Effects of atrial defibrillation shocks on the ventricles in isolated sheep hearts

The effect of pinacidil on postshock activation and ventricular defibrillation threshold in canine hearts

AIM

To determine the postshock activation patterns with both successful and failed shocks in a canine model of ventricular fibrillation, and whether piniacidil, an early after-depolarization (EAD) inhibitor, altered the defibrillation threshold (DFT) and postshock activation patterns.

METHODS

In 6 beagles, a basket catheter with 64 unipolar electrodes was placed in the LV for global endocardial mapping, a monophasic action potential catheter was inserted into the LV apex, and a catheter with the negative electrode in the right ventricle and the positive electrode in the superior vena cava was inserted for defibrillation. The DFT, 90% action potential duration (APD(90)) and activation recovery interval (ARI) were evaluated before and after pinacidil administration (loading dosage 0.5 mg/kg and maintenance dosage 0.5 mg·kg(-1)·h(-1), iv). Electrical heterogeneities were defined with the dispersion of ARI. After successful and failed shocks with near-DFT strength, the earliest postshock activation patterns (focal or nonfocal endocardial activation), interval and location were detected.

RESULTS

Pinacidil significantly decreased APD(90) (from 178±16 ms to 168±18 ms) and ARI from (152±10 ms to 143±10 ms) at pacing cycle length of 300 ms. The drug significantly increased VF activation rate (from 10.0±1.9 Hz to 10.8±2.0 Hz). The drug did not affect the dispersion of ARI, neither it changed DFT (baseline: 480±110 V; pinacidil: 425±55 V, P>0.05). The earliest postshock activation arose locally on the LV apical endocardium before and after the drug treatment. Pinacidil significantly prolonged the postshock cycle length of cycles 2 to 5 for the successful episodes but not for the failed episodes.

CONCLUSION

Pinacidil increases the postshock cycle length suggesting that EAD may play a role in postshock activation, while it fails to alter DFT suggesting that EAD produced by shock does not determine a defibrillation success or failure.

Low-energy multistage atrial defibrillation therapy terminates atrial fibrillation with less energy than a single shock

BACKGROUND

Implantable device therapy of atrial fibrillation (AF) is limited by pain from high-energy shocks. We developed a low-energy multistage defibrillation therapy and tested it in a canine model of AF.

METHODS AND RESULTS

AF was induced by burst pacing during vagus nerve stimulation. Our novel defibrillation therapy consisted of 3 stages: stage (ST) 1 (1-4 low-energy biphasic [BP] shocks), ST2 (6-10 ultralow-energy monophasic [MP] shocks), and ST3 (antitachycardia pacing). First, ST1 testing compared single or multiple MP and BP shocks. Second, several multistage therapies were tested: ST1 versus ST1+ST3 versus ST1+ST2+ST3. Third, 3 shock vectors were compared: superior vena cava to distal coronary sinus, proximal coronary sinus to left atrial appendage, and right atrial appendage to left atrial appendage. The atrial defibrillation threshold (DFT) of 1 BP shock was <1 MP shock (0.55 ± 0.1 versus 1.38 ± 0.31 J, P=0.003). Two to 3 BP shocks terminated AF with lower peak voltage than 1 BP or 1 MP shock and with lower atrial DFT than 4 BP shocks. Compared with ST1 therapy alone, ST1+ST3 lowered the atrial DFT moderately (0.51 ± 0.46 versus 0.95 ± 0.32 J, P=0.036), whereas 3-stage therapy (ST1+ST2+ST3) dramatically lowered the atrial DFT (0.19 ± 0.12 versus 0.95 ± 0.32 J for ST1 alone, P=0.0012). Finally, the 3-stage therapy was equally effective for all studied vectors.

CONCLUSIONS

Three-stage electrotherapy significantly reduces the AF DFT and opens the door to low-energy atrial defibrillation at or below the pain threshold.

Termination of sustained atrial flutter and fibrillation using low-voltage multiple-shock therapy

BACKGROUND

Defibrillation therapy for atrial fibrillation (AF) and flutter (AFl) is limited by pain induced by high-energy shocks. Thus, lowering the defibrillation energy for AFl/AF is desirable.

OBJECTIVE

In this study we applied low-voltage multiple-shock defibrillation therapy in a rabbit model of atrial tachyarrhythmias comparing its efficacy to single shocks and antitachycardia pacing (ATP).

METHODS

Optical mapping was performed in Langendorff-perfused rabbit hearts (n = 18). Acetylcholine (7 ± 5 to 17 ± 16 μM) was administered to promote sustained AFl and AF, respectively. Single and multiple monophasic shocks were applied within 1 or 2 cycle lengths (CLs) of the arrhythmia.

RESULTS

We observed AFl (CL = 83 ± 15 ms, n = 17) and AF (CL = 50 ± 8 ms, n = 11). ATP had a success rate of 66.7% in the case of AFl, but no success with AF (n = 9). Low-voltage multiple shocks had 100% success for both arrhythmias. Multiple low-voltage shocks terminated AFl at 0.86 ± 0.73 V/cm (within 1 CL) and 0.28 ± 0.13 V/cm (within 2 CLs), as compared with single shocks at 2.12 ± 1.31 V/cm (P < .001) and AF at 3.46 ± 3 V/cm (within 1 CL), as compared with single shocks at 6.83 ± 3.12 V/cm (P =.06). No ventricular arrhythmias were induced. Optical mapping revealed that termination of AFl was achieved by a properly timed, local shock-induced wave that collides with the arrhythmia wavefront, whereas AF required the majority of atrial tissue to be excited and reset for termination.

CONCLUSION

Low-voltage multiple-shock therapy terminates AFl and AF with different mechanisms and thresholds based on spatiotemporal characteristics of the arrhythmias.

Transmural optical measurements of Vm dynamics during long-duration ventricular fibrillation in canine hearts

BACKGROUND

Knowledge of transmural V(m) changes is important for understanding the mechanism of long-duration ventricular fibrillation (LDVF).

OBJECTIVE

The purpose of this study was to measure transmural V(m) changes during LDVF.

METHODS

V(m) was recorded optically at up to 8 transmural points separated by 1.5 mm in the left ventricle of Langendorff-perfused canine hearts (n = 6) using a bundle of optical fibers (optrode) during 10 minutes of LDVF followed by 3 minutes of VF with reperfusion. Measurements were grouped into 4 layers: epicardium, subepicardium, midwall, and subendocardium.

RESULTS

Activation rates (ARs) and action potential durations (APDs) decreased, whereas diastolic intervals (DIs) increased during LDVF in all transmural layers (P < .05). After approximately 3 minutes of LDVF, ARs were faster and DIs shorter in the midwall and subendocardium than in the epicardium and subepicardium (P < .05). Activations persisted at the subendocardium but disappeared from other layers after approximately 8 minutes of VF in the majority of hearts. There were no transmural differences in APD during LDVF or during pacing before and after LDVF (P > .05). Restitution plots showed no functional relationship between APD and DI in any layer at any stage of LDVF. Partial reperfusion during VF for 3 minutes restored transmural synchronicity of activation and eliminated gradients in activation parameters.

CONCLUSION

V(m) dynamics evolve differently at different transmural layers. The subendocardium maintains persistent and the fastest activation during 10 minutes of LDVF, suggesting it contains the source of VF wavefronts. There are no transmural APD gradients and no restitution relationship between APD and DI at any transmural layer, indicating these are not the primary factors in the mechanism of LDVF.

Internal defibrillation: where we have been and where we should be going?

Internal cardioversion has been developed as an alternative technique for patients who are resistant to external DC cardioversion of atrial fibrillation (AF) and was found to be associated with higher success rates. It used initially high energies (200-300 J) delivered between an intracardiac catheter and a backplate. Subsequent studies have shown that it is possible to terminate with energies of 1 to 6 Joules, paroxysmal or induced AF in 90 percent of patients and persistent AF in 75 percent of patients, using biphasic shocks delivered between a right atrium-coronary sinus vectors. Consequently, internal atrial defibrillation can be performed under sedation only without the need for general anesthesia. Recently developed external defibrillators, capable of delivering biphasic shocks, have increased the success rates of external cardioversion and reduced the need for internal cardioversion. However, internal defibrillation is still useful in overweight or obese patients, in patients with chronic obstructive pulmonary disease or asthma who are more difficult to defibrillate, and in patients with implanted devices which may be injured by high energy shocks. Low energy internal defibrillation has also proven to be safe and this has prompted the development of implantable devices for terminating AF. The first device used was the Metrix system, a stand-alone atrial defibrillator (without ventricular defibrillation) which was found to be safe and effective in selected groups of patients. Unfortunately, this device is no longer being marketed. Only double chamber defibrillators with pacing capabilities are presently available: the Medtronic GEM III AT, an updated version of the Jewel AF and the Guidant PRIZM AVT. These devices can be patient-activated or programmed to deliver automatically ounce atrial tachyarrhythmias are detected, therapies including pacing or/and shocks. Attempts to define the group of patients who might benefit from these devices are described but the respective role of atrial defibrillators versus other non-pharmacologic therapies for AF, such as surgery and radiofrequency catheter ablation, remains to be determined. Advantages and limitations or atrial defibrillators and approaches to reduce shock related discomfort which may be a concern in some patients, are reviewed. Studies have shown that despite shock discomfort, quality of life was improved in patients with atrial defibrillators and the need for repeated hospitalizations was reduced. The cost of these devices remains a concern for the treatment of a non-lethal arrhythmia. Attention that atrial defibrillators will receive from cardiologists and from the industry in the future, will depend of the long-term results of other non-pharmacological options and of the identification of the group of AF patients which will require restoration and maintenance of sinus rhythm. But there is no doubt that selected subsets of patients with AF could benefit from atrial defibrillation.

Shock-Induced Epicardial and Endocardial Virtual Electrodes Leading to Ventricular Fibrillation via Reentry, Graded Responses, and Transmural Activation

INTRODUCTION

The mechanism of ventricular fibrillation (VF) induction by T wave shocks has been attributed to reentry, propagated graded responses (PGR), and triggered activity. The limitation of recording transmembrane potential (V(m)) from only a single surface has hampered efforts to elucidate the relative role of these phenomena and their relationship to shock-induced virtual electrodes.

METHODS AND RESULTS

V(m) patterns from epicardial and endocardial surfaces of isolated sheep right ventricles were recorded with two CCD cameras for monophasic (M) and biphasic (B) shocks delivered at various coupling intervals (CI) from a unipolar mesh electrode on the epicardium. VF was induced via (1) the formation of reentry following make or break excitation; (2) propagated graded responses during apparent isoelectric window; and (3) breakthrough activation patterns coincident with endocardial-to-epicardial gradients in V(m). M shocks depolarized both surfaces at long CIs and polarized epicardial and endocardial surfaces oppositely at short CIs. At intermediate CIs, postshock V(m) patterns could lead to reentry on one surface or endocardial-to-epicardial gradients resulting in breakthrough. B induced VF less than M for short and intermediate CIs due to more homogeneous end-shock V(m) patterns. However, at long CIs these homogeneous patterns resulted in more VF induction because B left the tissue closer to the V(m) threshold for propagation.

CONCLUSION

Postshock activity occurred either immediately via epicardial or endocardial reentry, or after a delay caused by transmural propagation or propagated graded responses. These findings could explain the isoelectric window and focal activation patterns observed on the epicardium following VF induction shocks.

Extraction of periodic multivariate signals: mapping of voltage-dependent dye fluorescence in the mouse heart

In many experimental circumstances, heart dynamics are, to a good approximation, periodic. For this reason, it makes sense to use high-resolution methods in the frequency domain to visualize the spectrum of imaging data of the heart and to estimate the deterministic signal content and extract the periodic signal from background noise in experimental data. In this paper, we describe the first application of a new method that we call cardiac rhythm analysis which uses a combination of principal component analysis and multitaper harmonic analysis to extract periodic, deterministic signals from high-resolution imaging data of cardiac electrical activity, We show that this method significantly increases the signal-to-noise ratio of our recordings, allowing for better visualization of signal dynamics and more accurate quantification of the properties of electrical conduction. We visualize the spectra of three cardiac data sets of mouse hearts exhibiting sinus rhythm, paced rhythm and monomorphic tachycardia. Then, for pedagogical purposes, we investigate the tachycardia more closely, demonstrating the presence of two distinct periodicities in the re-entrant tachycardia. Analysis of the tachycardia shows that cardiac rhythm analysis not only allows for better visualization of electrical activity, but also provides new opportunities to study multiple periodicities in signal dynamics.

Transvenous atrial defibrillation--techniques and clinical applications

Atrial fibrillation (AF) is the most common arrhythmia requiring treatment. The most desirable therapy may be restoration and maintenance of sinus rhythm. Limitations of the current methods for cardioversion of AF have prompted the development of transvenous atrial defibrillation (TADF) as an alternative and more effective technique for converting AF. Recent advances in the technique of TADF, particularly in the design and configuration of the electrodes, and the use of an optimal biphasic shock waveform have dramatically improved the efficacy of TADF for the termination of all types of AF. The reduction in voltage and energy requirements for cardioversion by TADF may allow the procedure to be performed with little or no sedation and the risk of general anesthesia may be avoided. Both experimental and clinical studies have demonstrated the feasibility, safety, and efficacy of using TADF as a new temporary or "permanent" mode of electrical therapy for AF. It has several potential applications, from acute termination of AF in the electrophysiology laboratory and in patients who have failed to respond to external cardioversion, to its use as an implantable device for treating recurrent AF. This article reviews the current technique and clinical applications of TADF for treatment of AF.

The atrial defibrillator: a stand-alone device or part of a combined dual-chamber system?

Atrial fibrillation (AF) is an extremely common arrhythmia seen in clinical practice. Because of the limited efficacy of traditional therapeutic strategies to restore and maintain normal sinus rhythm, several nonpharmacologic options have evolved. The promising results achieved with internal atrial defibrillation have facilitated the development of an implantable atrial defibrilator. Preliminary results obtained from an initial study on a small number of highly selected patients with refractory AF suggest that atrial defibrillation can be performed effectively and safely with adequate patient tolerance by using a stand-alone device. The extension of this therapy will depend on the results of well-designed prospective studies comparing this new therapeutic option with traditional methods. Several acute studies have shown that internal conversion of AF is feasible at low energies with current endocardial transvenous lead configurations primarily designed for ventricular defibrillation, but long-term efficacy has, to date, only been demonstrated with atrial implantable defibrillator lead systems. As AF is a frequent arrhythmia in implantable cardioverter defibrillator (ICD) recipients, it would seem desirable to incorporate the capability for atrial defibrillation into an ICD. Clinical studies have shown that an atrial defibrillator, as part of a combined dual-chamber ICD system, may not require a potentially complicated switching network for establishing different electrode configurations for atrial and ventricular tachyarrhythmia. The efficacy in atrial cardioversion of such a combined, less complex device seems to be as high as reported for a pure atrial defibrillator, but generally at somewhat higher energy requirements. The results of further investigations will show whether a dual-chamber cardioverter defibrillator would be of clinical relevance in patients with ventricular and supraventricular tachyarrhythmia.