Responses of the sino-atrial node to change in pressure in the sinus node artery

Comparison of Low and High Doses of Pentobarbital or Thiopental for Euthanasia of Isoflurane-anesthetized Pigs

Barbiturate overdose is a common method for euthanizing pigs. However, barbiturates can cause tissue damage and may affect experimental results, so the minimal dose should be used. The minimal dose of barbiturate for euthanasia in pigs under isoflurane anesthesia has not yet been determined. In this study, we compared the effect of low and high doses of 2 barbiturates (pentobarbital, 30 or 60 mg/kg; thiopental, 20 and 40 mg/kg) on hemodynamic parameters and time to cardiac arrest in female pigs maintained on isoflurane. Acute decreases in blood pressure and end-tidal CO₂ occurred in all pigs shortly after administration of the barbiturate. However, these changes were not different between either of the high- and low dose groups. Cardiac arrest occurred significantly faster for high dose as compared with low dose thiopental groups, but this parameter was different between the 2 pentobarbital groups. The bispectral index fell immediately after dosing, in all pigs, but no significant differences were observed in the time needed to achieve 0 for the high or low-doses of either drug. In pigs maintained on isoflurane, a low dose of barbiturates is adequate for euthanasia and may result in less tissue damage.

Fibroblast-Specific Proteotranscriptomes Reveal Distinct Fibrotic Signatures of Human Sinoatrial Node in Nonfailing and Failing Hearts

BACKGROUND

Up to 50% of the adult human sinoatrial node (SAN) is composed of dense connective tissue. Cardiac diseases including heart failure (HF) may increase fibrosis within the SAN pacemaker complex, leading to impaired automaticity and conduction of electric activity to the atria. Unlike the role of cardiac fibroblasts in pathologic fibrotic remodeling and tissue repair, nothing is known about fibroblasts that maintain the inherently fibrotic SAN environment.

METHODS

Intact SAN pacemaker complex was dissected from cardioplegically arrested explanted nonfailing hearts (non-HF; n=22; 48.7±3.1 years of age) and human failing hearts (n=16; 54.9±2.6 years of age). Connective tissue content was quantified from Masson trichrome-stained head-center and center-tail SAN sections. Expression of extracellular matrix proteins, including collagens 1 and 3A1, CILP1 (cartilage intermediate layer protein 1), and POSTN (periostin), and fibroblast and myofibroblast numbers were quantified by in situ and in vitro immunolabeling. Fibroblasts from the central intramural SAN pacemaker compartment (≈10×5×2 mm³) and right atria were isolated, cultured, passaged once, and treated ± transforming growth factor β1 and subjected to comprehensive high-throughput next-generation sequencing of whole transcriptome, microRNA, and proteomic analyses.

RESULTS

Intranodal fibrotic content was significantly higher in SAN pacemaker complex from HF versus non-HF hearts (57.7±2.6% versus 44.0±1.2%; P<0.0001). Proliferating phosphorylated histone 3⁺/vimentin⁺/CD31^- (cluster of differentiation 31) fibroblasts were higher in HF SAN. Vimentin⁺/α-smooth muscle actin⁺/CD31^- myofibroblasts along with increased interstitial POSTN expression were found only in HF SAN. RNA sequencing and proteomic analyses identified unique differences in mRNA, long noncoding RNA, microRNA, and proteomic profiles between non-HF and HF SAN and right atria fibroblasts and transforming growth factor β1-induced myofibroblasts. Specifically, proteins and signaling pathways associated with extracellular matrix flexibility, stiffness, focal adhesion, and metabolism were altered in HF SAN fibroblasts compared with non-HF SAN.

CONCLUSIONS

This study revealed increased SAN-specific fibrosis with presence of myofibroblasts, CILP1, and POSTN-positive interstitial fibrosis only in HF versus non-HF human hearts. Comprehensive proteotranscriptomic profiles of SAN fibroblasts identified upregulation of genes and proteins promoting stiffer SAN extracellular matrix in HF hearts. Fibroblast-specific profiles generated by our proteotranscriptomic analyses of the human SAN provide a comprehensive framework for future studies to investigate the role of SAN-specific fibrosis in cardiac rhythm regulation and arrhythmias.

A 2:1 atrioventricular block presenting paradoxical ventriculophasic response

Ventriculophasic response (VR) is defined as the shortening of the sinus cycle length in the setting of greater than second-degree atrioventricular (AV) block. Typically, the PP intervals interposing a QRS complex are shorter than those without a QRS complex. Paradoxical VR is a rare clinical entity. We report about an 80-year-old man presenting with a 2:1 AV block, in whom typical and paradoxical VRs were observed.

Factors affecting ventriculophasic response: An investigation in patients with permanent pacemaker

BACKGROUND

Ventriculophasic response (VR) refers to the shortening of the atrial cycle length (P-P-interval) that occurs during the heart block when a QRS complex is interposed between two P-waves. The aim of this study was to determine the factors affecting this phenomenon.

METHODS

Thirty patients with high grade heart block treated with dual chamber pacemaker were studied. The pacer function of the patients' device was temporarily programmed to the ventricular-inhibited mode at 30 pulses per minute. A total of 330 recordings containing two P-waves with an interposed QRS and its previous P-P interval without any QRS were collected. The VR was defined as being present when the P-P interval with an interposed QRS shortened more than 3% compared to the preceding P-P interval.

RESULTS

The VR was present in 45% of the recordings. In the multivariate logistic regression analysis, only a mid position of the interposed QRS was a positive predictor for presence of VR. However, there were no differences between recordings with or without VR groups according to QRS duration, paced or intrinsic interposed QRS. Hypertension and age had a negative correlation with the presence of VR when the QRS was interposed in the mid part.

CONCLUSION

We found that the VR was present in approximately half of our cases. This phenomenon was mostly affected by position of the interposed QRS according to the previous P-P interval.

Fibrosis: a structural modulator of sinoatrial node physiology and dysfunction

Heart rhythm is initialized and controlled by the Sinoatrial Node (SAN), the primary pacemaker of the heart. The SAN is a heterogeneous multi-compartment structure characterized by clusters of specialized cardiomyocytes enmeshed within strands of connective tissue or fibrosis. Intranodal fibrosis is emerging as an important modulator of structural and functional integrity of the SAN pacemaker complex. In adult human hearts, fatty tissue and fibrosis insulate the SAN from the hyperpolarizing effect of the surrounding atria while electrical communication between the SAN and right atrium is restricted to discrete SAN conduction pathways. The amount of fibrosis within the SAN is inversely correlated with heart rate, while age and heart size are positively correlated with fibrosis. Pathological upregulation of fibrosis within the SAN may lead to tachycardia-bradycardia arrhythmias and cardiac arrest, possibly due to SAN reentry and exit block, and is associated with atrial fibrillation, ventricular arrhythmias, heart failure and myocardial infarction. In this review, we will discuss current literature on the role of fibrosis in normal SAN structure and function, as well as the causes and consequences of SAN fibrosis upregulation in disease conditions.

Paradoxical ventriculophasic sinus arrhythmia during 2:1 atrioventricular block

Ventriculophasic sinus arrhythmia is a particular phenomenon commonly observed in patients with complete atrioventricular (AV) block. Typically, the PP intervals which contain a QRS complex are shorter than the PP intervals which do not contain it. This phenomenon is present in more than 40% of cases with complete AV block and less common in the setting of second-degree AV block. We present a case with paradoxical ventriculophasic sinus arrhythmia during 2:1 AV block, in which the PP intervals containing a QRS complex are longer than the PP intervals without an intervening QRS complex. The possible mechanisms regarding this unusual phenomenon are also discussed.

Heart rate turbulence: standards of measurement, physiological interpretation, and clinical use: International Society for Holter and Noninvasive Electrophysiology Consensus

This consensus statement has been compiled on behalf of the International Society for Holter and Noninvasive Electrophysiology. It reviews the topic of heart rate turbulence (HRT) and concentrates on technologies for measurement, physiologic background and interpretation, and clinical use of HRT. It also lists suggestions for future research. The phenomenon of HRT refers to sinus rhythm cycle-length perturbations after isolated premature ventricular complexes. The physiologic pattern of HRT consists of brief heart rate acceleration (quantified by the so-called turbulence onset) followed by more gradual heart rate deceleration (quantified by the so-called turbulence slope) before the rate returns to a pre-ectopic level. Available physiologic investigations confirm that the initial heart rate acceleration is triggered by transient vagal inhibition in response to the missed baroreflex afferent input caused by hemodynamically inefficient ventricular contraction. A sympathetically mediated overshoot of arterial pressure is responsible for the subsequent heart rate deceleration through vagal recruitment. Hence, the HRT pattern is blunted in patients with reduced baroreflex. The HRT pattern is influenced by a number of factors, provocations, treatments, and pathologies reviewed in this consensus. As HRT measurement provides an indirect assessment of baroreflex, it is useful in those clinical situations that benefit from baroreflex evaluation. The HRT evaluation has thus been found appropriate in risk stratification after acute myocardial infarction, risk prediction, and monitoring of disease progression in heart failure, as well as in several other pathologies.

HYPOTHESIS: SET-POINTS and LONG-TERM CONTROL OF ARTERIAL PRESSURE. A THEORETICAL ARGUMENT FOR A LONG-TERM ARTERIAL PRESSURE CONTROL SYSTEM IN THE BRAIN RATHER THAN THE KIDNEY

1. It has been hypothesised that the 'set-point' for the long-term control of mean arterial (MAP) resides within the kidney. In this model, the set-point of the 'chronic renal function curve' establishes the steady state relationship between renal perfusion pressure and urinary excretion of sodium and water, which, in turn, affects blood volume and cardiac output. The 'renal-MAP set-point' theory predicts that the kidney controls MAP to maintain its own excretory function and that long-term regulation of blood volume and cardiac output are paramount to the regulation of arterial pressure. 2. An alternative hypothesis is proposed in which the 'set-point' for the long-term control of MAP resides within the central nervous system (CNS) rather than the kidney. In contrast with the 'renal-MAP set-point' model, the 'CNS-MAP set-point' model dictates that the brain controls MAP to maintain cerebral blood flow and CNS function. 3. The 'CNS-MAP set-point hypothesis' predicts that long-term regulation of MAP is paramount to the regulation of blood volume and cardiac output. It is proposed that the 'CNS-MAP set-point' system operates independently of the arterial baroreceptor reflex, which is a short-term controller of MAP. 4. The precise mechanisms by which the CNS 'senses' MAP are complex and remain to be discovered. The MAP 'sensor' likely involves integration of hormone levels linked to body fluid homeostasis and osmoreceptor and baroreceptor inputs. It is also proposed that an as yet undiscovered 'central baroreceptor' exists within the brain itself. 5. The 'CNS-MAP set-point hypothesis' predicts that many forms of experimental and essential hypertension are due to a primary shift in the CNS-MAP set-point.

Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction

BACKGROUND

Identification of high-risk patients after acute myocardial infarction is essential for successful prophylactic therapy. The predictive accuracy of currently used risk predictors is modest even when several factors are combined. Thus, establishment of a new powerful method for risk prediction independent of the available stratifiers is of considerable practical value.

METHODS

The study investigated fluctuations of sinus-rhythm cycle length after a single ventricular premature beat recorded in Holter electrocardiograms, and characterised the fluctuations (termed heart-rate turbulence) by two numerical parameters, termed turbulence onset and slope. The method was developed on a population of 100 patients with coronary heart disease and blindly applied to the population of the Multicentre Post-Infarction Program (MPIP; 577 survivors of acute infarction, 75 deaths during a median follow-up of 22 months) and to the placebo population of the European Myocardial Amiodarone Trial (EMIAT; 614 survivors of acute myocardial infarction, 87 deaths during median follow-up of 21 months). Multivariate risk stratification was done with the new parameters and conventional risk factors.

FINDINGS

One of the new parameters (turbulence slope) was the most powerful stratifier of follow-up mortality in EMIAT and the second most powerful stratifier in MPIP: MPIP risk ratio 3.5 (95% CI 2.2-5.5, p<0.0001), EMIAT risk ratio 2.7 (1.8-4.2, p<0.0001). In the multivariate analysis, low left-ventricular ejection fraction and turbulence slope were the only independent variables for mortality prediction in MPIP (p<0.001), whereas in EMIAT, five variables were independent mortality predictors: abnormal turbulence onset, abnormal turbulence slope, history of previous infarction, low left-ventricular ejection fraction, and high mean heart rate (p<0.001). In both MPIP and EMIAT, the combination of abnormal onset and slope was the most powerful multivariate risk stratifier: MPIP risk ratio 3.2 (1.7-6.0, p<0.0001), EMIAT risk ratio 3.2 (1.8-5.6, p<0.0001).

INTERPRETATION

The absence of the heart rate turbulence after ventricular premature beats is a very potent postinfarction risk stratifier that is independent of other known risk factors and which is stronger than other presently available risk predictors.

Beat-to-beat modulation of heart rate is coupled to coronary perfusion pressure in the isolated heart

A goal of clinicians caring for heart transplant recipients has been to use heart rate variability as a noninvasive means of diagnosing graft rejection. The determinants of beat-to-beat variability in the surgically denervated heart have yet to be elucidated. We used an isolated, blood buffer-perfused porcine heart preparation to quantitatively assess the relationship between coronary perfusion and sinus node automaticity. Hearts (n = 9) were suspended in a Langendorff preparation, and heart rate (HR) fluctuations were quantified while perfusion pressure was modulated between 70/50, 80/60, 90/70, and 100/80 mmHg at 0.067 Hz. In 32 of 32 recordings, the cross spectrum of perfusion pressure vs. HR showed the largest peak centered at 0.067 Hz. In eight of nine experiments during nonpulsatile perfusion, HR accelerated as perfusion pressure was increased from 40 to 110 mmHg (mean increase 24.2 +/- 3.0 beats/min). HR increased 0.34 beats/min per mmHg increase in perfusion pressure (least squares linear regression y = -25.8 mmHg + 0.34x; r = 0.88, P < 0.0001). Administration of low- and high-dose nitroglycerin (Ntg) resulted in a modest increase in flow but produced a significant decrease in HR and blunted the response of HR to changes in perfusion pressure (HR increase 0.26 beats. min-1. mmHg-1, r = 0.87, P < 0.0001 after low-dose Ntg; 0.25 beats. min-1. mmHg-1, r = 0.78, P < 0.0001 after high-dose Ntg). These experiments suggest that sinus node discharge in the isolated perfused heart is mechanically coupled to perfusion pressure on a beat-to-beat basis.

Respiratory sinus dysrhythmia persists in transplanted human hearts following autonomic blockade

1. The present study was performed to test whether beat-to-beat cardiovascular control in cardiac allograft recipients resides in cholinergic and/or adrenergic nerves that are intrinsic to the heart. 2. Heart rate (HR) fluctuations synchronous with respiration during spontaneous, double tidal volume and metronome-synchronized breathing were quantified in 13 human heart transplant recipients. We also examined the effects of sequential cholinergic and beta-adrenoceptor (combined) autonomic blockade on respiratory sinus arrhythmia (RSA). We computed RSA amplitude and the correlation between respiration and changes in HR (cardiopulmonary synchronization; CPS). Group means were compared using repeated-measures analysis of variance. Transplant recipients served as their own controls. 3. In the basal state, moderate RSA amplitude and CPS were observed. During cholinergic and combined blockade, we observed no significant change in RSA amplitude, whereas CPS increased significantly during combined blockade (P < 0.05). The amplitude of RSA increased during respiration at double baseline tidal volume, but not at any of the other breathing manoeuvres (P < 0.01). In contrast, CPS increased significantly during both patterned breathing manoeuvres. No significant correlation was seen between mean right atrial pressure and RSA amplitude. In 23% of subjects with low CPS, HR oscillated with arterial pressure. These oscillations were independent of respiration. During all three patterns of respiration, a significant inverse correlation was observed between CPS and pulse pressure (r = -0.53 to -0.73). Thus, as the amplitude of pulse pressure increased, respiration accounted for a smaller percentage of HR variation. 4. In conclusion, RSA persists and the magnitude of CPS increases following combined autonomic blockade. These studies suggest that while RSA after cardiac transplantation is not cholinergically or adrenergically mediated, it may be related to mechanical stretch of the sinus node caused by changes in intrathoracic pressure and perfusion pressure.

Electrocardiographic and electrophysiologic properties of cardiac allografts

The increasing number of heart transplant patients requires that physicians be able to recognize the electrocardiographic (ECG) and electrophysiologic properties of cardiac allografts. Cardiac allografts are characterized by modifications of resting ECGs and frequent arrhythmias in the postoperative period, and the loss of autonomic nervous control illustrated by permanent tachycardia and loss of heart rate variability during 24-hour ambulatory ECG recording. Some clinical and experimental observations suggest a mid-term reinnervation of the cardiac allograft, but this requires histologic confirmation. The electrophysiologic characteristics of the denervated myocardium are similar to those of the innervated myocardium at rest. However, supersensitivity to circulating catecholamines has been observed in cardiac allografts as in experimentally denervated hearts, which is responsible for a progressive increase in heart rate during exercise and a slow decrease during recovery. Supersensitivity of the denervated heart to acetylcholine may explain the high prevalence of donor sinus dysfunction due to impairment of its automaticity. More often, the sinus node dysfunction is transient and can be treated with an adenosine antagonist, such as theophylline, before permanent implantation of a pacemaker. In the case of pacemaker implantation, synchronization of the donor atria with the recipient atria is desirable, and an endocardial lead implantation is preferred. Several electrophysiologic changes have been observed during acute cardiac allograft rejection. From experimental studies, the most important of these are the disturbance of conduction in the atria and the atrioventricular node and a decrease in the amplitude of the ventricular potential. Initial studies on isolated myocytes show profound changes in membrane conductance during experimental cardiac rejection. The development of new noninvasive detection methods of cardiac allograft rejection, such as intramyocardial voltage electrogram monitoring and high-resolution ECG, could help early diagnosis.

Can power spectral analysis of heart rate variability identify a high risk subgroup of congestive heart failure patients with excessive sympathetic activation? A pilot study before and after heart transplantation

BACKGROUND AND OBJECTIVES

Autonomic dysfunction seems to be involved in the progression and prognosis of severe congestive heart failure. Parasympathetic activity can still be abnormal 4-8 weeks after haemodynamic improvement by heart transplantation. To identify patients in heart failure with a more pronounced neural derangement and to analyse the changes in sympathetic and parasympathetic activity soon after heart transplantation, spectral indices of heart rate variability were assessed in 30 patients in severe heart failure and in 13 patients after heart transplantation; a group of 15 age-matched subjects served as controls.

METHODS AND RESULTS

Heart rate variability was assessed by standard electrocardiography (ECG) in patients in heart failure and by oesophageal ECG in patients after heart transplantation. Compared with controls, the mean RR interval and total power were reduced in heart failure. The 30 patients showed two different patterns of heart rate variability: in 14 no power was detected in the low frequency band (0.03-0.15 Hz) (LF) and total power was mainly concentrated in the high frequency band (0.15-0.45 Hz) (HF), whereas in the remaining 16 patients power in the LF band was increased and power in HF band was reduced compared with the controls. Patients with undetectable LF had a lower mean RR interval and total power (745(25) v 864(36) ms, p < 0.05; 118(16) v 902(202) ms2, p < 0.001), higher concentration of plasma noradrenaline (635(75) v 329(54) pg/ml, p < 0.05), and worse clinical status and prognosis (4 deaths v no deaths at 6 month follow up) than patients with a dominant LF band. In the post-transplant patients both the mean PP interval of the remnant atrium and total power resembled results in the patients with heart failure; in 7 of the 13 post-transplant patients no power was detectable in the LF band: when both HF and LF power were present the results resembled those in the 16 patients in heart failure.

CONCLUSIONS

These data suggest that in more advanced stages of congestive heart failure, power spectral analysis of heart rate variability allows identification of a subgroup of patients with higher sympathetic activation and poorer clinical status who are at major risk of adverse events. In the short term after cardiac transplantation the spectral profile of the rhythm variability of the remnant atrium was not improved, suggesting that parasympathetic withdrawal and sympathetic hyperactivity persist, despite the restoration of ventricular function.

Heart rate variability in patients with orthotopic heart transplantation: long-term follow-up

To evaluate heart rate variability (expressed as the standard deviation of RR intervals) within 5 years of follow-up, we studied 20 patients (14 males, 6 females, mean age 44 +/- 12 years) who underwent orthotopic heart transplantation. Six measurements were taken: one in the first 3 weeks after transplantation, and the others once annually, for 5 years. Twenty healthy subjects (mean age 44 +/- 7 years) constituted the control group. Heart rate variability increased significantly in the first 3 years of follow-up (7.2 +/- 1 vs. 11.1 +/- 4, p < 0.001; 11.1 +/- 4 vs. 15.2 +/- 4, p < 0.01; 15.2 +/- 4 vs. 18.9 +/- 5, p < 0.05); in the following years this trend slackened and values did not reach a statistically significant difference (18.9 +/- 5 vs. 21.4 +/- 5; 21.4 +/- 5 vs. 22.5 +/- 5). The mean standard deviation was invariably greater in the control group (63.6 +/- 12). These findings show that sinus rhythm variability in the denervated heart progressively increased over 5 years of follow-up. The absence of presynaptic uptake, which is responsible for adrenergic hypersensitivity to circulating catecholamines and intrinsic cardiac reflexes, does not appear to cause this phenomenon, since these mechanisms are not able to evolve in time after cardiac transplantation. Therefore, an enhanced beta-adrenergic receptors density or affinity to circulating catecholamines or a limited sympathetic reinnervation may be the more probable underlying mechanism.

Immediate cardiovascular responses to orthostasis in the early and late months after cardiac transplantation

Immediate post-standing (< 30 s) heart rate and blood pressure regulation was studied in patients in the early (2 +/- 2 months, n = 10) and late months (49 +/- 18 months, n = 30) after orthotopic heart or heart and lung transplantation with continuous non-invasive blood pressure (Finapress) and ECG recordings, and was compared to 15 healthy subjects. Heart rate acceleration on standing was standing was absent in the early post-transplantation period. Modest, delayed heart rate acceleration (maximum 12 +/- 8 beats/min) was seen late post-transplantation. Subgroup analysis showed that 15 patients late post-transplantation had limited (maximum 6 +/- 3 beats/min) heart rate acceleration, 11 patients showed maximum heart rate acceleration between 11 and 19 beats/min and 4 patients showed heart rate acceleration comparable in magnitude with that of normal subjects (maximum 28 +/- 5 beats/min). The blood pressure transients were comparable in the 3 groups, with a tendency for greater drop and smaller overshoot in systolic blood pressure in transplant subjects. The findings of normal blood pressure transients in the setting of extensive afferent cardiac denervation questions the role of intracardiac (intraventricular) receptors in reflex blood pressure regulation. The development of heart rate responsiveness is compatible with sympathetic reinnervation in many patients in the late post-transplantation period; however, an intrinsic cardiac mechanism may also be possible.

Normalization of upright exercise hemodynamics and improved exercise capacity one year after orthotopic cardiac transplantation

The mechanisms of improved functional capacity over the first year after cardiac transplantation are not well studied. To assess the contribution of cardiac changes to this improvement, the serial evolution of upright rest and exercise hemodynamics during graded upright bicycle exercise was studied in 17 patients at 3 and 12 months after heart transplantation. Heart rate responsiveness, reflected by rapid heart rate acceleration on sitting and rapid deceleration after exercise, developed in the first year. Pulmonary capillary wedge pressure was lower at 1 year, both at rest and at peak exercise (10 +/- 3 vs 13 +/- 5 mm Hg at rest supine and 14 +/- 6 vs 18 +/- 8 mm Hg at peak exercise, p less than 0.05). Similarly, right atrial pressures were also significantly lower at 1 year (4 +/- 2 vs 6 +/- 3 mm Hg at rest supine and 6 +/- 5 vs 11 +/- 5 mm Hg at peak exercise, p less than 0.05). Cardiac index at peak exercise was greater at 12 months (6.4 +/- 1.3 vs 5.8 +/- 0.8 liters/min/m2, p less than 0.05), mediated primarily by higher exercise heart rate (135 +/- 16 vs 125 +/- 12 beats/min, p less than 0.05). In the first year after heart transplantation, improved rest and exercise hemodynamics and heart rate responsiveness contribute significantly to the improved functional capacity observed in these patients.

Evolution of heart rate responsiveness after orthotopic cardiac transplantation

Although anatomic reinnervation of the donor heart is unlikely after transplantation, individual subjects have been noted to show near physiologic heart rate (HR) responses to exercise. To assess development of this phenomenon, we studied HR changes in response to orthostasis and treadmill exercise in 52 orthotopic cardiac transplant recipients grouped according to time after transplantation. In group 1 (2.0 +/- 0.9 months), no significant increase in HR was seen up to 100 cardiac cycles after standing. A maximal acceleration of 4.0 +/- 3.8 beats was seen within 100 cardiac cycles after standing in group 2 (15.8 +/- 5.6 months). Patients in group 3 (42.4 +/- 12.4 months) showed significant cardioacceleration by 5 cardiac cycles after standing to a maximum of 10.7 +/- 5.8 beats/min within the first 100 cardiac cycles. During exercise, HR increased more rapidly during the first minute in group 3 compared with group 1 (p less than 0.01). After exercise, HR continued to increase in group 1 but decreased rapidly in the other groups, most notably group 3 (-26.5 +/- 16.5 by 2 minutes, p less than 0.0001 vs groups 1 and 2). These data indicate development of functional reinnervation after orthotopic heart transplantation. The phenomenon of early acceleration of the HR after orthostasis and rapid deceleration after exercise in transplant recipients implies a local cardiac mechanism rather than response to circulating catecholamines.

Effect of perfusion rate of cholinergic agonist on sinus node automaticity

Recent evidence supports a complex relationship between pressure in the sinus node artery and heart rate. In addition, it has been suggested that acetylcholine effects vary depending upon the pressure at which the drug is injected. We examined the cardiac chronotropic responses to acetylcholine, delivered via the sinus node artery using a constant flow perfusion technique. Dogs were anesthetized with chloralose and prepared to record ECG, arterial pressure and bipolar electrograms from the sinus node, sulcus terminalis, right atrium, right ventricle and His bundle. The sinus node artery was catheterized, distribution verified and autologously perfused via the femoral artery. Both vagi and both stellate ganglia were transected. Analog data were processed by computer for each cycle length during perfusion with normal Tyrode solution or Tyrode solution containing acetylcholine. Perfusion of normal Tyrode solution (1-4ml/min) resulted in prolongation in cycle length which was greater at higher flow rates but rapidly dissipated at all flow rates. Beyond mechanically-induced bradycardia, acetylcholine initially prolonged cycle length but cycle length prolongation faded with time. Delivery of acetylcholine at higher flow rates resulted in significantly greater prolongation of cycle length. Cycle length always returned back toward control although perfusion of acetylcholine continued. Thus, responses to acetylcholine are influenced not only by drug concentration but also by the flow rate at which the drug is delivered. This suggests a coupling of mechanical and pharmacologic components of chronotropic influences at the sinus node.

Presence of presynaptic inhibitory alpha 1-adrenoceptors in the cardiac sympathetic nerves of the dog: effects of prazosin and yohimbine on sympathetic neurotransmission to the heart

The effects of prazosin and yohimbine on sympathetic neurotransmission to the heart were investigated in perfused dog hearts in situ in an attempt to determine whether alpha 1-adrenoceptors are located presynaptically in the cardiac sympathetic nerves. Intra-arterial injections of prazosin (1-30 micrograms) and yohimbine (0.3-10 micrograms) into the right coronary artery during cardiac sympathetic nerve stimulation further increased the tachycardia resulting from the stimulation. Continuous infusions of methoxamine (20-40 micrograms/min) and of clonidine (2-4 micrograms/min) into the right coronary artery during cardiac sympathetic nerve stimulation caused sustained reduction of the tachycardia. Prazosin under methoxamine infusion enhanced the tachycardia to a greater extent than in the absence of methoxamine. Prazosin under clonidine infusion enhanced the tachycardia to the same extent as it did in the absence of clonidine. These results suggest that prazosin antagonizes the effect of methoxamine but does not antagonize that of clonidine. The results obtained with yohimbine were in contrast to the effects of prazosin, showing the antagonism of clonidine by yohimbine. Prazosin and yohimbine both had little effect on the heart rate during either the resting state or the infusion of norepinephrine. These results suggest that the prazosin- and yohimbine-induced enhancement of the tachycardia resulting from cardiac sympathetic nerve stimulation is due to a presynaptic effect. However, the presynaptic effect of prazosin appears to differ from that of yohimbine. The presence of presynaptic alpha 1-adrenoceptors regulating norepinephrine release, as well as of alpha 2-adrenoceptors, is suggested in the cardiac sympathetic nerves of the dog.

Inhibition of cardiac sympathetic neurotransmission by histamine in the dog is mediated by H1-receptors

1 The role of histamine H1- and H2-receptors in mediating prejunctional inhibition of cardiac sympathetic neurotransmission and histamine-induced coronary vasodilatation were investigated in perfused dog hearts in situ. 2 Intra-arterial injections of histamine into the right coronary artery during the resting state caused slightly positive chronotropic responses in doses larger than 1 microgram. 3 Histamine in doses of 0.1 to 10 micrograms into the right coronary artery reduced the tachycardia resulting from electrical stimulation of the cardiac sympathetic nerves. 4 Intra-coronary infusions of chlorpheniramine (300 micrograms/min) significantly reduced the histamine-induced depression of cardiac nerve stimulation. The effects of cimetidine (300 micrograms/min) and metiamide (300 micrograms/min) were less pronounced. 5 Histamine (1 to 10 micrograms) further increased heart rate resulting from the continuous intra-coronary infusion of noradrenaline (1 or 3 micrograms/min). 6 Intra-arterial injections of histamine (0.1 to 10 micrograms) caused an increase in coronary blood flow in a dose-dependent manner. This was partially inhibited by intra-coronary infusion of chlorpheniramine (10 to 300 micrograms/min) and by cimetidine (10 to 300 micrograms/min). The combination of both drugs (10 to 100 micrograms/min of each) caused a larger inhibition. 7 The present results suggest that the histamine-induced depression of heart rate during cardiac sympathetic nerve stimulation is due to a prejunctional effect mediated mainly by H1-receptors. Histamine-induced coronary vasodilatation in the dog is mediated both by H1- and H2-receptors.

Sinus node potential during cold cardioplegia

Epicardial potentials of the sinus node, the right atrium, and the right ventricle were recorded in dogs during cold potassium-induced cardioplegia. We found that the sinus node fibers were more resistant to the cardioplegia than were the other myocardial fibers. When the cardioplegia rendered the atrial muscle inexcitable, the high frequency atrial potential was delayed and then abolished in the sinus node electrogram, and a smooth tracing similar to the action potential of the sinus node cell appeared. These findings should be pertinent for the cardiac surgeon attempting to avoid surgically-induced sinoatrial arrhythmias.

Response of normal and abnormal sinus node to right ventricular stimulation

Right ventricular pacing at progressively increasing rates was performed in 25 patients with complete ventriculoatrial block, before and after autonomic blockade with intravenous propranolol and atropine. At the end of each ventricular pacing stage a right intraatrial electrogram and electrocardiographic leads were simultaneously recorded. The relation between right ventricular pacing and atrial rates was studied from the recordings obtained at each pacing stage in both group I, 8 patients with sick sinus syndrome, and group II, 17 patients with normal sinus function. Right ventricular pacing was associated with an increment in atrial rate that ws significantly smaller (probability [p] less than 0.001) in patients in group I (mean +/- standard error of the mean 8 +/- 6 beats/min) than in group II (mean 25 +/- 10 beats/min). The maximal atrial rate reached during right ventricular pacing exceeded 80 beats/min in all patients in group II but remained less than 74 beats/min in patients in group I. Because autonomic blockade did not significantly influence the preceding results, it is concluded that a mechanical effect on the sinus node may explain this phenomenon.

Effects of clonidine on canine cardiac neuroeffector structures controlling heart rate

1 In intact dogs anaesthetized with pentobarbitone, clonidine (10 mug/kg, i.v.) produced a sustained decrease in heart rate. This effect was significantly smaller in vagotomized dogs in which the sympathetic drive to the heart was either left intact or experimentally created by continuous electrical stimulation of the decentralized cardioaccelerator nerve. In the latter preparation, the negative chronotropic action of clonidine was reversed by an intravenous injection of phentolamine, whereas in the former experimental situation it was antagonized only by an intravenous plus an intravertebral artery injection of phentolamine.2 In dogs with denervated hearts the tachycardia produced by electrical stimulation of the cardioaccelerator nerve was accompanied by a rise in noradrenaline overflowing into the coronary sinus plasma. Clonidine inhibited both these effects and phentolamine restored them to pre-clonidine levels.3 Clonidine decreased heart rate in dogs with an intact parasympathetically innervated heart and decentralized stellate ganglia. When the low basal heart rate of this preparation was elevated by electrical stimulation of the cardioaccelerator nerve, clonidine had a negative chronotropic effect, the degree of which was similar to that observed in intact dogs.4 Clonidine neither modified baseline heart rates of dogs with denervated hearts nor the levels of heart rate which in this preparation were reduced by a sustained electrical stimulation of the right vagus or increased by intravenous infusions of either isoprenaline or noradrenaline.5 These findings indicate that in the intact dog, bradycardia induced by clonidine resulted both from a reduction of sympathetic drive and from a concomitant increase in parasympathetic tone. The latter action did not occur at the level of cardiac neuroeffector structures since it was observed only in the presence of centrally connected vagal pathways. The inhibition of cardiac sympathetic tone was of both peripheral and central origin. Clonidine, in fact, diminished the quantity of noradrenaline overflowing into the coronary sinus plasma in cardiac denervated dogs with a tachycardia elicited by electrical stimulation of the decentralized cardioaccelerator nerve. This peripheral effect was probably due to an activation of alpha-adrenoceptors located on sympathetic nerve terminals since it was antagonized by phentolamine. However, in vagotomized dogs (intact sympathetic pathways) intravenous phentolamine failed to antagonize the heart rate effects of clonidine which were abolished by a subsequent injection of phentolamine into the vertebral artery. Thus, the clonidine-induced inhibition of both the peripheral and central sympathetic drive to the heart would appear to be mediated via alpha-adrenoceptors.

Effects of clonidine, prazosin and phentolamine on heart rate and coronary sinus catecholamine concentration during cardioaccelerator nerve stimulation in spinal dogs

1 In spinal dogs, continuous electrical stimulation of the cardioaccelerator nerve produced a transient rise in aortic blood pressure and a sustained increase in both heart rate and coronary sinus blood flow. The latter effects were accompanied by a significant elevation in the coronary sinus plasma noradrenaline concentration without significant changes in the levels of dopamine and adrenaline. The concentrations of the three catecholamines in thoracic aorta plasma were not significantly changed by cardioaccelerator nerve stimulation.2 Clonidine (20 mug/kg, i.v.), given during cardioaccelerator nerve stimulation, increased both mean aortic blood pressure and coronary sinus blood flow and decreased heart rate and coronary sinus venous plasma noradrenaline overflow.3 Phentolamine (0.3 mg/kg, i.v.) completely antagonized these effects of clonidine. Prazosin (0.3 mg/kg, i.v.) inhibited by only 43 and 38% the respective reductions in heart rate and noradrenaline overflow elicited by clonidine.4 On termination of cardioaccelerator stimulation (about 10 min after either prazosin or phentolamine), heart rate and coronary sinus noradrenaline overflow returned to control prestimulation levels.5 Phentolamine or prazosin, administered alone during stimulation of the cardioaccelerator nerve, increased heart rate and noradrenaline overflow into the coronary sinus plasma. However, intravenous phentolamine and prazosin, in contrast to desipramine (0.3 mg/kg, i.v.) or tyramine (1.0 mg, i.a.), failed to change the tachycardia resulting from the local administration of noradrenaline into the sinus node artery (i.a.).6 These results show that in spinal dogs the clonidine-induced reduction in heart rate (elevated by electrical stimulation of the cardioaccelerator nerve) is accompanied by a fall in the quantity of noradrenaline overflowing into the coronary sinus plasma. The latter effect is presumably the result of an action of clonidine on cardiac presynaptic alpha-adrenoceptors, the activation of which is followed by a reduction in the release of noradrenaline per nerve impulse. Phentolamine and prazosin are both antagonists of cardiac presynaptic alpha-adrenoceptors in spinal dogs, as suggested by their action against clonidine and by their positive chronotropic effect when administered during stimulation of the cardioaccelerator nerve.

Direct chronotropic and inotropic responses to guanosine and five different guanine nucleotides in isolated perfused dog atria

The effects of guanosine and of five guanine nucleotides on sinus rate and contractile force were investigated using the isolated, blood-perfused dog atrium preparation. Guanosine consistently induced a positive chronotropic and inotropic effect which was not suppressed by treatment with a potent beta-adrenoceptor blocking agent, carteolol. GMP, GDP and CTP induced a biphasic chronotropic and inotropic effect. The potencies for inducing the positive effects of GMP, GDP and GTP were almost the same. However, their rank order of potency for inducing negative effects was GTP greater than or equal to GDP greater than GMP. The negative responses to GTP were not inhibited by atropine. Cyclic GMP and dibutyryl cyclic GMP produced only slight negative chronotropic and inotropic effects but not consistently even at larger doses. The positive chronotropic and inotropic responses to norepinephrine were not modified by treatment with dibutyryl cyclic GMP.

A new technique for selective cannulation of the sino-atrial node artery

The electrical activity of the sino-atrial node was studied after the selective cannulation of its artery in the intact open-chest dog. After tetrodotoxin infusion and despite cardiac arrest, a slow rhythmic activity was recorded from the sinus epicardial electrode.

Chronotropic effect of acetylstrophanthidin infusion into the canine sinus nodal artery

Studies were performed to determine the chronotropic effect of acetylstrophanthidin during constant infusion through cannulation of the sinus nodal artery. Ten mongrel dogs weighing 13.5 to 18 kg were studied under sodium thiamylal anesthesia. Epicardial atrial and ventricular electrograms were recorded. The sinus nodal artery was cannulated and infused for 20 minutes at a rate of 2 cc/min with a solution containing acetylstrophanthidin, 0.5 microng/cc. Mean results for the group of 10 animals were determined. There was a gradual acceleration of the atrial rate of 45 beats/min after 6 to 8 minutes of infusion. The peak atrial rate of 175 beats/min was achieved by 10 to 12 minutes. This tachycardia persisted for 2 to 4 minutes without atrioventricular block or premature beats. By 12 to 14 minutes, there was a gradual slowing of atrial rate followed by bradycardia, sinus pauses and atrial arrest. Sinus nodal arterial infusion of acetylstrophanthidin produces an initial positive chronotropic effect and, if maintained, a depression of atrial rate and, terminally, atrial arrest. The gradual time course of development and decline of the tachycardia suggests that the "paroxysmal" atrial tachycardia caused by digitalis excess is the result of enhanced pacemaker automatically rather than reentry, and thus is not truly paroxysmal.

Sinus slowing produced by intracoronary arterial injections of hyperosmotic solutions in man

The effect of intracoronary arterial injections of normal saline, contrast agent, hyperosmotic glucose, and mannitol solutions on the sinus rate was studied in 18 patients. Sinus slowing was not produced by isosmotic saline (0.3 Osm. per kilogram of water) when injected into either coronary artery, whereas 76% Urografin (1.9 Osm. per kilogram of water), 20% glucose (1.3 Osm. per kilogram of water), and mannitol (1.2 Osm. per kilogram of water) decreased the sinus rate significantly (P less than 0.001). Among these solutions, Urografin with the highest osmolality produced the most marked sinus slowing, whereas no significant difference was detected between change in the sinus rate with hyperosmotic glucose and mannitol solutions (P greater than 0.5). Moreover, there was no significant difference between the degree of sinus slowing produced by intracoronary injections into the coronary artery of the side which the sinus node artery originated from and the slowing produced by contralateral injections with hyperosmotic solutions (P greater than 0.2). Therefore, it seems unlikely that this sinus slowing would be a result of a direct action on the sinus node including hypoxia and elevated perfusion pressure. Reflex-mediated parasympathetic stimulation may be operative.

Chronotropic responses to experimental ischemia of the canine sino auricular node

(1) Using isolated, blood-perfused atrium preparation of dogs, the effect of ischemia on sinus rate was studied in ten preparations. Cessation of atrial perfusion usually induced gradual deceleration of the sinus rate which was not blocked by atropine. Occasionally, brief and slight sinus acceleration was initially observed in three of ten atrium preparations. This positive chronotropic effect was not blocked by a beta-adrenoceptor blocking agent, propranolol. (2) In every preparation, just after release of occlusion, there was an initial profound sinus deceleration, occasionally followed by oscillatory changes in sinus rate. (3) The chronotropic response pattern induced by temporary occlusion and release of the sinus node artery was not influenced by propranolol, phenoxybenzamine or atropine treatment. (4) These results suggest that ischemia exerts its principal effect directly on the sino auricular node pacemaker cells, rather than on neighboring nerve endings.

Effects of dopamine on sinus rate and ventricular contractile force of the dog heart in vitro and in vivo

1 Experiments were carried out on dog isolated papillary muscle and sinus node preparations perfused with arterial blood from a donor dog. The chronotropic and inotropic effects of dopamine were analysed by using reserpine, desmethylimipramine (DMI), cocaine and phenoxybenzamine, and the relative chronotropic and inotropic effects defined, the results being compared with those for noradrenaline (NA). 2 The effects of dopamine administered intra-arterially into the isolated preparations were reduced by pretreatment of animals with reserpine both in the papillary muscle and sinus node. The chronotropic effects, however, were affected less by pretreatment with reserpine than were the inotropic effects. 3 Desmethylimipramine (DMI) reduced the inotropic and chronotropic effects of dopamine, and enhanced the effects of NA and nerve stimulation; the chronotropic effects of the amines were less affected than the inotropic effects. 4 Cocaine enhanced considerably the inotropic and chronotropic effects of NA, and decreased the inotropic but not the chronotropic effect of dopamine. 5 Phenoxybenzamine enhanced the inotropic effects of dopamine, NA and nerve stimulation, but did not affect the chronotropic effects of the amines. 6 When dopamine (1 to 300 mug/kg) was administered intravenously to the donor dog, it increased preferentially the contractile force of the ventricular myocardium with a comparatively small change of the sinus rate in the isolated preparations as well as in the heart in vivo. NA (0.1 to 10 mug/kg) caused effects similar to those of dopamine. The maximal inotropic responses to these catecholamines were reached with lower doses than the chronotropic ones. 7 It is concluded that both the positive inotropic and the positive chronotropic responses to dopamine are mediated partially by a direct and partially by an indirect stimulant effect on beta-adrenoceptors in the dog heart. The present results suggest that the difference in activity of dopamine and NA between the ventricular myocardium and the sinus node may be ascribed to the unequal innervation with adrenergic nerve fibres of the atrium and the ventricle (Furnival, Linden & Snow, 1971). The sinus node which is densely innervated by adrenergic nerve fibres may inactivate noradrenaline and dopamine more effectively than the ventricular myocardium through the uptake into the nerve and thereby be less sensitive to the exogenous catecholamines.

Mechanisms mediating bradycardia during coronary arteriography

Cardiac slowing occurring during diagnostic coronary arteriography was studied in 78 patients. Comparable degrees of slowing occurred with injections into the right and into the left coronary arteries into the contralateral artery, and with injections into the coronary artery giving rise to the sinus node artery and into the contralateral artery. Rapid intracoronary injections of isosmotic dextrose solution produced significantly less slowing than comparable injections of contrast medium. Slow injections of contrast medium produced cardiac slowing comparable to that caused by rapid injections of contrast medium. However, the cardiac slowing was significantly greater than that produced by rapid injections of dextrose solution. Inhalation of 100% oxygen did not alter the heart rate response to injections of contrast medium. Atropine produced dose-related attenuation of cardiac slowing. Bradycardia persisting after cholinergic blockade was significantly greater after injections into the coronary artery supplying the sinus node than it was after injections into the contralateral artery. Coronary arteriography produced transient, occasionally profound, arterial hypotension in 38 of 41 patients in whom arterial pressures were recorded. Arterial pressure did not change in three patients. This study suggests that the cardiac slowing which occurs during coronary arteriography in man is due primarily to a cholinergic reflex which may be a human counterpart of the Bezold-Jarisch reflex, observed heretofore only in experimental animals. This slowing appears to be mediated primarily by receptors sensitive to contrast medium, rather than by changes of coronary artery pressure, and secondarily, by direct depression of sinus node function by contrast medium.

Left ventricular contractility and developed tension in the intact dog submitted to an intracoronary infusion of adenosine

1. The effect of adenosine on left ventricular contractility and developed tension was studied in the anaesthetized intact dog. Normal and propranolol-treated animals were used. Adenosine was infused through a catheter into one of the two main branches of the left coronary artery, usually the circumflex branch. The rate of infusion was 150 x 10(-9)M/min. The infusion was maintained during 50 min.2. In both series of animals, no change was observed in the heart rate, aortic pressure, left ventricular end-diastolic pressure, time from onset of left ventricular contraction to peak dP/dt, peak dP/dt and left ventricular tension-time index. It is concluded that a regional increase in adenosine concentration in the left ventricular wall has no inotropic effect when the adrenergic mechanisms are normal or depressed.3. The myocardial blood flow response to adenosine was determined at the 10th, 30th and 50th min of the infusion by the radioactive inert gas method. At the 10th min of the infusion, the myocardial blood flow averaged three times the control value in both series of dogs. Thereafter, the flow response remained stable in the normal dogs but declined at the 50th min of the infusion in the propranolol-treated animals. It is suggested that autoregulation of the coronary circulation in response to overperfusion of the myocardium at constant cardiac work may be enhanced at the lower myocardial oxygen requirements of the propranolol-treated dogs while, in the normal animals, it was insufficient to overcome the potent coronary dilator action of adenosine.

Blocking effect of McN-A-343 on cardiac slowing produced by vagal stimulation

The effect of McN-A-343 was studied by direct administration into the sinus node artery of dogs vagotomized at the mid-cervical level. McN-A-343 blocked sinus bradycardia caused by electrical stimulation of the right vagus, while bradycardia induced by administration of acetylcholine or nicotine into the sinus node artery was not modified.