Analysis of interectopic activation patterns during sustained ventricular tachycardia

New drug discovery of cardiac anti-arrhythmic drugs: insights in animal models

Cardiac rhythm regulated by micro-macroscopic structures of heart. Pacemaker abnormalities or disruptions in electrical conduction, lead to arrhythmic disorders may be benign, typical, threatening, ultimately fatal, occurs in clinical practice, patients on digitalis, anaesthesia or acute myocardial infarction. Both traditional and genetic animal models are: In-vitro: Isolated ventricular Myocytes, Guinea pig papillary muscles, Patch-Clamp Experiments, Porcine Atrial Myocytes, Guinea pig ventricular myocytes, Guinea pig papillary muscle: action potential and refractory period, Langendorff technique, Arrhythmia by acetylcholine or potassium. Acquired arrhythmia disorders: Transverse Aortic Constriction, Myocardial Ischemia, Complete Heart Block and AV Node Ablation, Chronic Tachypacing, Inflammation, Metabolic and Drug-Induced Arrhythmia. In-Vivo: Chemically induced arrhythmia: Aconitine antagonism, Digoxin-induced arrhythmia, Strophanthin/ouabain-induced arrhythmia, Adrenaline-induced arrhythmia, and Calcium-induced arrhythmia. Electrically induced arrhythmia: Ventricular fibrillation electrical threshold, Arrhythmia through programmed electrical stimulation, sudden coronary death in dogs, Exercise ventricular fibrillation. Genetic Arrhythmia: Channelopathies, Calcium Release Deficiency Syndrome, Long QT Syndrome, Short QT Syndrome, Brugada Syndrome. Genetic with Structural Heart Disease: Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Atrial Fibrillation, Sick Sinus Syndrome, Atrioventricular Block, Preexcitation Syndrome. Arrhythmia in Pluripotent Stem Cell Cardiomyocytes. Conclusion: Both traditional and genetic, experimental models of cardiac arrhythmias' characteristics and significance help in development of new antiarrhythmic drugs.

Animal Models to Study Cardiac Arrhythmias

Cardiac arrhythmias are a significant cause of morbidity and mortality worldwide, accounting for 10% to 15% of all deaths. Although most arrhythmias are due to acquired heart disease, inherited channelopathies and cardiomyopathies disproportionately affect children and young adults. Arrhythmogenesis is complex, involving anatomic structure, ion channels and regulatory proteins, and the interplay between cells in the conduction system, cardiomyocytes, fibroblasts, and the immune system. Animal models of arrhythmia are powerful tools for studying not only molecular and cellular mechanism of arrhythmogenesis but also more complex mechanisms at the whole heart level, and for testing therapeutic interventions. This review summarizes basic and clinical arrhythmia mechanisms followed by an in-depth review of published animal models of genetic and acquired arrhythmia disorders.

Ventricular Tachycardia in Structural Heart Disease

Patients with structural heart disease (SHD) are at risk of ventricular tachycardia (VT), which can be difficult to manage clinically. Many treatment options are currently available, but no single approach can be applied with 100% perfect results; often, a combination of therapies is required to achieve good control of ventricular arrhythmias. Coronary artery disease with previous myocardial infarction (MI) is the most common form of SHD presenting with VT, with scar-mediated reentry being the predominant mechanism. Other cardiomyopathies such as arrhythmogenic right ventricular cardiomyopathy, sarcoidosis, Chagas disease, and repaired congenital heart disease can also present in conjunction with ventricular arrhythmias. A thorough analysis of the patient’s history, 12-lead electrocardiogram, and imaging findings are essential for understanding the mechanism and guiding localization of the site of origin of the arrhythmia and the presence of underlying heart disease, which will improve outcomes following catheter ablation if such is indicated. Separately, antiarrhythmic drugs have not been shown to decrease mortality in this patient population but can help to reduce the VT burden and subsequently the need for implantable cardioverter-defibrillator therapy. Unfortunately, most antiarrhythmic agents are negative inotropes, with the possibility of worsening heart failure. This review aims to discuss the current options available for the management of VT in SHD.

A review of the literature on cardiac electrical activity between fibroblasts and myocytes

Myocardial injuries often lead to fibrotic deposition. This review presents evidence supporting the concept that fibroblasts in the heart electrically couple to myocytes.

Electrophysiological and inotropic characterization of a novel class III antiarrhythmic agent, GLG-V-13, in the mammalian heart

GLG-V-13, a novel 3,7-diheterabicyclo(3.3.1)nonane, was examined both in vivo and in vitro to characterize its electrophysiological, hemodynamic, and inotropic properties. In anesthetized guinea pigs, GLG-V-13 [0.5-500 micrograms/kg intravenously (i.v.), n = 6] lengthened the epicardial monophasic action potential (MAP) duration, the atrioventricular (AV) conduction time and the RR interval in a dose-dependent manner. At the highest dose, these variables were increased by 30, 13, and 23%, respectively. No significant effects were noted on QRS duration or blood pressure (BP). In rabbit atrial and papillary muscle preparations, GLG-V-13 (0.32-3.2 mg/L) did not exert a negative inotropic action and in isolated rabbit cardiomyocytes the agent blocked the rapidly activating delayed rectifier K+ current (IKr, EC50 = 48 micrograms/L). In 10 intact anesthetized mongrel dogs, the left ventricular (LV) endocardial MAP was measured during atrial pacing before and after administration of GLG-V-13 (3 and 6 mg/kg i.v.). As compared with the drug-free state, the agent induced a significant prolongation of the MAP at all pacing frequencies (2.0-4.5 Hz). In 15 anesthetized dogs studied 1-4 days after two-stage ligation of the left anterior descending coronary artery (LAD), the antiarrhythmic/proarrhythmic potential of GLG-V-13 was compared with that of lidocaine. ECG, His bundle, LV (IZepi), and composite and normal zone composite electrograms were recorded. Programmed electrical stimulation (PES) and burst pacing (4.0-7.0 Hz) were delivered to the right ventricular outflow tract. In the drug-free state, sustained monomorphic ventricular tachycardia (SMVT) was inducible in 6 dogs (6 of 15). After lidocaine, SMVT was induced in 7 other dogs (13 of 15). GLG-V-13 prevented induction of SMVT in 5 of 6 dogs; a proarrhythmic action was noted in 1 dog only. GLG-V-13 slowed the heart rate (HR), increased the AH and the HV intervals, prolonged the paced (2.5 Hz) QT interval, and increased the ventricular effective refractory period (VERP). These effects were associated with 2:1 block of late potentials in the IZepi electrograms, a phenomenon also observed during rapid atrial pacing (2.5-3.5 Hz), suggestive of a marked prolongation of refractoriness in the ischemically damaged myocardium. In light of the recent Cardiac Arrhythmia Suppression Trial (CAST) study, the antiarrhythmic efficacy, together with the low proarrhythmic potential and lack of cardiodepressant properties of GLG-V-13, may merit further investigation of this novel class III antiarrhythmic agent.

Entrainment techniques for mapping atrial and ventricular tachycardias

Many atrial tachycardias, atrial flutter, and postmyocardial infarction ventricular tachycardias are due to reentry through large "macroreentrant" circuits. These circuits can be difficult to define by catheter mapping of the activation sequence. Entrainment techniques allow the relation of a mapping site to the reentrant circuit to be assessed on a site-by-site basis during catheter mapping. Regions of abnormal conduction that are in the reentrant circuit can be distinguished from bystander sites outside the circuit. A mapping site classification to guide catheter ablation is reviewed.

Facilitation of reentry by lidocaine in canine myocardial infarction

The authors studied the effects of lidocaine in 18 consecutive dogs with myocardial infarction 1 to 4 days after two-stage left anterior descending coronary artery ligation. Electrophysiologic testing was performed in anesthetized dogs after infarction with single-, double-, or triple-programmed extrastimuli or rapid bursts (3 beats at 240 to 420 beats/min) delivered to the right ventricular outflow tract. Inducibility of sustained monomorphic ventricular tachycardia after an intravenous bolus of lidocaine (3 to 6 mg/kg) was compared in the same animal to the premedicated state. In the control state, sustained monomorphic ventricular tachycardia was inducible in 6 of 18 dogs. After administration of lidocaine, electrically induced sustained monomorphic ventricular tachycardia was initiated in an additional nine dogs (which were previously noninducible; after lidocaine administration vs control p < 0.02). The antiarrhythmic agent induced further rate-dependent slowing of conduction in the periinfarction subepicardium, which at a critical value of rate and amount of conduction delay resulted in sustained reentrant monomorphic tachycardia. These results show that lidocaine has marked proarrhythmic action in this canine model of myocardial infarction, probably because of its depressant effect on injured cardiac tissue.

Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction

BACKGROUND

Ventricular tachycardia reentry circuits in chronic infarct scars can contain slow conduction zones, which are difficult to distinguish from bystander areas adjacent to the circuit during catheter mapping. This study developed criteria for identifying reentry circuit sites using computer simulations. These criteria then were tested during catheter mapping in humans to predict sites at which radiofrequency current application terminated ventricular tachycardia.

METHODS AND RESULTS

In computer simulations, effects of single stimuli and stimulus trains at sites in and adjacent to reentry circuits were analyzed. Entrainment with concealed fusion, defined as ventricular tachycardia entrainment with no change in QRS morphology, could occur during stimulation in reentry circuit common pathways and adjacent bystander sites. Pacing at reentry circuit common pathway sites, the stimulus to QRS (S-QRS) interval equals the electrogram to QRS interval (EG-QRS) during tachycardia. The postpacing interval from the last stimulus to the following electrogram equals the tachycardia cycle length. Pacing at bystander sites the S-QRS exceeds the EG-QRS interval when the conduction time from the bystander site to the circuit is short but may be less than or equal to the EG-QRS interval when the conduction time to the circuit is long. The postpacing interval, however, always exceeds the tachycardia cycle length. When conduction in the circuit slows during pacing, the S-QRS and postpacing intervals increase and the slowest stimulus train most closely reflects conduction times during tachycardia. Endocardial catheter mapping and radiofrequency ablation were performed during 31 monomorphic ventricular tachycardias in 15 patients with drug refractory ventricular tachycardia late after myocardial infarction. During ventricular tachycardia, trains of electrical stimuli or scanning single stimuli were evaluated before application of radiofrequency current at the same site. Radiofrequency current terminated ventricular tachycardia at 24 of 241 sites (10%) in 12 of 15 patients (80%). Ventricular tachycardia termination occurred more frequently at sites with entrainment with concealed fusion (odds ratio, 3.4; 95% confidence interval [CI], 1.4 to 8.3), a postpacing interval approximating the ventricular tachycardia cycle length (odds ratio, 4.6; 95% CI, 1.6 to 12.9) and an S-QRS interval during entrainment of more than 60 milliseconds and less than 70% of the ventricular tachycardia cycle length (odds ratio, 4.9; 95% CI, 1.4 to 17.1). Ventricular tachycardia termination was also predicted by the presence of isolated diastolic potentials or continuous electrical activity (odds ratio, 5.2; 95% CI, 1.8 to 15.5), but these electrograms were infrequent (8% of all sites). Combinations of entrainment with concealed fusion, postpacing interval, S-QRS intervals, and isolated diastolic potentials or continuous electrical activity predicted a more than 35% incidence of ventricular tachycardia termination during radiofrequency current application versus a 4% incidence when none suggested that the site was in the reentry circuit. Analysis of the postpacing interval and S-QRS interval suggested that 25% of the sites with entrainment with concealed fusion were in bystander areas not within the reentry circuit. At restudy 5 to 7 days later, 6 patients had no monomorphic ventricular tachycardia inducible, and inducible ventricular tachycardias were modified in 4 patients. None of these 10 patients have suffered arrhythmia recurrences during a follow-up of 316 +/- 199 days, although 4 continue to receive previously ineffective medications.

CONCLUSIONS

Regions giving rise to reentry after myocardial infarction are complex and can include bystander areas, slow conduction zones, and isthmuses for impulse propagation at which radiofrequency current lesions can interrupt reentry.

Seasonal variation in sudden cardiac death after experimental myocardial infarction

The authors studied the incidence of sudden death by monitoring the ECG after ligation of the left anterior descending coronary artery in 184 dogs. A significant number of sudden deaths (46 dogs) occurred in the cold weather months, November-February (42%), compared to the summer months, July and August (6%). All deaths resulted from ventricular tachyarrhythmias (greater than or equal to 300/min) and occurred between 13 and 22 hours after coronary artery ligation. The survivors (138 dogs) were subjected to electrophysiological study, during which a significantly higher number showed induced sustained monomorphic ventricular tachycardia (VT) (heart rate greater than or equal to 300/min) during the winter months than during the summer months. Heart weight and infarct mass were not significantly different throughout the year. Higher sympathetic tone or catecholamine levels may account for the seasonal variation in sudden death during evolving myocardial infarction.

Pleomorphic ventricular tachycardia: demonstration of conduction reversal within the reentry circuit

A case is presented of a patient with incessant ventricular tachycardia of left bundle branch block morphology. Endocardial mapping revealed the site of earliest activation during tachycardia to be the proximal right ventricular septum. Pacing at this site elicited the clinical tachycardia, whereas pacing at the proximal left ventricular septum induced a right bundle branch block morphology identical to that of a previously recorded spontaneous ventricular tachycardia. Electrophysiological evidence is given that both types of tachycardia originate from a single reentry circuit located in the proximal ventricular septum in which the reentrant wavefront may travel either orthodromically (during spontaneous tachycardia and right ventricular pacing) or antidromically (during left ventricular pacing).

Electrogram patterns predicting successful catheter ablation of ventricular tachycardia

Ventricular tachycardia in patients with remote myocardial infarction is thought to be due to reentry. To improve the efficacy of catheter ablation, we sought to identify electrograms identifying essential components of the reentrant circuit. In this study we compared the efficacy of shocks delivered at sites of early ventricular activation during tachycardia (presumably exit sites from the reentrant circuit) with that of shocks delivered at sites recording mid-diastolic potentials that were not continuous with the main ventricular potential recorded during the QRS complex, but that always remained associated with the tachycardia during initiation, termination, and resetting with extrastimuli (presumably activation of a segment of the slowly conducting region of the reentrant circuit). A total of 20 attempts was made to ablate 14 monomorphic ventricular tachycardias in 10 patients with remote myocardial infarction with use of one to five shocks of 50 to 370 J (200 J in 70%). All seven tachycardias in which isolated mid-diastolic potentials were targeted were successfully ablated, although one required a second attempt. Twelve attempts were made to ablate seven tachycardias by delivering shocks at sites of early activation during tachycardia when mid-diastolic potentials were not identified. Only three attempts (25%) were successful. Activation preceded the QRS complex by 60, 85, and 120 msec in the three successful attempts and by 20 to 110 msec (median 55 msec) in the nine unsuccessful attempts. For the total 20 attempts, there was no significant difference between successful and nonsuccessful ablation in the number of shocks or total energy delivered.(ABSTRACT TRUNCATED AT 250 WORDS)

Validation of double-spike electrograms as markers of conduction delay or block in atrial flutter

Recent mapping studies of atrial flutter have shown that fragmented electrograms can be found in most cases from the posterior, posteroseptal and posterolateral walls of the right atrium. The fragmentation pattern most often consists of a double spike. To further assess double-spike electrograms as a possible marker of conduction delay, bipolar electrograms were continuously recorded during atrial overdrive pacing of common flutter from the right atrium (7 patients) and from the proximal coronary sinus (5). Baseline double-spike separation of 50 to 130 ms was unchanged in 1 patient and slightly increased (5 to 25 ms) in 4 by coronary sinus pacing. The electrogram sequence was unchanged and the surface morphology was similar to that of basal flutter. Right atrial pacing decreased double-spike separation by 25 to 85 ms from basal values of 45 to 175 ms (23 to 83%), suggesting fusion in the area of fragmented electrograms. These findings suggest that double-spike electrograms represent activation on both sides of a conduction delay zone. The changes induced in these electrograms by pacing from the anterior right atrium and the coronary sinus are consistent with flutter circuits rotating counterclockwise (frontal plane) in the posterior right atrial wall in common atrial flutter.

Fragmented electrograms and continuous electrical activity in atrial flutter

Multiple endocardial bipolar electrograms were recorded in 13 patients with atrial flutter (AF) to locate areas of fragmented electrical activity. Stable fragmentation patterns were found in each case, covering between 36% and 100% of the flutter cycle. Double or triple spike patterns were common. The direction of atrial activation was approximately defined in 11 patients, and in all of them at least part of the areas showing fragmentation was included in the circuit. In 1 patient an area of continuous electrical activity was found. AF circuits appeared to be included in the right atrium in 12 patients and in the left atrium in 1 patient. During atrial stimulation changes in fragmented electrograms coincided with changes in AF pattern before its interruption, while restoration of stable AF after stimulation was accompanied by reappearance of previous stable fragmented electrograms. In 6 patients electrograms were recorded after sinus rhythm was reestablished, and all showed marked decreases or disappearance of fragmentation. It is concluded that fragmented electrograms are often found in AF and may be related to abnormal local conduction in relation to the reentrant activation circuits.