Aftereffects of high-intensity DC stimulation on the electromechanical performance of ventricular muscle

How to alleviate cardiac injury from electric shocks at the cellular level

Electric shocks, the only effective therapy for ventricular fibrillation, also electroporate cardiac cells and contribute to the high-mortality post-cardiac arrest syndrome. Copolymers such as Poloxamer 188 (P188) are known to preserve the membrane integrity and viability of electroporated cells, but their utility against cardiac injury from cardiopulmonary resuscitation (CPR) remains to be established. We studied the time course of cell killing, mechanisms of cell death, and protection with P188 in AC16 human cardiomyocytes exposed to micro- or nanosecond pulsed electric field (μsPEF and nsPEF) shocks. A 3D printer was customized with an electrode holder to precisely position electrodes orthogonal to a cell monolayer in a nanofiber multiwell plate. Trains of nsPEF shocks (200, 300-ns pulses at 1.74 kV) or μsPEF shocks (20, 100-μs pulses at 300 V) produced a non-uniform electric field enabling efficient measurements of the lethal effect in a wide range of the electric field strength. Cell viability and caspase 3/7 expression were measured by fluorescent microscopy 2-24 h after the treatment. nsPEF shocks caused little or no caspase 3/7 activation; most of the lethally injured cells were permeable to propidium dye already at 2 h after the exposure. In contrast, μsPEF shocks caused strong activation of caspase 3/7 at 2 h and the number of dead cells grew up to 24 h, indicating the prevalence of the apoptotic death pathway. P188 at 0.2-1% reduced cell death, suggesting its potential utility in vivo to alleviate electric injury from defibrillation.

Beneficial Effects of Adjusted Perfusion and Defibrillation Strategies on Rhythm Control within Controlled Automated Reperfusion of the Whole Body (CARL) for Refractory Out-of-Hospital Cardiac Arrest

Survival and neurological outcomes after out-of-hospital cardiac arrest (OHCA) remain low. The further development of prehospital extracorporeal resuscitation (ECPR) towards Controlled Automated Reperfusion of the Whole Body (CARL) has the potential to improve survival and outcome in these patients. In CARL therapy, pulsatile, high blood-flow reperfusion is performed combined with several modified reperfusion parameters and adjusted defibrillation strategies. We aimed to investigate whether pulsatile, high-flow reperfusion is feasible in refractory OHCA and whether the CARL approach improves heart-rhythm control during ECPR. In a reality-based porcine model of refractory OHCA, 20 pigs underwent prehospital CARL or conventional ECPR. Significantly higher pulsatile blood-flow proved to be feasible, and critical hypotension was consistently prevented via CARL. In the CARL group, spontaneous rhythm conversions were observed using a modified priming solution. Applying potassium-induced secondary cardioplegia proved to be a safe and effective method for sustained rhythm conversion. Moreover, significantly fewer defibrillation attempts were needed, and cardiac arrhythmias were reduced during reperfusion via CARL. Prehospital CARL therapy thus not only proved to be feasible after prolonged OHCA, but it turned out to be superior to conventional ECPR regarding rhythm control.

Right ventricular insertion promotes reinitiation of ventricular fibrillation in defibrillation failure

BACKGROUND

Shocks near defibrillation threshold (nDFT) strength commonly extinguish all ventricular fibrillation (VF) wavefronts, but a train of rapid, well-organized postshock activations (PAs) typically appears before sinus rhythm ensues. If one of the PA waves undergoes partial propagation block (wavebreak), reentry may be induced, causing VF to reinitiate and the shock to fail.

OBJECTIVE

The purpose of this study was to determine whether wavebreak leading to VF reinititation following nDFT shocks occurs preferentially at the right ventricular insertion (RVI), which previous studies have identified as a key site for wavebreak.

METHODS

We used panoramic optical mapping to image the ventricular epicardium of 6 isolated swine hearts during nDFT defibrillation episodes. After each experiment, the hearts were fixed and their geometry scanned with magnetic resonance imaging (MRI). The MRI and mapping datasets were spatially coregistered. For failed shocks, we identified the site of the first wavebreak of a PA wave during VF reinitiation.

RESULTS

We recorded 59 nDFT failures. In 31 of these, the first wavebreak event occurred within 1 cm of the RVI centerline, most commonly on the anterior side of the right ventricular insertion (aRVI) (23/31). The aRVI region occupies 16.8% ± 2.5% of the epicardial surface and would be expected to account for only 10 wavebreaks if they were uniformly distributed. By χ2 analysis, aRVI wavebreaks were significantly overrepresented.

CONCLUSION

The anterior RVI is a key site in promoting nDFT failure. Targeting this site to prevent wavebreak could convert defibrillation failure to success and improve defibrillation efficacy.

The Defibrillation Conundrum: New Insights into the Mechanisms of Shock-Related Myocardial Injury Sustained from a Life-Saving Therapy

Implantable cardiac defibrillators (ICDs) are recommended to prevent the risk of sudden cardiac death. However, shocks are associated with an increased mortality with a dose response effect, and a strategy of reducing electrical therapy burden improves the prognosis of implanted patients. We review the mechanisms of defibrillation and its consequences, including cell damage, metabolic remodeling, calcium metabolism anomalies, and inflammatory and pro-fibrotic remodeling. Electrical shocks do save lives, but also promote myocardial stunning, heart failure, and pro-arrhythmic effects as seen in electrical storms. Limiting unnecessary implantations and therapies and proposing new methods of defibrillation in the future are recommended.

Electroporation induced by internal defibrillation shock with and without recovery in intact rabbit hearts

Defibrillation shocks from implantable cardioverter defibrillators can be lifesaving but can also damage cardiac tissues via electroporation. This study characterizes the spatial distribution and extent of defibrillation shock-induced electroporation with and without a 45-min postshock period for cell membranes to recover. Langendorff-perfused rabbit hearts (n = 31) with and without a chronic left ventricular (LV) myocardial infarction (MI) were studied. Mean defibrillation threshold (DFT) was determined to be 161.4 ± 17.1 V and 1.65 ± 0.44 J in MI hearts for internally delivered 8-ms monophasic truncated exponential (MTE) shocks during sustained ventricular fibrillation (>20 s, SVF). A single 300-V MTE shock (twice determined DFT voltage) was used to terminate SVF. Shock-induced electroporation was assessed by propidium iodide (PI) uptake. Ventricular PI staining was quantified by fluorescent imaging. Histological analysis was performed using Masson's Trichrome staining. Results showed PI staining concentrated near the shock electrode in all hearts. Without recovery, PI staining was similar between normal and MI groups around the shock electrode and over the whole ventricles. However, MI hearts had greater total PI uptake in anterior (P < 0.01) and posterior (P < 0.01) LV epicardial regions. Postrecovery, PI staining was reduced substantially, but residual staining remained significant with similar spacial distributions. PI staining under SVF was similar to previously studied paced hearts. In conclusion, electroporation was spatially correlated with the active region of the shock electrode. Additional electroporation occurred in the LV epicardium of MI hearts, in the infarct border zone. Recovery of membrane integrity postelectroporation is likely a prolonged process. Short periods of SVF did not affect electroporation injury.

Ionic mechanism of shock-induced arrhythmias: role of intracellular calcium

BACKGROUND

Strong electrical shocks can cause focal arrhythmias, the mechanism of which is not well known. Strong shocks have been shown to produce diastolic Ca(i)(2+) increase, which may initiate focal arrhythmias via spontaneous Ca(i)(2+) rise (SCR), activation of inward Na(+)/Ca(2+) exchange current (I(NCX)), and rise in membrane potential (V(m)). It can be hypothesized that this mechanism is responsible for generation of shock-induced arrhythmias.

OBJECTIVE

The purpose of this study was to examine the roles of SCRs and I(NCX) in shock-induced arrhythmias.

METHODS

The occurrence of SCRs during shock-induced arrhythmias was assessed in neonatal rat myocyte cultures.

RESULTS

Simultaneous V(m)-Ca(i)(2+) optical mapping at arrhythmia source demonstrated that V(m) upstrokes always preceded Ca(i)(2+) transients, and V(m)-Ca(i)(2+) delays were not different between arrhythmic and paced beats (5.5 ± 0.9 and 5.7 ± 0.4 ms, respectively, P = .5). Shocks caused gradual rise of diastolic Ca(i)(2+) consistent with membrane electroporation but no significant Ca(i)(2+) rises immediately before V(m) upstrokes. Application of the Ca(i)(2+) chelator BAPTA-AM (10 μmol/L) decreased the duration of shock-induced arrhythmias whereas application of the I(NCX) inhibitor KB-R7943 (2 μmol/L) increased it, indicating that, despite the absence of SCRs, changes in Ca(i)(2+) affected arrhythmias. It is hypothesized that this effect is mediated by Ca(i)(2+) inhibition of outward I(K1) current and destabilization of resting V(m). The possible role of I(K1) was supported by application of the I(K1) inhibitor BaCl(2) (0.2 mmol/L), which increased the arrhythmia duration.

CONCLUSION

Shock-induced arrhythmias in neonatal rat myocyte monolayers are not caused by SCRs and inward I(NCX). However, these arrhythmias depend on Ca(i)(2+) changes, possibly via Ca(i)(2+)-dependent modulation of outward I(K1) current.

Spatial distribution and extent of electroporation by strong internal shock in intact structurally normal and chronically infarcted rabbit hearts

INTRODUCTION

Although life-saving, a strong internal defibrillation shock may temporarily or permanently damage the heart via disruption of cell membranes (electroporation). Spatial extent of electroporation in intact, normal, or infarcted hearts has not been investigated. In this study, shock-induced electroporation in intact rabbit hearts with and without chronic (>4 weeks) left ventricular myocardial infarction (MI) was characterized.

METHODS AND RESULTS

A coil shock electrode was inserted in the right ventricle of Langendorff-perfused hearts. One truncated exponential monophasic shock (+300 V, 8 ms) was delivered by a 150 microF capacitor clinical defibrillator while the heart was perfused with membrane-impermeant dye propidium iodide (PI). The heart was sectioned transversely, and uptake of PI into ventricular myocardium through electropores was quantified. Histological evaluation was performed via Masson's trichrome staining. PI accumulation was minimal in the control (n = 3) and MI (n = 3) hearts without shock. Following shock delivery, (1) in control (n = 5) and MI (n = 5) hearts, electroporation mostly occurred near the shock electrode and was longitudinally distributed along the active region of the shock electrode; (2) in MI group, electroporation was significantly increased (P < 0.05) in the surviving anterior epicardial layers of the infarcted region; and (3) between the control and MI groups, the overall extent of electroporation was similar.

CONCLUSION

Shock-induced electroporation was spatially dependent on the location and dimension of the active region of the shock electrode. The overall extent of electroporation in the MI heart was comparable with the control heart, but the surviving anterior epicardial layers in the infarcted region were more susceptible to electroporation.

Atria are more susceptible to electroporation than ventricles: implications for atrial stunning, shock-induced arrhythmia and defibrillation failure

BACKGROUND

Defibrillation shock is known to induce atrial stunning, which is electrical and mechanical dysfunction.

OBJECTIVE

We hypothesized that atrial stunning is caused by higher atrial susceptibility to electroporation vs ventricles. We also hypothesize that electroporation may be responsible for early recurrence of atrial fibrillation.

METHODS

We investigated electroporation induced by 10-ms epicardial high-intensity shocks applied locally in atria and ventricles of Langendorff-perfused rabbit hearts (n = 12) using optical mapping.

RESULTS

Electroporation was centered at the electrode and was evident from transient diastolic depolarization and reduction of action potential amplitude and maximum upstroke derivative. Electroporation was voltage-dependent and polarity-dependent and was significantly more pronounced in the atria vs ventricles (P <.01), with a summary 50% of Effective Dose (ED50) for main measured parameters of 9.2 +/- 3.6 V/cm and 13.6 +/- 3.2 V/cm in the atria vs 37.4 +/- 1.5 V/cm and 48.4 +/- 2.8 V/cm in the ventricles, for anodal and cathodal stimuli, respectively. In atria (n = 5), shocks of both polarities (27.2 +/- 1.1 V/cm) transiently induced conduction block and reentry around the inexcitable area. Electroporation-induced ectopic activity was a possible trigger for reentry. However, in the thicker ventricles, electroporation and resulting conduction slowing and block were restricted to the surface only, preventing complete block and arrhythmia. The upstroke morphology revealed that the wave front dived below the electroporated region and resurfaced into unaffected epicardial tissue.

CONCLUSION

We showed that the atria are more vulnerable to electroporation and resulting block and arrhythmia than the ventricles.

Mechanisms of unpinning and termination of ventricular tachycardia

High-energy defibrillation shock is the only therapy for ventricular tachyarrhythmias. However, because of adverse side effects, lowering defibrillation energy is desirable. We investigated mechanisms of unpinning, destabilization, and termination of ventricular tachycardia (VT) by low-energy shocks in isolated rabbit right ventricular preparations (n = 22). Stable VT was initiated with burst pacing and was optically mapped. Monophasic "unpinning" shocks (10 ms) of different strengths were applied at various phases throughout the reentry cycle. In 8 of 22 preparations, antitachycardia pacing (ATP: 8-20 pulses, 50-105% of period, 0.8-10 mA) was also applied. Termination of reentry by ATP was achieved in only 5 of 8 preparations. Termination by unpinning occurred in all 22 preparations. Rayleigh's test showed a statistically significant unpinning phase window, during which reentry could be unpinned and subsequently terminated with E80 (magnitude at which 80% of reentries were unpinned) = 1.2 V/cm. All reentries were unpinned with field strengths < or = 2.4 V/cm. Unpinning was achieved by inducing virtual electrode polarization and secondary sources of excitation at the core of reentry. Optical mapping revealed the mechanisms of phase-dependent unpinning of reentry. These results suggest that a 20-fold reduction in energy could be achieved compared with conventional high-energy defibrillation and that the unpinning method may be more effective than ATP for terminating stable, pinned reentry in this experimental model.

Asymmetry in membrane responses to electric shocks: insights from bidomain simulations

Models of myocardial membrane dynamics have not been able to reproduce the experimentally observed negative bias in the asymmetry of transmembrane potential changes (DeltaVm) induced by strong electric shocks delivered during the action potential plateau. The goal of this study is to determine what membrane model modifications can bridge this gap between simulation and experiment. We conducted simulations of shocks in bidomain fibers and sheets with membrane dynamics represented by the LRd'2000 model. We found that in the fiber, the negative bias in DeltaVm asymmetry could not be reproduced by addition of electroporation only, but by further addition of hypothetical outward current, Ia, activated upon strong shock-induced depolarization. Furthermore, the experimentally observed rectangularly shaped positive DeltaVm, negative-to-positive DeltaVm ratio (asymmetry ratio) = approximately 2, electroporation occurring at the anode only, and the increase in positive DeltaVm caused by L-type Ca2+-channel blockade were reproduced in the strand only if Ia was assumed to be a part of K+ flow through the L-type Ca2+-channel. In the sheet, Ia not only contributed to the negative bias in DeltaVm asymmetry at sites polarized by physical and virtual electrodes, but also restricted positive DeltaVm. Inclusion of Ia and electroporation is thus the bridge between experiment and simulation.

Virtual electrode theory explains pacing threshold increase caused by cardiac tissue damage

The virtual electrode polarization (VEP) effect is believed to play a key role in electrical stimulation of heart muscle. However, under certain conditions, including clinically, its existence and importance remain unknown. We investigated the influence of acute tissue damage produced by continuous pacing with strong current (40-mA, 4-ms biphasic pulses with 4-Hz frequency for 5 min) on stimulus-generated VEPs and pacing thresholds. A fluorescent optical mapping technique was used to obtain stimulus-induced transmembrane potential distribution around a pacing electrode applied to the ventricular surface of a Langendorff-perfused rabbit heart ( n = 5). Maps and pacing thresholds were recorded before and after tissue damage. Spatial extents of electroporation and cell uncoupling were assessed by propidium iodide ( n = 2) and connexin43 ( n = 3) antibody staining, respectively. On the basis of these data, passive and active three-dimensional bidomain models were built to determine VEP patterns and thresholds for different-sized areas of the damaged region. Electrophysiological results showed that acute tissue damage led to disappearance of the VEP with an associated significant increase in pacing thresholds. Damage was expressed in electroporation and cell uncoupling within a ∼1.0-mm-diameter area around the tip of the electrode. According to computer simulations, cell uncoupling, rather than electroporation, might be the direct cause of VEP elimination and threshold increase, which was nonlinearly dependent on the size of the damaged region. Fiber rotation with depth did not substantially affect the numerical results. The study explains failure to stimulate damaged tissue within the concepts of the VEP theory.

Hyperpolarization and lysophosphatidylcholine induce inward currents and ethidium fluorescence in rabbit ventricular myocytes

Strong electric pulses produce reversible or irreversible membrane breakdown (electroporation). We analysed the permeation properties of minute pores caused by hyperpolarization or lysophosphatidylcholine (LPC) by comparing the amount of charge carried by irregular inward currents (I(hi)) with changes in ethidium bromide (EB) fluorescence in isolated rabbit ventricular myocytes. Forty-second negative pulses from a holding potential of -20 mV induced I(hi) whose conductance increased with hyperpolarization; the mean conductance (G(hi)) was 63.6 +/- 9.9 pS pF(-1) (mean +/- S.E.M., n = 9) at -160 mV. EB fluorescence increased during voltage pulses in parallel with the time integral of I(hi) (Q(hi)), with the magnitude of the increases in nuclear EB fluorescence being 5.3 times greater than in the cytoplasm at -160 mV. Similar hyperpolarization-induced parallel increases in I(hi) and EB fluorescence were also obtained in Na(+)-free, N-methyl-D-glucamine (NMDG) solution. LPC (10 microM) induced large (101.2 +/- 21.2 pS pF(-1), n = 16), rapid (rise times, 1-10 ms) I(hi) with slow relaxation rates at -80 mV that reflected increases in G(hi) to 94.3 +/- 24.8 pS pF(-1) (n = 8) at 6 min. Plots of EB fluorescence vs. Q(hi) were well fitted by a common Hill's equation with a Hill coefficient of 0.97. Taken together, our findings indicate that hyperpolarization and LPC produced pores having the same filter properties for the permeation of small ions, including ethidium(+), and that I(hi) (carried in part by Ca(2+)) generated by membrane breakdown are capable of supplying sufficient ions to evoke abnormal excitation and contraction in cardiac myocytes.

Both low and high energy cardioversion induced accelerated ventricular tachycardia in a patient treated with an implantable cardioverter defibrillator

A 72-year old male with an old myocardial infarction who had drug-refractory ventricular tachyarrhythmias received an implantable cardioverter-defibrillator (ICD). The patient did not take his prescribed beta-blocking agent for two days, following which he experienced six discrete shocks for spontaneous VT while riding his bicycle. Both 5J and 30J cardioversions were ineffective at terminating the VT and accelerated VT developed following the shocks. After admission, an electrophysiological study was performed while he was taking the beta-blocking agent, both low and high energy cardioversions reproducibly terminated the clinical VT without showing any accelerated rhythm. These findings suggest that the increase in sympathetic discharge may enhance the proarrhythmic potential of ICDs.

Low K+-induced hyperpolarizations trigger transient depolarizations and action potentials in rabbit ventricular myocytes

1. The effects of large reductions of [K+]o on membrane potential were studied in isolated rabbit ventricular myocytes using the whole-cell patch clamp technique. 2. Decreasing [K+]o from the normal level of 5.4 mM to 0.1 mM increased resting membrane potential (Vrest) from -75.6 +/- 0.3 to -140.3 +/- 1.9 mV (means +/- s.e.m; n = 127), induced irregular, transient depolarizations with mean maximal amplitudes of 19.5 +/- 1.5 mV and elicited action potentials in 56.7 % of trials. The action potentials exhibited overshoots of 37.9 +/- 1.5 mV (n = 72) and sustained plateaux. 3. Addition of 0.1 mM La3+ in the presence of 0.1 mM [K+]o significantly increased Vrest but decreased the amplitude of transient depolarizations and suppressed the firing of action potentials. 4. Replacement of external Na+ or Cl- with N-methyl-D-glucamine or aspartate, respectively, or internal dialysis with 10 mM EGTA or BAPTA had little effect on low [K+]o-induced membrane potential changes. 5. Hyperpolarizing voltage clamp pulses to potentials between -110 and -200 mV activated irregular inward currents that increased in amplitude and frequency with increasing hyperpolarization and were depressed by 0.1 mM La3+. 6. The generation of transient depolarizations by low [K+]o can be explained as being a consequence of decreasing the inward rectifier K+ current (IK1) and the appearance of inward currents reflecting electroporation resulting from strong electric fields across the membrane.