 scanned in 5-ms steps). Conduction curves (S2-H2 vs. S1-S2, S3-H3 vs. S2-S3, and S3-H3 vs. H2-S3) were constructed. Facilitation (i.e., shortening of S3-H3 when S1-S2 was shortened) was demonstrated in all preparations using the H2-S3 (P < 0.001) but not the S2-S3 format. Microelectrode recordings revealed a causal relationship between the improved proximal AV nodal cellular responses in facilitation and the prolonged S2-S3 interval. There was no evidence for enhanced nodal dromotropic function directly resulting from the introduction of the facilitating beats. Thus facilitation is based on inherent cycle-length-dependent properties of the AV node during application of a complex pacing protocol and primarily reflects the uncontrolled modulation of the proximal cellular response.