1
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Tóth N, Szlovák J, Kohajda Z, Bitay G, Veress R, Horváth B, Papp JG, Varró A, Nagy N. The development of L-type Ca 2+ current mediated alternans does not depend on the restitution slope in canine ventricular myocardium. Sci Rep 2021; 11:16652. [PMID: 34404848 PMCID: PMC8371021 DOI: 10.1038/s41598-021-95299-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/23/2021] [Indexed: 11/25/2022] Open
Abstract
Cardiac alternans have crucial importance in the onset of ventricular fibrillation. The early explanation for alternans development was the voltage-driven mechanism, where the action potential (AP) restitution steepness was considered as crucial determining factor. Recent results suggest that restitution slope is an inadequate predictor for alternans development, but several studies still claim the role of membrane potential as underlying mechanism of alternans. These controversial data indicate that the relationship of restitution and alternans development is not completely understood. APs were measured by conventional microelectrode technique from canine right ventricular papillary muscles. Ionic currents combined with fluorescent measurements were recorded by patch-clamp technique. APs combined with fluorescent measurements were monitored by sharp microelectrodes. Rapid pacing evoked restitution-independent AP duration (APD) alternans. When non-alternating AP voltage command was used, Ca2+i-transient (CaT) alternans were not observed. When alternating rectangular voltage pulses were applied, CaT alternans were proportional to ICaL amplitude alternans. Selective ICaL inhibition did not influence the fast phase of APD restitution. In this study we found that ICaL has minor contribution in shaping the fast phase of restitution curve suggesting that ICaL—if it plays important role in the alternans mechanism—could be an additional factor that attenuates the reliability of APD restitution slope to predict alternans.
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Affiliation(s)
- Noémi Tóth
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary
| | - Jozefina Szlovák
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary
| | - Zsófia Kohajda
- ELKH-SZTE Research Group of Cardiovascular Pharmacology, Szeged, Hungary
| | - Gergő Bitay
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary
| | - Roland Veress
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Julius Gy Papp
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary.,ELKH-SZTE Research Group of Cardiovascular Pharmacology, Szeged, Hungary
| | - András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary.,ELKH-SZTE Research Group of Cardiovascular Pharmacology, Szeged, Hungary.,Department of Pharmacology and Pharmacotherapy, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
| | - Norbert Nagy
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, P.O. Box 427, 6720, Szeged, Hungary. .,ELKH-SZTE Research Group of Cardiovascular Pharmacology, Szeged, Hungary.
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2
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Kulkarni K, Walton RD, Armoundas AA, Tolkacheva EG. Clinical Potential of Beat-to-Beat Diastolic Interval Control in Preventing Cardiac Arrhythmias. J Am Heart Assoc 2021; 10:e020750. [PMID: 34027678 PMCID: PMC8483541 DOI: 10.1161/jaha.121.020750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Life‐threatening ventricular arrhythmias and sudden cardiac death are often preceded by cardiac alternans, a beat‐to‐beat oscillation in the T‐wave morphology or duration. However, given the spatiotemporal and structural complexity of the human heart, designing algorithms to effectively suppress alternans and prevent fatal rhythms is challenging. Recently, an antiarrhythmic constant diastolic interval pacing protocol was proposed and shown to be effective in suppressing alternans in 0‐, 1‐, and 2‐dimensional in silico studies as well as in ex vivo whole heart experiments. Herein, we provide a systematic review of the electrophysiological conditions and mechanisms that enable constant diastolic interval pacing to be an effective antiarrhythmic pacing strategy. We also demonstrate a successful translation of the constant diastolic interval pacing protocol into an ECG‐based real‐time control system capable of modulating beat‐to‐beat cardiac electrical activity and preventing alternans. Furthermore, we present evidence of the clinical utility of real‐time alternans suppression in reducing arrhythmia susceptibility in vivo. We provide a comprehensive overview of this promising pacing technique, which can potentially be translated into a clinically viable device that could radically improve the quality of life of patients experiencing abnormal cardiac rhythms.
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Affiliation(s)
- Kanchan Kulkarni
- IHU-LIRYC, Electrophysiology and Heart Modeling InstituteFondation Bordeaux Université Pessac, Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux University of Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux INSERM Bordeaux France
| | - Richard D Walton
- IHU-LIRYC, Electrophysiology and Heart Modeling InstituteFondation Bordeaux Université Pessac, Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux University of Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux INSERM Bordeaux France
| | - Antonis A Armoundas
- Cardiovascular Research Center Massachusetts General Hospital Boston MA.,Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering University of Minnesota-Twin Cities Minneapolis MN
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3
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Tse G, Li KHC, Cheung CKY, Letsas KP, Bhardwaj A, Sawant AC, Liu T, Yan GX, Zhang H, Jeevaratnam K, Sayed N, Cheng SH, Wong WT. Arrhythmogenic Mechanisms in Hypokalaemia: Insights From Pre-clinical Models. Front Cardiovasc Med 2021; 8:620539. [PMID: 33614751 PMCID: PMC7887296 DOI: 10.3389/fcvm.2021.620539] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/13/2021] [Indexed: 12/21/2022] Open
Abstract
Potassium is the predominant intracellular cation, with its extracellular concentrations maintained between 3. 5 and 5 mM. Among the different potassium disorders, hypokalaemia is a common clinical condition that increases the risk of life-threatening ventricular arrhythmias. This review aims to consolidate pre-clinical findings on the electrophysiological mechanisms underlying hypokalaemia-induced arrhythmogenicity. Both triggers and substrates are required for the induction and maintenance of ventricular arrhythmias. Triggered activity can arise from either early afterdepolarizations (EADs) or delayed afterdepolarizations (DADs). Action potential duration (APD) prolongation can predispose to EADs, whereas intracellular Ca2+ overload can cause both EADs and DADs. Substrates on the other hand can either be static or dynamic. Static substrates include action potential triangulation, non-uniform APD prolongation, abnormal transmural repolarization gradients, reduced conduction velocity (CV), shortened effective refractory period (ERP), reduced excitation wavelength (CV × ERP) and increased critical intervals for re-excitation (APD-ERP). In contrast, dynamic substrates comprise increased amplitude of APD alternans, steeper APD restitution gradients, transient reversal of transmural repolarization gradients and impaired depolarization-repolarization coupling. The following review article will summarize the molecular mechanisms that generate these electrophysiological abnormalities and subsequent arrhythmogenesis.
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Affiliation(s)
- Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Ka Hou Christien Li
- Faculty of Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Aishwarya Bhardwaj
- Division of Cardiology, Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, United States
| | - Abhishek C Sawant
- Division of Cardiology, Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, United States
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical Center, Wynnewood, PA, United States
| | - Henggui Zhang
- School of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Nazish Sayed
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Shuk Han Cheng
- Department of Biomedical Sciences, College of Veterinary Medicine and Life Science, City University of Hong Kong, Hong Kong, China.,State Key Laboratory of Marine Pollution (SKLMP), City University of Hong Kong, Hong Kong, China.,Department of Materials Science and Engineering, College of Science and Engineering, City University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
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4
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Muñoz LM, Ampofo MO, Cherry EM. Controllability of voltage- and calcium-driven cardiac alternans in a map model. CHAOS (WOODBURY, N.Y.) 2021; 31:023139. [PMID: 33653066 DOI: 10.1063/5.0040064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
Certain cardiac arrhythmias are preceded by electrical alternans, a state characterized by beat-to-beat alternation in cellular action potential duration. Cardiac alternans may arise from different mechanisms including instabilities in voltage or intracellular calcium cycling. Although a number of techniques have been proposed to suppress alternans, these methods have mainly been tested using models that do not support calcium-driven alternans. Therefore, it is important to understand how control methods may perform when alternans is driven by instabilities in calcium cycling. In this study, we applied controllability analysis to a discrete map of alternans dynamics in a cardiac cell. We compared two different controllability measures to determine to what extent different control strategies could suppress alternans and tested these predictions using three feedback controllers. We found a modal controllability measure, unlike the minimum singular value of the controllability matrix, consistently indicated the control strategies requiring the least control effort and yielding the smallest closed-loop eigenvalue. In addition, action potential duration was identified as the most effective variable through which control can be applied, regardless of alternans mechanism, although sarcoplasmic reticulum calcium load was also useful for the calcium-driven alternans cases.
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Affiliation(s)
- Laura M Muñoz
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York 14623-5602, USA
| | - Mark O Ampofo
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York 14623-5602, USA
| | - Elizabeth M Cherry
- School of Computational Science and Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332-4017, USA
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5
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Parthiban P, Newell S, Tolkacheva EG. Effect of constant-DI pacing on single cell pacing dynamics. CHAOS (WOODBURY, N.Y.) 2020; 30:103122. [PMID: 33138461 DOI: 10.1063/5.0022066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/02/2020] [Indexed: 06/11/2023]
Abstract
Cardiac alternans, beat-to-beat alternations in action potential duration, is a precursor to fatal arrhythmias such as ventricular fibrillation. Previous research has shown that voltage driven alternans can be suppressed by application of a constant diastolic interval (DI) pacing protocol. However, the effect of constant-DI pacing on cardiac cell dynamics and its interaction with the intracellular calcium cycle remains to be determined. Therefore, we aimed to examine the effects of constant-DI pacing on the dynamical behavior of a single-cell numerical model of cardiac action potential and the influence of voltage-calcium (V-Ca) coupling on it. Single cell dynamics were analyzed in the vicinity of the bifurcation point using a hybrid pacing protocol, a combination of constant-basic cycle length (BCL) and constant-DI pacing. We demonstrated that in a small region beneath the bifurcation point, constant-DI pacing caused the cardiac cell to remain alternans-free after switching to the constant-BCL pacing, thus introducing a region of bistability (RB). The size of the RB increased with stronger V-Ca coupling and was diminished with weaker V-Ca coupling. Overall, our findings demonstrate that the application of constant-DI pacing on cardiac cells with strong V-Ca coupling may induce permanent changes to cardiac cell dynamics increasing the utility of constant-DI pacing.
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Affiliation(s)
- P Parthiban
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - S Newell
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - E G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota 55455, USA
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6
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Kulkarni K, Merchant FM, Kassab MB, Sana F, Moazzami K, Sayadi O, Singh JP, Heist EK, Armoundas AA. Cardiac Alternans: Mechanisms and Clinical Utility in Arrhythmia Prevention. J Am Heart Assoc 2019; 8:e013750. [PMID: 31617437 PMCID: PMC6898836 DOI: 10.1161/jaha.119.013750] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | | | - Mohamad B. Kassab
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Furrukh Sana
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Kasra Moazzami
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Omid Sayadi
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Jagmeet P. Singh
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - E. Kevin Heist
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - Antonis A. Armoundas
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA
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7
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Reynard JT, Oshodi OM, Lai JC, Lai RW, Bazoukis G, Fragakis N, Letsas KP, Korantzopoulos P, Liu FZ, Liu T, Xia Y, Tse G, Li CK. Electrocardiographic conduction and repolarization markers associated with sudden cardiac death: moving along the electrocardiography waveform. Minerva Cardioangiol 2019; 67:131-144. [PMID: 30260143 DOI: 10.23736/s0026-4725.18.04775-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
The QT interval along with its heart rate corrected form (QTc) are well-established ECG markers that have been found to be associated with malignant ventricular arrhythmogenesis. However, extensive preclinical and clinical investigations over the years have allowed for novel clinical ECG markers to be generated as predictors of arrhythmogenesis and sudden cardiac death. Repolarization markers include the older QTc, QT dispersion and newer Tpeak - Tend intervals, (Tpeak - Tend) / QT ratios, T-wave alternans (TWA), microvolt TWA and T-wave area dispersion. Meanwhile, conduction markers dissecting the QRS complex, such as QRS dispersion (QRSD) and fragmented QRS, were also found to correlate conduction velocity and unidirectional block with re-entrant substrates in various cardiac conditions. Both repolarization and conduction parameters can be combined into the excitation wavelength (λ). A surrogate marker for λ is the index of Cardiac Electrophysiological Balance (iCEB: QT / QRSd). Other markers based on conduction-repolarization are [QRSD x (Tpeak-Tend) / QRSd] and [QRSD x (Tpeak-Tend) / (QRSd x QT)]. Advancement in technology permitted sophisticated electrophysiological analyses such as principal component analysis and periodic repolarization dynamics to further improve risk stratification. This was closely followed by other novel indices including ventricular ectopic QRS interval, the f99 index and EntropyXQT, which integrates mathematical and physical calculations for determining the risk markers. Though proven to be effective in limited patient cohorts, more clinical studies across different cardiac pathologies are required to confirm their validity. As such, this review seeks to encapsulate the development of old and new ECG markers along with their associated utility and shortcomings in clinical practice.
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Affiliation(s)
- Jack T Reynard
- Faculty of Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | | | - Jenny C Lai
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Rachel W Lai
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Nikolaos Fragakis
- Third Department of Cardiology, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Konstantinos P Letsas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Panagiotis Korantzopoulos
- Third Department of Cardiology, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Fang-Zhou Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital affiliated to South China University of Technology, Guangzhou, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Christien K Li
- Faculty of Medicine, Newcastle University, Newcastle Upon Tyne, UK -
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
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8
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Ni H, Zhang H, Grandi E, Narayan SM, Giles WR. Transient outward K + current can strongly modulate action potential duration and initiate alternans in the human atrium. Am J Physiol Heart Circ Physiol 2018; 316:H527-H542. [PMID: 30576220 DOI: 10.1152/ajpheart.00251.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Efforts to identify the mechanisms for the initiation and maintenance of human atrial fibrillation (AF) often focus on changes in specific elements of the atrial "substrate," i.e., its electrophysiological properties and/or structural components. We used experimentally validated mathematical models of the human atrial myocyte action potential (AP), both at baseline in sinus rhythm (SR) and in the setting of chronic AF, to identify significant contributions of the Ca2+-independent transient outward K+ current ( Ito) to electrophysiological instability and arrhythmia initiation. First, we explored whether changes in the recovery or restitution of the AP duration (APD) and/or its dynamic stability (alternans) can be modulated by Ito. Recent reports have identified disease-dependent spatial differences in expression levels of the specific K+ channel α-subunits that underlie Ito in the left atrium. Therefore, we studied the functional consequences of this by deletion of 50% of native Ito (Kv4.3) and its replacement with Kv1.4. Interestingly, significant changes in the short-term stability of the human atrial AP waveform were revealed. Specifically, this K+ channel isoform switch produced discontinuities in the initial slope of the APD restitution curve and appearance of APD alternans. This pattern of in silico results resembles some of the changes observed in high-resolution clinical electrophysiological recordings. Important insights into mechanisms for these changes emerged from known biophysical properties (reactivation kinetics) of Kv1.4 versus those of Kv4.3. These results suggest new approaches for pharmacological management of AF, based on molecular properties of specific K+ isoforms and their changed expression during progressive disease. NEW & NOTEWORTHY Clinical studies identify oscillations (alternans) in action potential (AP) duration as a predictor for atrial fibrillation (AF). The abbreviated AP in AF also involves changes in K+ currents and early repolarization of the AP. Our simulations illustrate how substitution of Kv1.4 for the native current, Kv4.3, alters the AP waveform and enhances alternans. Knowledge of this "isoform switch" and related dynamics in the AF substrate may guide new approaches for detection and management of AF.
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Affiliation(s)
- Haibo Ni
- Biological Physics Group, School of Physics and Astronomy, University of Manchester , Manchester , United Kingdom.,Department of Pharmacology, University of California , Davis, California
| | - Henggui Zhang
- Biological Physics Group, School of Physics and Astronomy, University of Manchester , Manchester , United Kingdom
| | - Eleonora Grandi
- Department of Pharmacology, University of California , Davis, California
| | - Sanjiv M Narayan
- Division of Cardiology, Cardiovascular Institute, Stanford University , Stanford, California
| | - Wayne R Giles
- Faculties of Kinesiology and Medicine, University of Calgary , Calgary, Alberta , Canada
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9
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Kanaporis G, Kalik ZM, Blatter LA. Action potential shortening rescues atrial calcium alternans. J Physiol 2018; 597:723-740. [PMID: 30412286 DOI: 10.1113/jp277188] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/08/2018] [Indexed: 01/08/2023] Open
Abstract
KEY POINTS Cardiac alternans refers to a beat-to-beat alternation in contraction, action potential (AP) morphology and Ca2+ transient (CaT) amplitude, and represents a risk factor for cardiac arrhythmia, including atrial fibrillation. We developed strategies to pharmacologically manipulate the AP waveform with the goal to reduce or eliminate the occurrence of CaT and contraction alternans in atrial tissue. With combined patch-clamp and intracellular Ca2+ measurements we investigated the effect of specific ion channel inhibitors and activators on alternans. In single rabbit atrial myocytes, suppression of Ca2+ -activated Cl- channels eliminated AP duration alternans, but prolonged the AP and failed to eliminate CaT alternans. In contrast, activation of K+ currents (IKs and IKr ) shortened the AP and eliminated both AP duration and CaT alternans. As demonstrated also at the whole heart level, activation of K+ conductances represents a promising strategy to suppress alternans, and thus reducing a risk factor for atrial fibrillation. ABSTRACT At the cellular level alternans is observed as beat-to-beat alternations in contraction, action potential (AP) morphology and magnitude of the Ca2+ transient (CaT). Alternans is a well-established risk factor for cardiac arrhythmia, including atrial fibrillation. This study investigates whether pharmacological manipulation of AP morphology is a viable strategy to reduce the risk of arrhythmogenic CaT alternans. Pacing-induced AP and CaT alternans were studied in rabbit atrial myocytes using combined Ca2+ imaging and electrophysiological measurements. Increased AP duration (APD) and beat-to-beat alternations in AP morphology lowered the pacing frequency threshold and increased the degree of CaT alternans. Inhibition of Ca2+ -activated Cl- channels reduced beat-to-beat AP alternations, but prolonged APD and failed to suppress CaT alternans. In contrast, AP shortening induced by activators of two K+ channels (ML277 for Kv7.1 and NS1643 for Kv11.1) abolished both APD and CaT alternans in field-stimulated and current-clamped myocytes. K+ channel activators had no effect on the degree of Ca2+ alternans in AP voltage-clamped cells, confirming that suppression of Ca2+ alternans was caused by the changes in AP morphology. Finally, activation of Kv11.1 channel significantly attenuated or even abolished atrial T-wave alternans in isolated Langendorff perfused hearts. In summary, AP shortening suppressed or completely eliminated both CaT and APD alternans in single atrial myocytes and atrial T-wave alternans at the whole heart level. Therefore, we suggest that AP shortening is a potential intervention to avert development of alternans with important ramifications for arrhythmia prevention and therapy.
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Affiliation(s)
- Giedrius Kanaporis
- Department of Physiology & Biophysics, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Zane M Kalik
- Department of Physiology & Biophysics, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Lothar A Blatter
- Department of Physiology & Biophysics, Rush University Medical Center, Chicago, IL, 60612, USA
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10
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Landaw J, Qu Z. Control of voltage-driven instabilities in cardiac myocytes with memory. CHAOS (WOODBURY, N.Y.) 2018; 28:113122. [PMID: 30501225 PMCID: PMC6274634 DOI: 10.1063/1.5040854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/29/2018] [Indexed: 06/09/2023]
Abstract
Sudden cardiac death is known to be associated with dynamical instabilities in the heart, and thus control of dynamical instabilities is considered a potential therapeutic strategy. Different control methods were developed previously, including time-delayed feedback pacing control and constant diastolic interval pacing control. Experimental, theoretical, and simulation studies have examined the efficacy of these control methods in stabilizing action potential dynamics. In this study, we apply these control methods to control complex action potential (AP) dynamics under two diseased conditions: early repolarization syndrome and long QT syndrome, in which voltage-driven instabilities occur in the presence of short-term cardiac memory. In addition, we also develop a feedback pacing method to stabilize these instabilities. We perform theoretical analyses using iterated map models and carry out numerical simulations of AP models. We show that under the normal condition where the memory effect is minimal, all three methods can effectively control the action potential duration (APD) dynamics. Under the two diseased conditions where the memory effect is exacerbated, constant diastolic pacing control is least effective, while the feedback pacing control is most effective. Under a very strong memory effect, all three methods fail to stabilize the voltage-driven instabilities. The failure of effective control is due to memory and the all-or-none AP dynamics which results in very steep changes in APD.
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Affiliation(s)
- Julian Landaw
- Department of Medicine (Cardiology), University of California, Los Angeles, California 90095, USA
| | - Zhilin Qu
- Department of Medicine (Cardiology), University of California, Los Angeles, California 90095, USA
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11
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Heart rate variability alters cardiac repolarization and electromechanical dynamics. J Theor Biol 2018; 442:31-43. [DOI: 10.1016/j.jtbi.2018.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/05/2018] [Accepted: 01/10/2018] [Indexed: 11/23/2022]
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12
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Tse G, Yan BP. Traditional and novel electrocardiographic conduction and repolarization markers of sudden cardiac death. Europace 2018; 19:712-721. [PMID: 27702850 DOI: 10.1093/europace/euw280] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022] Open
Abstract
Sudden cardiac death, frequently due to ventricular arrhythmias, is a significant problem globally. Most affected individuals do not arrive at hospital in time for medical treatment. Therefore, there is an urgent need to identify the most-at-risk patients for insertion of prophylactic implantable cardioverter defibrillators. Clinical risk markers derived from electrocardiography are important for this purpose. They can be based on repolarization, including corrected QT (QTc) interval, QT dispersion (QTD), interval from the peak to the end of the T-wave (Tpeak - Tend), (Tpeak - Tend)/QT, T-wave alternans (TWA), and microvolt TWA. Abnormal repolarization properties can increase the risk of triggered activity and re-entrant arrhythmias. Other risk markers are based solely on conduction, such as QRS duration (QRSd), which is a surrogate marker of conduction velocity (CV) and QRS dispersion (QRSD) reflecting CV dispersion. Conduction abnormalities in the form of reduced CV, unidirectional block, together with a functional or a structural obstacle, are conditions required for circus-type or spiral wave re-entry. Conduction and repolarization can be represented by a single parameter, excitation wavelength (λ = CV × effective refractory period). λ is an important determinant of arrhythmogenesis in different settings. Novel conduction-repolarization markers incorporating λ include Lu et al.' index of cardiac electrophysiological balance (iCEB: QT/QRSd), [QRSD× (Tpeak - Tend)/QRSd] and [QRSD × (Tpeak - Tend)/(QRSd × QT)] recently proposed by Tse and Yan. The aim of this review is to provide up to date information on traditional and novel markers and discuss their utility and downfalls for risk stratification.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, P.R. China
| | - Bryan P Yan
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, P.R. China.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, Australia
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13
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Real-Time Closed Loop Diastolic Interval Control Prevents Cardiac Alternans in Isolated Whole Rabbit Hearts. Ann Biomed Eng 2018; 46:555-566. [PMID: 29356998 DOI: 10.1007/s10439-018-1981-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
Cardiac alternans, a beat-to-beat alternation in action potential duration (APD), can lead to fatal arrhythmias. During periodic pacing, changes in diastolic interval (DI) depend on subsequent changes in APD, thus enhancing cardiac instabilities through a 'feedback' mechanism. Recently, an anti-arrhythmic Constant DI pacing protocol was proposed and shown to be effective in suppressing alternans in 0D and 1D in silico studies. However, previous experimental validation of Constant DI pacing in the heart has been unsuccessful due to the spatio-temporal complexity of 2D cardiac tissue and the technical challenges in its real-time implementation. Here, we developed a novel closed loop system to detect T-waves from real-time ECG data, enabling successful implementation of Constant DI pacing protocol, and performed high-resolution optical mapping experiments on isolated whole rabbit hearts to validate its anti-arrhythmic effects. The results were compared with: (1) Periodic pacing (feedback inherent) and (2) pacing with heart rate variability (HRV) (feedback modulation) introduced by using either Gaussian or Physiological patterns. We observed that Constant DI pacing significantly suppressed alternans in the heart, while maintaining APD spatial dispersion and flattening the slope of the APD restitution curve, compared to traditional Periodic pacing. In addition, introduction of HRV in Periodic pacing failed to prevent cardiac alternans, and was arrhythmogenic.
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14
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Cherry EM. Distinguishing mechanisms for alternans in cardiac cells using constant-diastolic-interval pacing. CHAOS (WOODBURY, N.Y.) 2017; 27:093902. [PMID: 28964159 DOI: 10.1063/1.4999354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Alternans, a proarrhythmic dynamical state in which cardiac action potentials alternate between long and short durations despite a constant pacing period, traditionally has been explained at the cellular level using nonlinear dynamics principles under the assumption that the action potential duration (APD) is determined solely by the time elapsed since the end of the previous action potential, called the diastolic interval (DI). In this scenario, APDs at a steady state should be the same provided that the preceding DIs are the same. Nevertheless, experiments attempting to eliminate alternans by dynamically adjusting the timing of pacing stimuli to keep the DI constant showed that alternans persisted, contradicting the traditional theory. It is now widely known that alternans also can arise from a different mechanism associated with intracellular calcium cycling. Our goal is to determine whether intracellular calcium dynamics can explain the experimental findings regarding the persistence of alternans despite a constant DI. For this, we use mathematical models capable of producing alternans through both voltage- and calcium-mediated mechanisms. We show that for voltage-driven alternans, action potentials elicited from a constant-DI protocol are always the same. However, in the case of calcium-driven alternans, the constant-DI protocol can result in alternans. Reducing the strength of the calcium instability progressively reduces and finally eliminates constant-DI alternans. Our findings suggest that screening for the presence of alternans using a constant-DI protocol has the potential for differentiating between voltage-driven and calcium-driven alternans.
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Affiliation(s)
- Elizabeth M Cherry
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York 14623, USA
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15
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Otani NF. Theory of the development of alternans in the heart during controlled diastolic interval pacing. CHAOS (WOODBURY, N.Y.) 2017; 27:093935. [PMID: 28964128 DOI: 10.1063/1.5003250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The beat-to-beat alternation in action potential durations (APDs) in the heart, called APD alternans, has been linked to the development of serious cardiac rhythm disorders, including ventricular tachycardia and fibrillation. The length of the period between action potentials, called the diastolic interval (DI), is a key dynamical variable in the standard theory of alternans development. Thus, methods that control the DI may be useful in preventing dangerous cardiac rhythms. In this study, we examine the dynamics of alternans during controlled-DI pacing using a series of single-cell and one-dimensional (1D) fiber models of alternans dynamics. We find that a model that combines a so-called memory model with a calcium cycling model can reasonably explain two key experimental results: the possibility of alternans during constant-DI pacing and the phase lag of APDs behind DIs during sinusoidal-DI pacing. We also find that these results can be replicated by incorporating the memory model into an amplitude equation description of a 1D fiber. The 1D fiber result is potentially concerning because it seems to suggest that constant-DI control of alternans can only be effective over only a limited region in space.
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Affiliation(s)
- Niels F Otani
- Department of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York 14623, USA
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16
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Zlochiver S, Johnson C, Tolkacheva EG. Constant DI pacing suppresses cardiac alternans formation in numerical cable models. CHAOS (WOODBURY, N.Y.) 2017; 27:093903. [PMID: 28964144 DOI: 10.1063/1.4999355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cardiac repolarization alternans describe the sequential alternation of the action potential duration (APD) and can develop during rapid pacing. In the ventricles, such alternans may rapidly turn into life risking arrhythmias under conditions of spatial heterogeneity. Thus, suppression of alternans by artificial pacing protocols, or alternans control, has been the subject of numerous theoretical, numerical, and experimental studies. Yet, previous attempts that were inspired by chaos control theories were successful only for a short spatial extent (<2 cm) from the pacing electrode. Previously, we demonstrated in a single cell model that pacing with a constant diastolic interval (DI) can suppress the formation of alternans at high rates of activation. We attributed this effect to the elimination of feedback between the pacing cycle length and the last APD, effectively preventing restitution-dependent alternans from developing. Here, we extend this idea into cable models to study the extent by which constant DI pacing can control alternans during wave propagation conditions. Constant DI pacing was applied to ventricular cable models of up to 5 cm, using human kinetics. Our results show that constant DI pacing significantly shifts the onset of both cardiac alternans and conduction blocks to higher pacing rates in comparison to pacing with constant cycle length. We also demonstrate that constant DI pacing reduces the propensity of spatially discordant alternans, a precursor of wavebreaks. We finally found that the protective effect of constant DI pacing is stronger for increased electrotonic coupling along the fiber in the sense that the onset of alternans is further shifted to higher activation rates. Overall, these results support the potential clinical applicability of such type of pacing in improving protocols of implanted pacemakers, in order to reduce the risk of life-threatening arrhythmias. Future research should be conducted in order to experimentally validate these promising results.
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Affiliation(s)
- S Zlochiver
- Department of Biomedical Engineering, Tel-Aviv University, Tel-Aviv 69379, Israel
| | - C Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis 55455, USA
| | - E G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis 55455, USA
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17
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Kanaporis G, Blatter LA. Alternans in atria: Mechanisms and clinical relevance. MEDICINA-LITHUANIA 2017; 53:139-149. [PMID: 28666575 DOI: 10.1016/j.medici.2017.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/25/2017] [Indexed: 12/29/2022]
Abstract
Atrial fibrillation is the most common sustained arrhythmia and its prevalence is rapidly rising with the aging of the population. Cardiac alternans, defined as cyclic beat-to-beat alternations in contraction force, action potential (AP) duration and intracellular Ca2+ release at constant stimulation rate, has been associated with the development of ventricular arrhythmias. Recent clinical data also provide strong evidence that alternans plays a central role in arrhythmogenesis in atria. The aim of this article is to review the mechanisms that are responsible for repolarization alternans and contribute to the transition from spatially concordant alternans to the more arrhythmogenic spatially discordant alternans in atria.
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Affiliation(s)
- Giedrius Kanaporis
- Department of Physiology & Biophysics, Rush University Medical Center, Chicago, USA.
| | - Lothar A Blatter
- Department of Physiology & Biophysics, Rush University Medical Center, Chicago, USA
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18
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Tse G, Liu T, Li KHC, Laxton V, Chan YWF, Keung W, Li RA, Yan BP. Electrophysiological Mechanisms of Brugada Syndrome: Insights from Pre-clinical and Clinical Studies. Front Physiol 2016; 7:467. [PMID: 27803673 PMCID: PMC5067537 DOI: 10.3389/fphys.2016.00467] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022] Open
Abstract
Brugada syndrome (BrS), is a primary electrical disorder predisposing affected individuals to sudden cardiac death via the development of ventricular tachycardia and fibrillation (VT/VF). Originally, BrS was linked to mutations in the SCN5A, which encodes for the cardiac Na+ channel. To date, variants in 19 genes have been implicated in this condition, with 11, 5, 3, and 1 genes affecting the Na+, K+, Ca2+, and funny currents, respectively. Diagnosis of BrS is based on ECG criteria of coved- or saddle-shaped ST segment elevation and/or T-wave inversion with or without drug challenge. Three hypotheses based on abnormal depolarization, abnormal repolarization, and current-load-mismatch have been put forward to explain the electrophysiological mechanisms responsible for BrS. Evidence from computational modeling, pre-clinical, and clinical studies illustrates that molecular abnormalities found in BrS lead to alterations in excitation wavelength (λ), which ultimately elevates arrhythmic risk. A major challenge for clinicians in managing this condition is the difficulty in predicting the subset of patients who will suffer from life-threatening VT/VF. Several repolarization risk markers have been used thus far, but these neglect the contributions of conduction abnormalities in the form of slowing and dispersion. Indices incorporating both repolarization and conduction and based on the concept of λ have recently been proposed. These may have better predictive values than the existing markers.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Chinese University of Hong KongHong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Chinese University of Hong KongHong Kong, Hong Kong
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjin, China
| | - Ka H. C. Li
- Faculty of Medicine, Newcastle UniversityNewcastle, UK
| | - Victoria Laxton
- Intensive Care Department, Royal Brompton and Harefield NHS TrustLondon, UK
| | - Yin W. F. Chan
- School of Biological Sciences, University of CambridgeCambridge, UK
| | - Wendy Keung
- Stem Cell and Regenerative Medicine Consortium, Li Ka Shing Faculty of Medicine, The University of Hong KongPokfulam, Hong Kong
| | - Ronald A. Li
- Ming Wai Lau Centre for Reparative Medicine, Karolinska InstitutetSolna, Sweden
| | - Bryan P. Yan
- Department of Medicine and Therapeutics, Chinese University of Hong KongHong Kong, Hong Kong
- Department of Epidemiology and Preventive Medicine, Monash UniversityMelbourne, VIC, Australia
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19
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Tse G, Wong ST, Tse V, Lee YT, Lin HY, Yeo JM. Cardiac dynamics: Alternans and arrhythmogenesis. J Arrhythm 2016; 32:411-417. [PMID: 27761166 PMCID: PMC5063258 DOI: 10.1016/j.joa.2016.02.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 01/28/2016] [Accepted: 02/22/2016] [Indexed: 12/23/2022] Open
Abstract
Pre-existing heterogeneities present in cardiac tissue are essential for maintaining the normal electrical and mechanical functions of the heart. Exacerbation of such heterogeneities or the emergence of dynamic factors can produce repolarization alternans, which are beat-to-beat alternations in the action potential time course. Traditionally, this was explained by restitution, but additional factors, such as cardiac memory, calcium handling dynamics, refractory period restitution, and mechano-electric feedback, are increasingly recognized as the underlying causes. The aim of this article is to review the mechanisms that generate cardiac repolarization alternans and convert spatially concordant alternans to the more arrhythmogenic spatially discordant alternans. This is followed by a discussion on how alternans generate arrhythmias in a number of clinical scenarios, and concluded by an outline of future therapeutic targets for anti-arrhythmic therapy.
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Affiliation(s)
- Gary Tse
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Sheung Ting Wong
- Faculty of Medicine, Imperial College London, SW7 2AZ London, UK
| | - Vivian Tse
- Department of Physiology, McGill University, Canada
| | - Yee Ting Lee
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Hiu Yu Lin
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Jie Ming Yeo
- Faculty of Medicine, Imperial College London, SW7 2AZ London, UK
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20
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Kulkarni K, Tolkacheva EG. Real-time feedback based control of cardiac restitution using optical mapping. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:5920-3. [PMID: 26737639 DOI: 10.1109/embc.2015.7319739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac restitution is the shortening of the action potential duration with an increase in the heart rate. A shorter action potential duration enables a longer diastolic interval which ensures that the heart gets adequate time to refill with blood. At higher rates however, restitution becomes steep and thus, can lead to unstable electrical activity (alternans) in the heart, leading to fatal cardiac rhythms. It has been proposed that maintaining a shallow slope of cardiac restitution could have potentially anti-arrhythmic effects. Previous studies involved the control of action potential duration (APD) or diastolic interval (DI) in isolated tissue samples based on the feedback from single microelectrode recordings. This limited the spatial resolution of the feedback system. Here, we aimed to develop a real time feedback control system that enabled the detection of APDs from various single pixels based on optical mapping recordings. Stimuli were applied after a predefined fixed DI after detection of an APD. We validated our algorithm using optical mapping movies from an ex-vivo rabbit heart. Thus, we provide an optical mapping based approach for the control of cardiac restitution and a potential means to validate its anti-arrhythmic effects.
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21
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Prudat Y, Madhvani RV, Angelini M, Borgstom NP, Garfinkel A, Karagueuzian HS, Weiss JN, de Lange E, Olcese R, Kucera JP. Stochastic pacing reveals the propensity to cardiac action potential alternans and uncovers its underlying dynamics. J Physiol 2016; 594:2537-53. [PMID: 26563830 DOI: 10.1113/jp271573] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022] Open
Abstract
KEY POINTS Beat-to-beat alternation (alternans) of the cardiac action potential duration is known to precipitate life-threatening arrhythmias and can be driven by the kinetics of voltage-gated membrane currents or by instabilities in intracellular calcium fluxes. To prevent alternans and associated arrhythmias, suitable markers must be developed to quantify the susceptibility to alternans; previous theoretical studies showed that the eigenvalue of the alternating eigenmode represents an ideal marker of alternans. Using rabbit ventricular myocytes, we show that this eigenvalue can be estimated in practice by pacing these cells at intervals varying stochastically. We also show that stochastic pacing permits the estimation of further markers distinguishing between voltage-driven and calcium-driven alternans. Our study opens the perspective to use stochastic pacing during clinical investigations and in patients with implanted pacing devices to determine the susceptibility to, and the type of alternans, which are both important to guide preventive or therapeutic measures. ABSTRACT Alternans of the cardiac action potential (AP) duration (APD) is a well-known arrhythmogenic mechanism. APD depends on several preceding diastolic intervals (DIs) and APDs, which complicates the prediction of alternans. Previous theoretical studies pinpointed a marker called λalt that directly quantifies how an alternating perturbation persists over successive APs. When the propensity to alternans increases, λalt decreases from 0 to -1. Our aim was to quantify λalt experimentally using stochastic pacing and to examine whether stochastic pacing allows discriminating between voltage-driven and Ca(2+) -driven alternans. APs were recorded in rabbit ventricular myocytes paced at cycle lengths (CLs) decreasing progressively and incorporating stochastic variations. Fitting APD with a function of two previous APDs and CLs permitted us to estimate λalt along with additional markers characterizing whether the dependence of APD on previous DIs or CLs is strong (typical for voltage-driven alternans) or weak (Ca(2+) -driven alternans). During the recordings, λalt gradually decreased from around 0 towards -1. Intermittent alternans appeared when λalt reached -0.8 and was followed by sustained alternans. The additional markers detected that alternans was Ca(2+) driven in control experiments and voltage driven in the presence of ryanodine. This distinction could be made even before alternans was manifest (specificity/sensitivity >80% for -0.4 > λalt > -0.5). These observations were confirmed in a mathematical model of a rabbit ventricular myocyte. In conclusion, stochastic pacing allows the practical estimation of λalt to reveal the onset of alternans and distinguishes between voltage-driven and Ca(2+) -driven mechanisms, which is important since these two mechanisms may precipitate arrhythmias in different manners.
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Affiliation(s)
- Yann Prudat
- Department of Physiology, University of Bern, Bern, Switzerland
| | - Roshni V Madhvani
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Marina Angelini
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nils P Borgstom
- Department of Bioengineering, University of California, Los Angeles, CA, USA
| | - Alan Garfinkel
- Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Hrayr S Karagueuzian
- Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - James N Weiss
- Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Enno de Lange
- Department of Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Riccardo Olcese
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jan P Kucera
- Department of Physiology, University of Bern, Bern, Switzerland
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22
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Abstract
RATIONALE Alternans is a risk factor for cardiac arrhythmia, including atrial fibrillation. At the cellular level alternans manifests as beat-to-beat alternations in contraction, action potential duration (APD), and magnitude of the Ca(2+) transient (CaT). Electromechanical and CaT alternans are highly correlated, however, it has remained controversial whether the primary cause of alternans is a disturbance of cellular Ca(2+) signaling or electrical membrane properties. OBJECTIVE To determine whether a primary failure of intracellular Ca(2+) regulation or disturbances in membrane potential and AP regulation are responsible for the occurrence of alternans in atrial myocytes. METHODS AND RESULTS Pacing-induced APD and CaT alternans were studied in single rabbit atrial and ventricular myocytes using combined [Ca(2+)]i and electrophysiological measurements. In current-clamp experiments, APD and CaT alternans strongly correlated in time and magnitude. CaT alternans was observed without alternation in L-type Ca(2+) current, however, elimination of intracellular Ca(2+) release abolished APD alternans, indicating that [Ca(2+)]i dynamics have a profound effect on the occurrence of CaT alternans. Trains of 2 distinctive voltage commands in form of APs recorded during large and small alternans CaTs were applied to voltage-clamped cells. CaT alternans was observed with and without alternation in the voltage command shape. During alternans AP-clamp large CaTs coincided with both long and short AP waveforms, indicating that CaT alternans develop irrespective of AP dynamics. CONCLUSIONS The primary mechanism underlying alternans in atrial cells, similarly to ventricular cells, resides in a disturbance of Ca(2+) signaling, whereas APD alternans are a secondary consequence, mediated by Ca(2+)-dependent AP modulation.
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Affiliation(s)
- Giedrius Kanaporis
- From the Department of Molecular Biophysics and Physiology, Rush University Medical Center, Chicago, IL
| | - Lothar A Blatter
- From the Department of Molecular Biophysics and Physiology, Rush University Medical Center, Chicago, IL.
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23
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Heart rate variability and alternans formation in the heart: The role of feedback in cardiac dynamics. J Theor Biol 2014; 350:90-7. [DOI: 10.1016/j.jtbi.2014.02.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 01/28/2014] [Accepted: 02/13/2014] [Indexed: 11/18/2022]
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MONIGATTI-TENKORANG JOANNA, JOUSSET FLORIAN, PASCALE PATRIZIO, VESIN JEANMARC, RUCHAT PATRICK, FROMER MARTIN, NARAYAN SANJIVM, PRUVOT ETIENNE. Intermittent Atrial Tachycardia Promotes Repolarization Alternans and Conduction Slowing During Rapid Rates, and Increases Susceptibility to Atrial Fibrillation in a Free-Behaving Sheep Model. J Cardiovasc Electrophysiol 2014; 25:418-427. [DOI: 10.1111/jce.12353] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 11/09/2013] [Accepted: 12/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - FLORIAN JOUSSET
- Applied Signal Processing Group; Swiss Federal Institute of Technology; Lausanne Switzerland
| | - PATRIZIO PASCALE
- Department of Cardiology; Lausanne University Hospital; Lausanne Switzerland
| | - JEAN-MARC VESIN
- Applied Signal Processing Group; Swiss Federal Institute of Technology; Lausanne Switzerland
| | - PATRICK RUCHAT
- Department of Cardiovascular Surgery; Lausanne University Hospital; Lausanne Switzerland
| | - MARTIN FROMER
- Department of Cardiology; Lausanne University Hospital; Lausanne Switzerland
| | | | - ETIENNE PRUVOT
- Department of Cardiology; Lausanne University Hospital; Lausanne Switzerland
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25
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Jing L, Patwardhan A. Hysteresis in DI independent mechanisms in threshold for transition between 1:1 and 2:2 rhythms in pigs. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:665-8. [PMID: 23365980 DOI: 10.1109/embc.2012.6346019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Previous studies have shown hysteresis in transition from 1:1 to 2:2 rhythms in action potential durations (APD) during decreasing and increasing cycle length pacing. As cycle lengths were constant, when alternans of APD occurred, so did of preceding diastolic intervals (DIs), which engaged the restitution mechanism, i.e. dependence of APD on preceding DI, making it impossible to determine whether the hysteresis originates from the DI independent or dependent mechanism. By using pacing with explicit control of DI, in the present study we investigated whether hysteresis in activation threshold exists in DI independent mechanism of alternans of APD. Transmembrane potentials were recorded from the left ventricles of 6 farm pigs, and the state transition was obtained from two pacing protocols where DIs decreased and increased in steps of 10 msec between 50 and 20 msec with 30 (15) beats at each DI level. Results showed hysteresis: for the 30 (15) beats protocol, onset and termination of alternans occurred at 27 (33) and 47 (49) msec DIs; average alternans amplitude was 22 (13) and 26 (15) msec for decreasing and increasing DIs. Because constant DI pacing was used, restitution dependent effect was eliminated, therefore, observation of hysteresis in our results suggests that restitution independent mechanisms such as activation memory also contribute to the hysteresis in this state transition.
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Affiliation(s)
- Linyuan Jing
- Center for Biomedical Engineering, University of Kentucky, Lexington, KY 40503, USA.
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26
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Weinberg SH, Tung L. Oscillation in cycle length induces transient discordant and steady-state concordant alternans in the heart. PLoS One 2012; 7:e40477. [PMID: 22792346 PMCID: PMC3390356 DOI: 10.1371/journal.pone.0040477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 06/08/2012] [Indexed: 11/19/2022] Open
Abstract
Alternans is a beat-to-beat alternation of the cardiac action potential duration (APD) or intracellular calcium (Cai) transient. In cardiac tissue, alternans can be spatially concordant or discordant, of which the latter has been shown to increase dispersion of repolarization and promote a substrate for initiation of ventricular fibrillation. Alternans has been studied almost exclusively under constant cycle length pacing conditions. However, heart rate varies greatly on a beat-by-beat basis in normal and pathological conditions. The purpose of this study was to determine if applying a repetitive but non-constant pacing pattern, specifically cycle length oscillation (CLO), promotes or suppresses a proarrhythmic substrate. We performed computational simulations and optical mapping experiments to investigate the potential consequences of CLO. In a single cell computational model, CLO induced APD and Cai alternans, which became “phase-matched” with the applied oscillation. As a consequence of the phase-matching, in one-dimensional cable simulations, neonatal rat ventricular myocyte monolayers, and isolated adult guinea pig hearts CLO could transiently induce spatial and electromechanical discordant alternans followed by a steady-state of concordance. Our results demonstrated that under certain conditions, CLO can initiate ventricular fibrillation in the isolated hearts. On the other hand, CLO can also exert an antiarrhythmic effect by converting an existing state of discordant alternans to concordant alternans.
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Affiliation(s)
- Seth H. Weinberg
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail: (SHW); (LT)
| | - Leslie Tung
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail: (SHW); (LT)
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27
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Jing L, Agarwal A, Chourasia S, Patwardhan A. Phase Relationship between Alternans of Early and Late Phases of Ventricular Action Potentials. Front Physiol 2012; 3:190. [PMID: 22701104 PMCID: PMC3370287 DOI: 10.3389/fphys.2012.00190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/21/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Alternans of early phase and of duration of action potential (AP) critically affect dispersion of refractoriness through their influence on conduction and repolarization. We investigated the phase relationship between the two alternans and its effect on conduction. METHODS AND RESULTS Transmembrane potentials recorded from ventricles of eight swine and three canines during paced activation intervals of ≤300 ms were used to quantify alternans of maximum rate of depolarization (|dv/dt|(max)) and of action potential duration (APD). Incidence of APD alternans was 62 and 76% in swine and canines. Alternans of APD was frequently accompanied with alternans of |dv/dt|(max). Of these, 4 and 26% were out of phase in swine and canines, i.e., low |dv/dt|(max) preceded long APD. Computer simulations show that out of phase alternans attenuate variation of wavelength and thus minimize formation of spatially discordant alternans. CONCLUSION The spontaneous switching of phase relationship between alternans of depolarization and repolarization suggests that mechanisms underlying these alternans may operate independent of each other. The phase between these alternans can critically impact spatial dispersion of refractoriness and thus stability of conduction, with the in phase relation promoting transition from concord to discord while out of phase preventing formation of discord.
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Affiliation(s)
- Linyuan Jing
- Center for Biomedical Engineering, University of KentuckyLexington, KY, USA
| | - Anuj Agarwal
- Center for Biomedical Engineering, University of KentuckyLexington, KY, USA
| | - Sonam Chourasia
- Center for Biomedical Engineering, University of KentuckyLexington, KY, USA
| | - Abhijit Patwardhan
- Center for Biomedical Engineering, University of KentuckyLexington, KY, USA
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28
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Gaeta SA, Christini DJ. Non-linear dynamics of cardiac alternans: subcellular to tissue-level mechanisms of arrhythmia. Front Physiol 2012; 3:157. [PMID: 22783195 PMCID: PMC3389489 DOI: 10.3389/fphys.2012.00157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/05/2012] [Indexed: 12/22/2022] Open
Abstract
Cardiac repolarization alternans is a rhythm disturbance of the heart in which rapid stimulation elicits a beat-to-beat alternation in the duration of action potentials and magnitude of intracellular calcium transients in individual cardiac myocytes. Although this phenomenon has been identified as a potential precursor to dangerous reentrant arrhythmias and sudden cardiac death, significant uncertainty remains regarding its mechanism and no clinically practical means of halting its occurrence or progression currently exists. Cardiac alternans has well-characterized tissue, cellular, and subcellular manifestations, the mechanisms and interplay of which are an active area of research.
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Affiliation(s)
- Stephen A. Gaeta
- Department of Physiology, Biophysics and Systems
Biology, Weill Cornell Medical CollegeNew York, NY, USA
| | - David J. Christini
- Department of Physiology, Biophysics and Systems
Biology, Weill Cornell Medical CollegeNew York, NY, USA
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29
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Lemay M, de Lange E, Kucera JP. Uncovering the dynamics of cardiac systems using stochastic pacing and frequency domain analyses. PLoS Comput Biol 2012; 8:e1002399. [PMID: 22396631 PMCID: PMC3291525 DOI: 10.1371/journal.pcbi.1002399] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 01/10/2012] [Indexed: 11/18/2022] Open
Abstract
Alternans of cardiac action potential duration (APD) is a well-known arrhythmogenic mechanism which results from dynamical instabilities. The propensity to alternans is classically investigated by examining APD restitution and by deriving APD restitution slopes as predictive markers. However, experiments have shown that such markers are not always accurate for the prediction of alternans. Using a mathematical ventricular cell model known to exhibit unstable dynamics of both membrane potential and Ca²⁺ cycling, we demonstrate that an accurate marker can be obtained by pacing at cycle lengths (CLs) varying randomly around a basic CL (BCL) and by evaluating the transfer function between the time series of CLs and APDs using an autoregressive-moving-average (ARMA) model. The first pole of this transfer function corresponds to the eigenvalue (λ(alt)) of the dominant eigenmode of the cardiac system, which predicts that alternans occurs when λ(alt) ≤ -1. For different BCLs, control values of λ(alt) were obtained using eigenmode analysis and compared to the first pole of the transfer function estimated using ARMA model fitting in simulations of random pacing protocols. In all versions of the cell model, this pole provided an accurate estimation of λ(alt). Furthermore, during slow ramp decreases of BCL or simulated drug application, this approach predicted the onset of alternans by extrapolating the time course of the estimated λ(alt). In conclusion, stochastic pacing and ARMA model identification represents a novel approach to predict alternans without making any assumptions about its ionic mechanisms. It should therefore be applicable experimentally for any type of myocardial cell.
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Affiliation(s)
- Mathieu Lemay
- Department of Physiology, University of Bern, Bern, Switzerland
| | - Enno de Lange
- Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Jan P. Kucera
- Department of Physiology, University of Bern, Bern, Switzerland
- * E-mail:
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30
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Osadchii OE, Soltysinska E, Olesen SP. Na+ channel distribution and electrophysiological heterogeneities in guinea pig ventricular wall. Am J Physiol Heart Circ Physiol 2011; 300:H989-1002. [DOI: 10.1152/ajpheart.00816.2010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We sought to explore the distribution pattern of Na+ channels across ventricular wall, and to determine its functional correlates, in the guinea pig heart. Voltage-dependent Na+ channel (Nav) protein expression levels were measured in transmural samples of ventricular tissue by Western blotting. Isolated, perfused heart preparations were used to record monophasic action potentials and volume-conducted ECG, and to measure effective refractory periods (ERPs) and pacing thresholds, in order to assess excitability, electrical restitution kinetics, and susceptibility to stimulation-evoked tachyarrhythmias at epicardial and endocardial stimulation sites. In both ventricular chambers, Nav protein expression was higher at endocardium than epicardium, with midmyocardial layers showing intermediate expression levels. Endocardial stimulation sites showed higher excitability, as evidenced by lower pacing thresholds during regular stimulation and downward displacement of the strength-interval curve reconstructed after extrasystolic stimulation compared with epicardium. ERP restitution assessed over a wide range of pacing rates showed greater maximal slope and faster kinetics at endocardial than epicardial stimulation sites. Flecainide, a Na+ channel blocker, reduced the maximal ERP restitution slope, slowed restitution kinetics, and eliminated epicardial-to-endocardial difference in dynamics of electrical restitution. Greater excitability and steeper electrical restitution have been associated with greater arrhythmic susceptibility of endocardium than epicardium, as assessed by measuring ventricular fibrillation threshold, inducibility of tachyarrhythmias by rapid cardiac pacing, and the magnitude of stimulation-evoked repolarization alternans. In conclusion, higher Na+ channel expression levels may contribute to greater excitability, steeper electrical restitution slopes and faster restitution kinetics, and greater susceptibility to stimulation-evoked tachyarrhythmias at endocardium than epicardium in the guinea pig heart.
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Affiliation(s)
- Oleg E. Osadchii
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Ewa Soltysinska
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Soren Peter Olesen
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
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31
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Agarwal A, Patwardhan A. A new approach to measure the contribution of restitution to repolarization alternans. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2009:4516-8. [PMID: 19964640 DOI: 10.1109/iembs.2009.5334109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Several studies suggest link between repolarization alternans and arrhythmia. A potential target for minimization of alternans amplitude is pharmacological flattening of restitution function, which links a diastolic interval (DI) and subsequent action potential duration (APD). While our recent studies have shown that DI dependent restitution is not a necessary mechanism for alternans, in circumstances of nearly invariant activation intervals, restitution contributes to alternans. Determination of the degree to which restitution contributes to alternans during stable alternans, which requires determination of the gain between DI and APD, is not possible because it always is unity. We propose that the rate of change of alternans along the length of the tissue may provide an estimate of the degree to which restitution contributes to alternans amplitude. We conducted experiments with swine to demonstrate the above approach. In a linear strand of tissue, we paced such that DIs for successive activations were invariant at one end, which eliminates the restitution dependent mechanism of alternans at this end. Due to conduction delays, at the distal end, both restitution dependent and independent mechanisms manifest. Action potentials recorded from right ventricular endocardial tissue from swine (n = 3) showed an average difference in amplitudes of alternans between the two ends to be 11.99, 25.49, and 39.37 msec. Rates of change of alternans amplitude as a function of distance, computed using linear interpolation, were 0.36, 1.69 and 0.97. We propose that this rate of change may provide an indirect measure of degree of contribution of restitution to alternans and thus may be useful in evaluating therapeutic approaches to minimize its amplitude.
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32
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de Lange E, Kucera JP. The transfer functions of cardiac tissue during stochastic pacing. Biophys J 2010; 96:294-311. [PMID: 19134481 DOI: 10.1016/j.bpj.2008.09.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 09/29/2008] [Indexed: 11/18/2022] Open
Abstract
The restitution properties of cardiac action potential duration (APD) and conduction velocity (CV) are important factors in arrhythmogenesis. They determine alternans, wavebreak, and the patterns of reentrant arrhythmias. We developed a novel approach to characterize restitution using transfer functions. Transfer functions relate an input and an output quantity in terms of gain and phase shift in the complex frequency domain. We derived an analytical expression for the transfer function of interbeat intervals (IBIs) during conduction from one site (input) to another site downstream (output). Transfer functions can be efficiently obtained using a stochastic pacing protocol. Using simulations of conduction and extracellular mapping of strands of neonatal rat ventricular myocytes, we show that transfer functions permit the quantification of APD and CV restitution slopes when it is difficult to measure APD directly. We find that the normally positive CV restitution slope attenuates IBI variations. In contrast, a negative CV restitution slope (induced by decreasing extracellular [K(+)]) amplifies IBI variations with a maximum at the frequency of alternans. Hence, it potentiates alternans and renders conduction unstable, even in the absence of APD restitution. Thus, stochastic pacing and transfer function analysis represent a powerful strategy to evaluate restitution and the stability of conduction.
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Affiliation(s)
- Enno de Lange
- Department of Physiology, University of Bern, Bern, Switzerland
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33
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Osadchii OE, Larsen AP, Olesen SP. Predictive value of electrical restitution in hypokalemia-induced ventricular arrhythmogenicity. Am J Physiol Heart Circ Physiol 2010; 298:H210-20. [DOI: 10.1152/ajpheart.00695.2009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The ventricular action potential (AP) shortens exponentially upon a progressive reduction of the preceding diastolic interval. Steep electrical restitution slopes have been shown to promote wavebreaks, thus contributing to electrical instability. The present study was designed to assess the predictive value of electrical restitution in hypokalemia-induced arrhythmogenicity. We recorded monophasic APs and measured effective refractory periods (ERP) at distinct ventricular epicardial and endocardial sites and monitored volume-conducted ECG at baseline and after hypokalemic perfusion (2.5 mM K+ for 30 min) in isolated guinea pig heart preparations. The restitution of AP duration measured at 90% repolarization (APD90) was assessed after premature extrastimulus application at variable coupling stimulation intervals, and ERP restitution was assessed by measuring refractoriness over a wide range of pacing rates. Hypokalemia increased the amplitude of stimulation-evoked repolarization alternans and the inducibility of tachyarrhythmias and reduced ventricular fibrillation threshold. Nevertheless, these changes were associated with flattened rather than steepened APD90 restitution slopes and slowed restitution kinetics. In contrast, ERP restitution slopes were significantly increased in hypokalemic hearts. Although epicardial APD90 measured during steady-state pacing (S1-S1 = 250 ms) was prolonged in hypokalemic hearts, the left ventricular ERP was shortened. Consistently, the epicardial ERP measured at the shortest diastolic interval achieved upon a progressive increase in pacing rate was reduced in the hypokalemic left ventricle. In conclusion, this study highlights the superiority of ERP restitution at predicting increased arrhythmogenicity in the hypokalemic myocardium. The lack of predictive value of APD90 restitution is presumably related to different mode of changes in ventricular repolarization and refractoriness in a hypokalemic setting, whereby APD90 prolongation may be associated with shortened ERP.
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Affiliation(s)
- Oleg E. Osadchii
- The Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Anders Peter Larsen
- The Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Soren Peter Olesen
- The Danish National Research Foundation Centre for Cardiac Arrhythmia, Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
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NARAYAN SANJIVM. Is Heart Rate Irregularity the Key to Unmasking Ventricular Proarrhythmia? J Cardiovasc Electrophysiol 2009; 20:880-2. [DOI: 10.1111/j.1540-8167.2009.01486.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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35
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Narayan SM, Franz MR, Lalani G, Kim J, Sastry A. T-Wave Alternans, Restitution of Human Action Potential Duration, and Outcome. J Am Coll Cardiol 2007; 50:2385-92. [DOI: 10.1016/j.jacc.2007.10.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 10/04/2007] [Accepted: 10/18/2007] [Indexed: 10/22/2022]
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36
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Chauhan VS, Selvaraj RJ. Utility of microvolt T-wave alternans to predict sudden cardiac death in patients with cardiomyopathy. Curr Opin Cardiol 2007; 22:25-32. [PMID: 17143041 DOI: 10.1097/hco.0b013e328011aa49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Sudden cardiac death remains a major cause of mortality among patients with cardiomyopathy and implantable cardioverter-defibrillator therapy has been shown to improve survival in these patients. Effective use of prophylactic implantable cardioverter-defibrillator therapy requires accurate risk stratification beyond assessment of ejection fraction, however. Repolarization alternans is a harbinger of ventricular arrhythmias and its measurement from body-surface recordings, also known as microvolt T-wave alternans, is emerging as an effective prognostic tool in these patients based on recent clinical trials. RECENT FINDINGS We review the pathogenesis and determinants of repolarization alternans. The current techniques for measuring T-wave alternans from the body surface are compared, including the spectral and modified moving average methods. Recent clinical trials evaluating the prognostic utility of T-wave alternans in patients with ischemic and nonischemic cardiomyopathy and no prior arrhythmic events are summarized. The findings of these studies are discussed in the context of implantable cardioverter-defibrillator prophylaxis. Body-surface T-wave alternans is an evolving technique and its limitations are presented along with approaches to improve its predictive accuracy. SUMMARY Risk stratification with T-wave alternans has the potential to guide prophylactic implantable cardioverter-defibrillator therapy in a growing population of patients with cardiomyopathy.
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Affiliation(s)
- Vijay S Chauhan
- Division of Cardiology, University Health Network, Toronto, Canada.
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