Effects of extracellular potassium on ventricular automaticity and evidence for a pacemaker current in mammalian ventricular myocardium

K2P1 leak cation channels contribute to ventricular ectopic beats and sudden death under hypokalemia

Hypokalemia causes ectopic heartbeats, but the mechanisms underlying such cardiac arrhythmias are not understood. In reduced serum K⁺ concentrations that occur under hypokalemia, K2P1 two-pore domain K⁺ channels change ion selectivity and switch to conduct inward leak cation currents, which cause aberrant depolarization of resting potential and induce spontaneous action potential of human cardiomyocytes. K2P1 is expressed in the human heart but not in mouse hearts. We test the hypothesis that K2P1 leak cation channels contribute to ectopic heartbeats under hypokalemia, by analysis of transgenic mice, which conditionally express induced K2P1 specifically in hearts, mimicking K2P1 channels in the human heart. Conditional expression of induced K2P1 specifically in the heart of hypokalemic mice results in multiple types of ventricular ectopic beats including single and multiple ventricular premature beats as well as ventricular tachycardia and causes sudden death. In isolated mouse hearts that express induced K2P1, sustained ventricular fibrillation occurs rapidly after perfusion with low K⁺ concentration solutions that mimic hypokalemic conditions. These observed phenotypes occur rarely in control mice or in the hearts that lack K2P1 expression. K2P1-expressing mouse cardiomyocytes of transgenic mice much more frequently fire abnormal single and/or rhythmic spontaneous action potential in hypokalemic conditions, compared to wild type mouse cardiomyocytes without K2P1 expression. These findings confirm that K2P1 leak cation channels induce ventricular ectopic beats and sudden death of transgenic mice with hypokalemia and imply that K2P1 leak cation channels may play a critical role in human ectopic heartbeats under hypokalemia.

Approach to Ventricular Arrhythmias in the Intensive Care Unit

Arrhythmias are commonly encountered in the intensive care unit as a primary admitting diagnosis or secondary to an acute illness. Appropriate identification and treatment of ventricular arrhythmias in this setting are particularly important to reduce morbidity and mortality. This review highlights the epidemiology, mechanisms, electrocardiographic features, and treatment of ventricular arrhythmias.

Role of abnormal repolarization in the mechanism of cardiac arrhythmia

In cardiac patients, life-threatening tachyarrhythmia is often precipitated by abnormal changes in ventricular repolarization and refractoriness. Repolarization abnormalities typically evolve as a consequence of impaired function of outward K⁺ currents in cardiac myocytes, which may be caused by genetic defects or result from various acquired pathophysiological conditions, including electrical remodelling in cardiac disease, ion channel modulation by clinically used pharmacological agents, and systemic electrolyte disorders seen in heart failure, such as hypokalaemia. Cardiac electrical instability attributed to abnormal repolarization relies on the complex interplay between a provocative arrhythmic trigger and vulnerable arrhythmic substrate, with a central role played by the excessive prolongation of ventricular action potential duration, impaired intracellular Ca²⁺ handling, and slowed impulse conduction. This review outlines the electrical activity of ventricular myocytes in normal conditions and cardiac disease, describes classical electrophysiological mechanisms of cardiac arrhythmia, and provides an update on repolarization-related surrogates currently used to assess arrhythmic propensity, including spatial dispersion of repolarization, activation-repolarization coupling, electrical restitution, TRIaD (triangulation, reverse use dependence, instability, and dispersion), and the electromechanical window. This is followed by a discussion of the mechanisms that account for the dependence of arrhythmic vulnerability on the location of the ventricular pacing site. Finally, the review clarifies the electrophysiological basis for cardiac arrhythmia produced by hypokalaemia, and gives insight into the clinical importance and pathophysiology of drug-induced arrhythmia, with particular focus on class Ia (quinidine, procainamide) and Ic (flecainide) Na⁺ channel blockers, and class III antiarrhythmic agents that block the delayed rectifier K⁺ channel (dofetilide).

Reduction in dynamin-2 is implicated in ischaemic cardiac arrhythmias

Ischaemic cardiac arrhythmias cause a large proportion of sudden cardiac deaths worldwide. The ischaemic arrhythmogenesis is primarily because of the dysfunction and adverse remodelling of sarcolemma ion channels. However, the potential regulators of sarcolemma ion channel turnover and function in ischaemic cardiac arrhythmias remains unknown. Our previous studies indicate that dynamin-2 (DNM2), a cardiac membrane-remodelling GTPase, modulates ion channels membrane trafficking in the cardiomyocytes. Here, we have found that DNM2 plays an important role in acute ischaemic arrhythmias. In rat ventricular tissues and primary cardiomyocytes subjected to acute ischaemic stress, the DNM2 protein and transcription levels were markedly down-regulated. This DNM2 reduction was coupled with severe ventricular arrhythmias. Moreover, we identified that the down-regulation of DNM2 within cardiomyocytes increases the action potential amplitude and prolongs the re-polarization duration by depressing the retrograde trafficking of Nav1.5 and Kir2.1 channels. These effects are likely to account for the DNM2 defect-induced arrhythmogenic potentials. These results suggest that DNM2, with its multi-ion channel targeting properties, could be a promising target for novel antiarrhythmic therapies.

Mechanisms of hypokalemia-induced ventricular arrhythmogenicity

Hypokalemia is a common biochemical finding in cardiac patients and may represent a side effect of diuretic therapy or result from endogenous activation of renin-angiotensin system and high adrenergic tone. Hypokalemia is independent risk factor contributing to reduced survival of cardiac patients and increased incidence of arrhythmic death. Animal studies demonstrate that hypokalemia-induced arrhythmogenicity is attributed to prolonged ventricular repolarization, slowed conduction, and abnormal pacemaker activity. The prolongation of ventricular repolarization in hypokalemic setting is caused by inhibition of outward potassium currents and often associated with increased propensity for early afterdepolarizations. Slowed conduction is attributed to membrane hyperpolarization and increased excitation threshold. Abnormal pacemaker activity is attributed to increased slope of diastolic depolarization in Purkinje fibers, as well as delayed afterdepolarizations caused by Ca2+ overload secondary to inhibition of Na+--K+ pump and stimulation of the reverse mode of the Na+--Ca2+ exchange. Hypokalemia effect on repolarization is not uniform at distinct ventricular sites thereby contributing to amplified spatial repolarization gradients which promote unidirectional conduction block. In hypokalemic heart preparations, the prolongation of action potential may be associated with shortening of effective refractory period, thus increasing the propensity for ventricular re-excitation over late phase of repolarization. Shortened refractoriness and slowed conduction contribute to reduced excitation wavelength thereby facilitating re-entry. The interplay of triggering factors (early and delayed afterdepolarizations, oscillatory prepotentials in Purkinje fibers) and a favorable electrophysiological substrate (unidirectional conduction block, reduced excitation wavelength, increased critical interval for ventricular re-excitation) may account for the mechanism of life-threatening tachyarrhythmias in hypokalemic patients.

Repolarization of the cardiac action potential. Does an increase in repolarization capacity constitute a new anti-arrhythmic principle?

The cardiac action potential can be divided into five distinct phases designated phases 0-4. The exact shape of the action potential comes about primarily as an orchestrated function of ion channels. The present review will give an overview of ion channels involved in generating the cardiac action potential with special emphasis on potassium channels involved in phase 3 repolarization. In humans, these channels are primarily K(v)11.1 (hERG1), K(v)7.1 (KCNQ1) and K(ir)2.1 (KCNJ2) being the responsible alpha-subunits for conducting I(Kr), I(Ks) and I(K1). An account will be given about molecular components, biophysical properties, regulation, interaction with other proteins and involvement in diseases. Both loss and gain of function of these currents are associated with different arrhythmogenic diseases. The second part of this review will therefore elucidate arrhythmias and subsequently focus on newly developed chemical entities having the ability to increase the activity of I(Kr), I(Ks) and I(K1). An evaluation will be given addressing the possibility that this novel class of compounds have the ability to constitute a new anti-arrhythmic principle. Experimental evidence from in vitro, ex vivo and in vivo settings will be included. Furthermore, conceptual differences between the short QT syndrome and I(Kr) activation will be accounted for.

Class III effects of dofetilide and arrhythmias are modulated by [K+]o in an in vitro model of simulated-ischemia and reperfusion in guinea-pig ventricular myocardium

To evaluate class III effects of clinically relevant concentrations of dofetilide (5 and 10 nmol/l) and the effects of extracellular potassium [K+]o modulation of arrhythmias onset at the level of the "border zone," we used a previously reported in vitro model whereby normoxic and ischemic/reperfused zones were studied. Guinea-pig right ventricular strips (driven at 1 Hz at 36.5+/-0.5 degrees C) were superfused with Tyrode's solution in oxygenated (HCO3- 25 mmol/l, K+ 4 mmol/l, pH 7.35+/-0.05, glucose 5.5 mmol/l: normal zone) and ischemia-simulating conditions (HCO3- 9 mmol/l, pH 6.90+/-0.05, no oxygen and no glucose: altered zone) having either [K+]o 4 (n=20), 8 (n=20) or 12 (n=20) mmol/l. Action potentials in normal and altered zones were recorded simultaneously during 30 min of simulated-ischemia and after 30 min of reperfusion with oxygenated Tyrode's solution. Each preparation served as control for successive phases of dofetilide studies (at 5 and 10 nmol/l) and action potential values were normalized to those present at the beginning of the experiment. During simulated-ischemia, the higher the [K+]o the worse were action potential changes, although full recovery was seen upon 30 min of reperfusion in all [K+]o groups. A high incidence of ischemia/reperfusion arrhythmias was observed in 4 and 12 mmol/l [K+]o groups as opposed to a low incidence of arrhythmias in 8 mmol/l [K+]o group. Dofetilide at 5 and 10 nmol/l with all [K+]o explored: (i) exhibited class III effects, (ii) was effective (or neutral) against ventricular arrhythmias during both simulated-ischemia and reperfusion, and (iii) did not globally increase the dispersion of action potential durations between normal and altered zones. Different arrhythmogenic mechanisms are involved in this model at different [K+]o with 8 mmol/l providing relative protection. Class III effects of dofetilide are evident in the normal zone when in the ischemic-like zone [K+]o ranges from 4 to 12 mmol/l. Thus dofetilide did not increase dispersion of repolarization and had either an antiarrhythmic or a neutral effect during ischemia/reperfusion.

Refining detection of drug-induced proarrhythmia: QT interval and TRIaD

QT interval prolongation is so frequently associated with torsades de pointes (TdP) that it has come to be recognized as a surrogate marker of this unique tachyarrhythmia. However, not only does TdP not always follow QT interval prolongation, but TdP can occur even in the absence of a prolonged QT interval. Worse still, even shortening of the QT interval may be associated with serious arrhythmias (particularly ventricular tachycardia [VT] and ventricular fibrillation [VF]). It appears increasingly probable that the distinction between various ventricular tachyarrhythmias may be arbitrary, and drug-induced TdP, polymorphic VT, VT, catecholaminergic polymorphic VT, and VF may represent discrete entities within a spectrum of drug-induced proarrhythmia. Although they are differentiated by the coupling interval and the duration of QT interval, they appear to share a common substrate: a set of disturbances of repolarization characterized by Triangulation, Reverse use dependency, electrical Instability of the action potential, and Dispersion (TRIaD). It is becoming increasingly evident that augmentation of TRIaD, rather than changes in the duration of QT interval, provides the proarrhythmic substrate. In contrast, when not associated with an increase of TRIaD, QT interval prolongation can be an antiarrhythmic property. Electrophysiologically, augmentation of TRIaD can be explained by inhibition of hERG (human ether-a-go-go related gene) channel. Because drug-induced disturbances in repolarization commonly result from inhibition of hERG channels or I(Kr), hERG blockade and the resulting prolongation of QT interval are important properties of a drug to be studied. However, these need only be a concern if associated with TRIaD. More significantly, TRIaD so often precedes prolongation of action potential duration or QT interval and ventricular tachyarrhythmias that it should be considered a marker of proarrhythmia until proven otherwise, even in the absence of QT interval prolongation. Detecting drug-induced augmentation of TRIaD may offer an additional, more sensitive, and accurate indicator of the broader proarrhythmic potential of a drug than may QT interval prolongation alone.

Induced automaticity in isolated rat atrial cells by incorporation of a stretch-activated conductance

Stretch of the atrium and sympathetic activity have been implicated as substrates for atrial fibrillation. We investigate how a model of stretch in combination with sympathetic stimulation can induce automaticity in atrial cells. We adapted our coupling clamp circuit so that a model ionic current that represents stretch-activated channels (SACs) was injected into an isolated rat atrial cell in real time. This current was calculated as ISAC= GSAC (Vm-ESAC), where GSAC and ESAC are the conductance and reversal potential of SACs and Vm is the cell's membrane potential. Repetitive automaticity was induced by a sufficiently large GSAC and this critical value of GSAC was decreased by exposure to isoproterenol. The critical value of GSAC decreased from 0.63+/-0.05 nS (mean+/-SE) in control to 0.40+/-0.07 nS in isoproterenol (P<0.05). Additionally, after exposure to isoproterenol, automaticity continued after GSAC was no longer applied and was accompanied by delayed after-depolarizations. In three cells, repetitive automaticity could not be induced at any value of GSAC. Exposure to 10 nM isoproterenol converted these cells to cells with repetitive automaticity in response to GSAC. We conclude that automaticity can be induced in isolated rat atrial cells by application of a model of SACs. Exposure to isoproterenol enhances this effect.

Aqueous extract of Monascus purpureus M9011 prevents and reverses fructose-induced hypertension in rats

This study aimed to determine the antihypertensive and metabolic effects of an aqueous extract of Monascus purpureus M9011 on fructose-induced hypertensive rats. After dietary feeding of fructose for 2 weeks, the rats exhibited significantly higher systolic blood pressure (SBP), mean arterial pressure (MAP), and plasma insulin and triglyceride levels, but lower insulin sensitivity than those in control rats on regular diet. The intragastric loading of fructose-fed rats with M9011 containing gamma-aminobutyric acid (GABA, 1 mg.kg(-)(1).day(-)(1)) prevented the development of fructose-induced hypertension. After fructose-induced hypertension had been established, intragastric loading of M9011 reversed the elevated blood pressure to normal level. Administration of pure GABA at the same dose as that contained in M9011 failed to prevent or reverse hypertension due to fructose consumption. Chronic M9011 treatment significantly suppressed the fructose-induced elevation in total cholesterol levels and enhanced the recovery of high-density lipoprotein cholesterol/total cholesterol ratio. However, M9011 treatment did not alter insulin sensitivity or the plasma levels of insulin, glucose, and triglyceride in fructose-fed and control rats. The present results suggest that M9011 is a novel, potent, food-based antihypertensive agent with the capability to improve long-term control of cholesterol metabolism in rats and may be of importance in clinical application for the hypertensive diabetic population.

Cardiac ionic currents and acute ischemia: from channels to arrhythmias

The aim of this review is to provide basic information on the electrophysiological changes during acute ischemia and reperfusion from the level of ion channels up to the level of multicellular preparations. After an introduction, section II provides a general description of the ion channels and electrogenic transporters present in the heart, more specifically in the plasma membrane, in intracellular organelles of the sarcoplasmic reticulum and mitochondria, and in the gap junctions. The description is restricted to activation and permeation characterisitics, while modulation is incorporated in section III. This section (ischemic syndromes) describes the biochemical (lipids, radicals, hormones, neurotransmitters, metabolites) and ion concentration changes, the mechanisms involved, and the effect on channels and cells. Section IV (electrical changes and arrhythmias) is subdivided in two parts, with first a description of the electrical changes at the cellular and multicellular level, followed by an analysis of arrhythmias during ischemia and reperfusion. The last short section suggests possible developments in the study of ischemia-related phenomena.

Antiarrhythmic effect and its underlying ionic mechanism of 17beta-estradiol in cardiac myocytes

1. The effects of oestrogens on action potential and membrane currents were examined in single guinea-pig atrial myocytes. 2. 17Beta-estradiol (3-10 microM) shortened the action potential duration without significant changes in the resting membrane potential. E-4031 (1 microM) markedly prolonged the action potential duration and induced early afterdepolarization, and 17beta-estradiol (10 microM) abolished it. 3. When cells were perfused in isoproterenol-containing solution, action potentials due to abnormal automaticity caused by membrane depolarization developed, and were also inhibited by 17beta-estradiol. 4. Under voltage clamp conditions, the voltage-dependent Ca2+ currents consisted of both T-(I(Ca,T)) and L-type (I(Ca,L)). 17Beta-estradiol reduced I(Ca,L) concentration-dependently, while it (10 microM) suppressed I(Ca,T) only by approximately 10%. 17Beta-estradiol did not affect time courses of I(Ca,L) inactivation, but it shifted the steady-state inactivation curve to more negative potentials. 5. 17Beta-estradiol (10 microM) did not affect the time-dependent K+ current (I(K)), referred to as I(Kr) and I(Ks) and inwardly rectifying K+ current. However, 17beta-estradiol (30 microM) or diethylstilbestrol (10 microM) inhibited K+ currents. 6. DES and ethinylestradiol (EES) also suppressed I(Ca,L), but testosterone and progesterone failed to inhibit I(Ca,L) The potency of the inhibitory effect on I(Ca,L) was DES> EES> 17beta-estradiol. 7. 17Beta-estradiol and DES also inhibited the cyclic AMP-enhanced I(Ca,L), but cyclic GMP in the pipette or pretreatment of L-NAME could not block the effects of oestrogen on I(Ca,L). 8 These results suggest that oestrogen specifically has antiarrhythmic effects, possibly by acting the L-type Ca2+ channels. The antiarrhythmic effects of oestrogens may contribute to the cardioprotective actions of oestrogens.

Cellular electrophysiologic mechanisms of cardiac arrhythmias

Cardiac arrhythmias are caused by alterations in the electrophysiologic properties of the cardiac cells, which affect the characteristics of the transmembrane potentials. The electrophysiologic properties that cause arrhythmias are automaticity, triggered activity, and reentrant excitation. Each of these mechanisms is described in terms of the characteristics of the transmembrane potentials and how these influence the appearance of the arrhythmia on the electrocardiogram.

Cellular electrophysiologic basis of cardiac arrhythmias

During normal sinus rhythm, the cardiac impulse originates in the sinus node at a rate appropriate to the age and activity of the animal and spreads in an orderly fashion throughout the atria, the atrioventricular (AV) node, the His-Purkinje system, and then throughout the ventricles. An arrhythmia is an abnormality in the rate, regularity, or site of origin of the cardiac impulse or a disturbance in conduction of the impulse so that the normal sequence of activation of atria and ventricles is altered. Cardiac arrhythmias and conduction disturbances occur in every region of the heart and are caused by numerous factors. In particular, some are aligned with certain disease states. In the final analysis, however, all arrhythmias and conduction disturbances--regardless of their pathoelectrophysiologic cause--result from critical alterations, either acute or chronic, in the electrical activity of the cardiac myocyte. This review will provide basic information on how normal cardiac electrophysiology can be changed by disease and how these changes can lead to conduction disturbances and cardiac arrhythmias.

Role of the Inward K Rectifier in the Repetitive Activity at the Depolarized Level in Single Ventricular Myocytes

The role of the inward K(+) rectifier in the repetitive activity at depolarized levels was studied in guinea pig single ventricular myocytes by voltage- and current-clamp methods. In action potentials arrested at the plateau by a depolarizing current, small superimposed hyperpolarizing currents caused much larger voltage displacements than at the resting potential and sometimes induced a regenerative repolarization. Around -20 mV, sub- and suprathreshold repetitive inward currents were found. In the same voltage range, small hyperpolarizing currents reversed their polarity. During depolarizing voltage-clamp ramps, around -20 mV there was a sudden decrease in the outward current (I(ns): current underlying the negative slope in the inward K(+) rectifier steady state I-V relation). During repolarizing ramps, the reincrease in outward current was smaller and slower. During depolarizing and repolarizing current ramps, sudden voltage displacements showed a similar asymmetry. Repetitive I(ns) could continue as long as the potential was kept at the level at which they appeared. Depolarizing voltage-clamp steps also caused repetitive I(ns) and depolarizing current steps induced repetitive slow responses. Cadmium and verapamil reduced I(ns) amplitude during the depolarizing ramp. BRL 34915 (cromakalim), an opener of the ATP-sensitive K(+) channel, eliminated the negative slope and I(ns), whereas barium increased I(ns) frequency (an effect abolished by adding BRL). Depolarization-induced slow responses persisted in an NaCl- Ca-free solution. Thus, the mechanism of repetitive activity at the depolarized level appears to be related to the presence of the negative slope in the inward K(+) rectifier I-V relation. Copyright 1994 S. Karger AG, Basel

Effect of coronary occlusion and reperfusion on local electrical resistivity of myocardium in dogs

The effect of coronary occlusion and reperfusion on myocardial electrical resistivity was studied in nine anesthetized open-chest dogs. Anisotropic resistivity was measured on the anterior free wall of the left ventricle (LV) before (control) and during transient occlusion of the left anterior descending (LAD) coronary artery, and during reperfusion. To measure local resistivity longitudinal (RL) and transverse (RT) to epicardial muscle fiber direction, a sensor was developed based on the four electrode (FE) technique with an electrode distance of 1 mm. Previous calculations showed that measurements with this system were confined to a 2-mm-thick epicardial layer. Control values for RL and RT were 243 +/- 32 ohms.cm and 358 +/- 45 ohms.cm (mean +/- SD, n = 9) respectively. During a 2-min LAD occlusion, RL increased gradually by 12.4% (p < 0.05) and RT by 7.8% (p < 0.05) above the preceding control values. During a 5-min reperfusion period resistivities returned towards control values, but tended to remain elevated. RL showed a slight initial further increase during the first min of reperfusion and remained significantly above control values during 3 min of reperfusion. RT returned to values not significantly different from control after about 1 min of reperfusion.

Electrophysiologic mechanisms for ventricular arrhythmias in left ventricular dysfunction: electrolytes, catecholamines and drugs

Cardiac arrhythmias are generated as the result of disorders of automaticity or of impulse conduction. Regardless of the mechanism, calcium is likely to be involved, although calcium antagonists are rarely useful antiarrhythmics in ventricular arrhythmias. Myocardial cells that do not ordinarily initiate action potentials may do so when they are partially depolarized, giving rise to an ectopic focus. Early afterdepolarizations (EADs) are also induced in cardiac cells by partial depolarization, whereas delayed afterdepolarizations (DADs) are induced by Ca++ overloading. EADs may be the initiating mechanism of torsade de pointes, a complication of QT prolongation associated with quinidine therapy. Both in the animal model and in humans, treatment with magnesium, isoproterenol, or pacing, all of which suppress EADs, will also suppress torsade de pointes. Ventricular tachycardia is a manifestation of ordered re-entry, and may be exacerbated by antiarrhythmics, especially class 1c drugs. In the individual patient, prediction of proarrhythmia is not possible. The risk of proarrhythmia is increased in patients with episodes of sustained ventricular tachycardia or with significant left ventricular dysfunction.

Electrophysiologic mechanisms of ventricular arrhythmias

In this work the electrophysiologic mechanisms of ventricular arrhythmias have been briefly summarized. Ventricular arrhythmias can be caused either by pacemaker activity or by reentrant excitation. Enhancement of normal automaticity can generate a parasystolic rhythm in normal fibers. Abnormal automaticity may arise from fibers in which maximum diastolic potential has been reduced by a variety of interventions. Triggered activity is caused by either an early (EAD) or delayed (DAD) afterdepolarization and requires a prior normal action potential for initiation. While there is growing evidence that EAD-induced triggered activity plays a significant role in the Long QTU syndrome and Torsade de Pointes, no clinical arrhythmias has definitely been ascribed to DADs, although DADs have been recorded in man after acute digoxin intoxication. Ventricular arrhythmias can be also caused by reentrant excitation, which can be subdivided into reflection or circus movement reentry (CMR). In the reflection model impulses in both directions are transmitted over the same pathway. In the CMR three models can be differentiated: the ring model, which requires a fixed anatomical obstacle; the figure-eight model and the leading circle model, where functional rather than fixed anatomical obstacles are involved.

A model study of stability and oscillations in the myocardial cell membrane

As a step towards an improved understanding of cardiac arrhythmias caused by abnormal automaticity, we perform a stability analysis of a Hodgkin-Huxley model of the myocardial cell membrane (modified Beeler-Reuter, MBR). The bifurcation structure of the model is obtained as a function of three parameters: the intensity of an applied constant current; the potassium equilibrium potential representing the accumulation of K+ ions in the external medium; and the maximum conductance of the slow inward current mimicking the local application of catecholamines on the membrane. For a range of parameter values, the model exhibits either stable automaticity or bistability between two quiescent states or between a quiescent state and an oscillatory state. These transformations of the bifurcation structure are shown to depend on the interrelationship between three elements: the activation of the slow inward current, the region of high slope conductance of the time-independent potassium current functions, and the slow variables controlling the activation of the potassium current and the inactivation of the slow inward current. Reduced two- and three-dimensional models are shown to reproduce the main stability properties of the full MBR model and to facilitate the understanding of its dynamic behavior. The onset of instability and the oscillatory features of the MBR model are in good agreement with relevant experimental results, and possible sources of disagreement on certain points are discussed.

Amantadine-induced afterpotentials and automaticity in guinea pig ventricular myocytes

The ionic mechanisms of amantadine-induced changes in membrane potential and automatic activity in guinea pig ventricular myocytes were studied using the suction-pipette whole-cell clamp method. While 25-100 microM amantadine decreased the action potential amplitude and duration, 200 and 400 microM amantadine lengthened the action potential duration and decreased the maximum diastolic potential with an appearance of diastolic depolarization and automaticity. In the presence of 25-100 microM amantadine, the preparations developed an afterpotential due to incomplete repolarization and a delayed afterdepolarization that eventually brought about triggered automaticity. The former type of afterpotential was abolished by tetrodotoxin (TTX) and the latter by Co2+. Spontaneous activity from the diastolic depolarization was also abolished by Co2+ but not by Cs+. Amantadine suppressed the calcium current to as much as half of the control at the concentrations used (25-200 microM). The drug also produced a depression of the inward rectifier K+ current. The outward current showing time-dependent decay was activated at the plateau voltages by concentrations lower than 100 microM, whereas the delayed outward K+ current was depressed by the drug in a concentration-dependent manner at more positive potentials. Amantadine activated the TTX-sensitive and TTX-insensitive inward currents on repolarization from depolarized states, without producing the transient inward current. These results indicate that the amantadine-induced diastolic depolarization and afterpotentials are caused by changes in multiple ionic currents and that, therefore, the drug can be used as a unique model for the study of arrhythmogenesis.

In-hospital cardiopulmonary resuscitation during asystole. Therapeutic factors associated with 24-hour survival

The most recent American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) during asystole include ventricular defibrillation, intubation, and the administration of epinephrine and atropine. This study reports results from a retrospective analysis of clinical, demographic, and treatment data collected during in-hospital CPR efforts in 123 patients in whom the initial rhythm was asystole. Twenty-eight (22.8 percent) of these patients were alive 24 h after CPR initiation. Patients who received norepinephrine drip (N = 43) were more likely to survive than those who did not (39.5 percent vs 14.1 percent; p less than .01), and those who received lidocaine drip were more likely to survive than those who did not (47.6 percent vs 18.2 percent; p less than .01). The best survival rate (57.1 percent) occurred among those who received both norepinephrine and lidocaine (N = 14). Survivors did not differ significantly from nonsurvivors in terms of age, gender, primary diagnosis, location of arrest, or duration of CPR efforts. The results suggest that aggressive resuscitation efforts which include the addition of norepinephrine and lidocaine drips to the AHA-recommended regimen of epinephrine and atropine may substantially increase the number of 24-h survivors. A pharmacologic mechanism involving norepinephrine-induced myocardial irritability and peripheral vasoconstriction, combined with lidocaine-induced suppression of abnormal automaticity, is offered as a possible explanation of the obtained results.

Effects of amiodarone on barium-induced automatic activity in guinea pig ventricular muscle

1. The electrophysiological effects of a potent antiarrhythmic agent, amiodarone, on BaCl2-induced automaticity of guinea pig ventricular papillary muscle were studied by means of conventional microelectrode techniques. 2. BaCl2 (5 x 10(-4) M) depolarized the maximum diastolic potential of muscle preparation to about -62 mV and induced the spontaneous activity at rate of about 62 beats/min. 3. The application of amiodarone (4.4 x 10(-5) M to 1.1 x 10(-3) M) to the BaCl2-induced automatic muscle fibers decreased the spontaneous rate and slope of slow diastolic depolarization in a dose-dependent manner, associated with insignificant changes in action potential duration. 4. Amiodarone may exert the inhibitory effects of BaCl2-induced automaticity by decreasing steady-state conductance for the Na+ and Ca2+, probably thereby permitting the manifestation of antiarrhythmic properties in combination of its other actions.

Effect of myocardial revascularization and vein graft blood flow on pacing function

The effect of myocardial revascularization and vein graft blood flow on pacing function was determined in nine patients undergoing aortocoronary bypass. Pacing variables including threshold, current, and resistance were measured with a pacing system analyzer during intermittent pacing with a transluminal bipolar ventricular pacing probe. Pacing function was analyzed immediately before cardiopulmonary bypass (CPB) and compared with measurements taken eight minutes after full flow through the vein grafts had been established. Comparison of these two times showed a significant decrease in resistance, P < 0.003, and threshold, P < 0.03. After the second measurement, left anterior descending (n = 8), or right coronary (n = 1) vein graft blood flow was interrupted. Pacing variables were analyzed at one minute, two minutes, and four minutes following vein graft clamping; and a final set of measurements was obtained one minute following release of the vein graft clamp. Threshold increased but did not reach statistical significance. Resistance increased significantly: P < 0.03. All values returned to baseline following release of the vein graft clamp and full return of blood flow. The results of this study suggest that pacing function measurements are sensitive to changes in vein graft blood flow and may provide useful information about the condition of the myocardium, especially immediately prior to weaning from CPB.

Repolarization current in embryonic chick atrial heart cells

1. We have measured the delayed rectifier potassium current, IK, with the whole-cell patch-clamp technique from single cultured cells from the atria of 6- to 11-day-old chick embryonic hearts. 2. The IK component was activated with depolarizing voltage-clamp steps positive to -30 mV (holding potential in the -60 to -40 mV range). Maximum activation of the IK conductance occurred at +25 mV, based on deactivation, or tail current amplitudes upon return to the holding potential. Activation and tail current kinetics could both be described by single-exponential functions of time. 3. The IK kinetics were voltage dependent, with a maximum time constant, tau n, of approximately 2 s at V = -20 mV. 4. The IK reversal potential measurements suggest that this current is carried predominantly by potassium ions. 5. The IK results from single cells, or clusters of two or three cells, were comparable to our recent measurements of IK (IX2) in heart cell aggregates (Shrier & Clay, 1986). However, we did not obtain clear evidence in single cells for the IX1 repolarization current, in contrast to the aggregate results. 6. Computer simulations based on our IK measurements demonstrate that this component is sufficient to initiate repolarization of the action potential in single cells. However, it is not sufficient to reproduce the latter phase of repolarization for potentials negative to -30 mV. Addition of a relatively small IX1 component (2% in absolute terms compared to the aggregate work) is sufficient to account for this part of the action potential.

Actions of three local anaesthetics: lidocaine, bupivacaine and ropivacaine on guinea pig papillary muscle sodium channels (Vmax)

The new local anaesthetic ropivacaine (LEA 103) like lidocaine and bupivacaine used as references, blocked cardiac sodium channels in a use-dependent fashion. At equimolar concentrations lidocaine had the lowest efficacy and bupivacaine the highest. The action potential was shortened and the plateau was depressed at high concentrations of each drug. Pacing a papillary muscle at 3.3 Hz in the presence of all three drugs resulted in a marked use-dependent accumulation of block (P less than 0.01). The accumulated block slowly dissipated after rest. At -90 mV holding (= resting) potential, and at a concentration of 10 microM, the time constant for recovery from block was 186 msec. in lidocaine (n = 4), 1.4 sec. in ropivacaine (n = 7), and 2.1 sec. in bupivacaine (n = 7). Lidocaine decreased Vmax progressively at high rates of stimulation, but not significantly at rates below 2 Hz. Ropivacaine progressively decreased Vmax significantly at rates above 1 Hz, but to a lesser degree than bupivacaine. The use-dependent action of the drugs was increased at more depolarized (less negative) holding potentials, whereas at more hyperpolarized potentials the block was diminished. Lidocaine and ropivacaine could be readily dissociated from the receptors at more hyperpolarized membrane potentials (-100 to -120 mV), whereas bupivacaine bound much harder. All three drugs blocked sodium channels more effectively after a long single conditioning pulse. Bupivacaine had the most prominent effect, and lidocaine was least effective. Bupivacaine and ropivacaine seem to interact with the inactivated state of the sodium channels, whereas lidocaine acted on both the open and on the inactivated state of the channels.(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of conduction slowing in ischemic rabbit myocardium by calcium-channel activation and blockade

Ventricular action potentials and longitudinal conduction times over short distances of epicardium were recorded in isolated rabbit hearts. Global ischemia produced a progressive decrease of resting membrane potential, depression of action potentials, and conduction slowing to approximately 50% of control values over 8 to 10 min. Verapamil (2 X 10(-6) M) markedly attenuated ischemia-induced conduction slowing in association with less depression of maximum upstroke velocity (Vmax) and slightly less change in resting membrane potential. In contrast, Bay K 8644 (10(-7) M), a calcium-channel agonist, exacerbated ischemia-induced conduction slowing and depression of Vmax but did not significantly affect resting membrane potential. Regression analysis of Vmax vs resting membrane potential and the square of conduction velocity vs Vmax demonstrated that verapamil and Bay K 8644 shifted these relationships in opposite directions. The results indicate that the calcium-channel activation state can modulate slowing of conduction during early ischemia. This is most likely due to alterations in calcium influx before and/or during ischemia. There appear to be three possible components to this effect: (1) a small alteration in the magnitude of ischemia-induced depolarization, (2) alterations of membrane responsiveness at depolarized values of resting membrane potential, and (3) alterations in "nonactive" components of conduction during ischemia, such as changes in excitability or cell-to-cell coupling.

Effects of enprofylline, theophylline and terbutaline on second inward currents in papillary muscles from ferrets and guinea-pigs

In ferret and guinea pig papillary muscles enprofylline (10 microM-10 mM) and theophylline (0.1-2 mM) alone or in combination with terbutaline (0.05 microM-0.1 microM) decreased the action potential duration and increased the plateau height, increased the peak force of contraction and facilitated the depolarization-induced automaticity. In voltage clamp, the xanthines alone or in combination with terbutaline increased second inward currents, ICa,f and ICa,2, but had relatively less effect on the time-dependent outward current. No qualitative differences between enprofylline and theophylline could be detected but the former was about 5 times more potent in increasing ICa,f. In clinically relevant concentrations, enprofylline and theophylline alone, or in combination with terbutaline caused a small (2-5%) shortening of the action potential.

Effects of beta-adrenergic blockade on verapamil-responsive and verapamil-irresponsive sustained ventricular tachycardias

To assess effects of beta-adrenergic blockade on ventricular tachycardia (VT) of various mechanisms, electrophysiology studies were performed before and after intravenous infusion of propranolol (0.2 mg/kg) in 33 patients with chronic recurrent VT, who had previously been tested with intravenous verapamil (0.15 mg/kg followed by 0.005 mg/kg/min infusion). In the verapamil-irresponsive group, 10 patients (group IA) had VT that could be initiated by programmed ventricular extrastimulation and terminated by overdrive ventricular pacing, and 11 patients (group IB) had VT that could be provoked by isoproterenol infusion (3-8 micrograms/min) but not by programmed electrical stimulation, and that could not be converted to a sustained sinus rhythm by overdrive ventricular pacing. Notably, in the group IA patients, all 10 patients had structural heart disease (coronary arteriosclerosis or idiopathic cardiomyopathy); beta-adrenergic blockade accelerated the VT rate in one patient but exerted no effects on the VT rate in the remaining 9 patients, and VT remained inducible in all 10 patients. By contrast, in the group IB patients, 7 of the 11 patients had no apparent structural heart disease; beta-adrenergic blockade completely suppressed the VT inducibility during isoproterenol infusion in all 11 patients. There were 12 patients with verapamil-responsive VT (group II). 11 of the 12 patients had no apparent structural heart disease. In these patients, the initiation of VT was related to attaining a critical range of cycle lengths during sinus, atrial-paced or ventricular-paced rhythm; beta-adrenergic blockade could only slow the VT rate without suppressing its inducibility. Of note, 14 of the total 33 patients had exercise provocable VT: two in group IA, five in group IB, and seven in group II. Thus, mechanisms of VT vary among patients, and so do their pharmacologic responses. Although reentry, catecholamine-sensitive automaticity, and triggered activity related to delayed afterdepolarizations are merely speculative, results of this study indicate that beta-adrenergic blockade is only specifically effective in a subset group (group IB) of patients with VT suggestive of catecholamine-sensitive automaticity.

Barium-induced automatic activity in isolated ventricular myocytes from guinea-pig hearts

1. A suction-pipette whole-cell clamp technique was applied to single ventricular myocytes isolated from guinea-pig hearts, in order to investigate the ionic mechanism underlying Ba2+-induced automatic activity. 2. The application of 0.1 mM or less Ba2+ to the myocytes caused a depolarization of the resting membrane potential without inducing spontaneous activity. The stimulated action potential showed a prolonged repolarization phase followed by an after-hyperpolarization. 3. Concentrations of Ba2+ of 0.2 mM or greater produced further depolarization of the resting membrane potential and induced spontaneous activity. Spontaneous activity developed from the slow diastolic depolarization preceded by after-hyperpolarizations of spontaneous or stimulated action potentials. 4. Under voltage-clamp conditions, a decaying outward or inward current in response to hyperpolarizing clamp steps from depolarized potentials appeared in the presence of Ba2+. The Ba2+-induced current decay showed a faster time course with increasing hyperpolarizing clamp pulses and reversed its polarity at around -90 mV, the presumed equilibrium potential for K+ (EK). In the late current-voltage (I-V) relation, Ba2+ almost eliminated the inward-rectifying property. These effects on the cardiac membrane are consistent with a time- and voltage-dependent blocking action of Ba2+ on inward-rectifying K+ currents as reported for other excitable tissues. 5. The concentration- and voltage-dependence of the steady-state block of the inward rectifying K+ current (IK1) was fitted by a simple model assuming 1:1 binding of Ba2+ to a site within the membrane. The apparent dissociation constant at the holding potential of 0 mV (K(0] was 0.3 mM, and the parameter for the membrane potential dependence of Ba2+ blockade (mu) was approximately 0.5. 6. A computer model of the ventricular action potential proposed by Beeler & Reuter (1977) was modified, based on the recent experiments using single cardiac myocytes. The modifications include (1) the current-voltage relationship of IK1, (2) time courses of activation and inactivation of the Ca2+ current (ICa), (3) the activation voltage range for the delayed outward K+ current (IK). 7. The time- and voltage-dependent blocking action of Ba2+ on IK1, including the experimentally determined values for K(0) and mu, were incorporated into the modified version of the action potential model. The computer model reproduced an after-hyperpolarization at doses of Ba2+ lower than 0.1 mM and automatic activity at doses higher than 0.15 mM.(ABSTRACT TRUNCATED AT 400 WORDS)

An analysis of the delayed outward current in single ventricular cells of the guinea-pig

Properties of the delayed outward current (IK) in ventricular myocytes of the guinea-pig were studied using the whole cell clamp method. The experiments were performed under conditions in which IK was enhanced by application of isoproterenol while the Ca2+ current was eliminated by Ca2+-removal and by the addition of Cd2+. The reversal potential (Erev) of IK, determined from the current tails, was about 10 mV less negative than the K+ equilibrium potential. This was estimated by examining the reversal potential of the inward rectifier K+ current in Ba2+-containing solution, or from the Nernst equation. The Erev--log[K+]o relationship had a slope of 49 mV per tenfold change in [K+]o. In Na+-free solution, Erev became more negative. Thus, although the major charge carriers in IK are K+ ions, Na+ ions may also contribute in part to this current. The PNa/PK ratio in IK, calculated by applying a Goldman-Hodgkin-Katz relation to the reversal potential, was 0.016. The activation of IK during depolarization showed a sigmoidal time course at the onset, while the time course of the current tails was monoexponential at voltages more negative than-50 mV, but biexponential at more positive voltages. These observations can be explained by the conductance equation of the Hodgkin-Huxley type in which the kinetic variable is raised to the second power. These and other features of IK observed in the ventricular cells are discussed in comparison to the properties of similar current systems reported in other cardiac preparations.

Mechanisms for cardiac arrhythmias

Possible cellular electrophysiological mechanisms for arrhythmias have been investigated through studies of isolated cardiac tissues. Records through extracellular and intracellular electrodes indicate that arrhythmias may result from either focal or non-focal mechanisms. Focal mechanisms include abnormal impulse initiation (normal or abnormal automaticity), triggering from either early or delayed afterdepolarizations and reflection, whereas the non-focal mechanisms are various forms of reentry due to circus movement. It is reasonable to assume that these mechanisms also occur in vivo. Although it is safe to identify macro-re-entry as the cause of some atrial and ventricular arrhythmias, for the most part direct proof of mechanism usually is lacking for the focal arrhythmias. If 'on line' activation sequence mapping techniques can be developed to quickly and specifically locate arrhythmogenic foci in the in situ heart, it may be possible to use unipolar extracellular recording techniques to identify the exact cellular electrophysiological mechanisms operating within them.

Mechanisms responsible for countershock-induced ventricular tachycardia in the intact canine heart

To determine the mechanism for postcountershock ventricular ectopy, internal and external shocks were delivered to 20 anesthetized dogs. Shock energies of 25 and 50 joules were employed internally while 100 and 200 joules were delivered externally. Experiments were performed in both the presence and absence of a nearly toxic dose of ouabain. All shocks resulted in the occurrence of nonsustained (less than 15 seconds) ventricular tachycardia. When bursts of rapid ventricular pacing were synchronized with a shock, the pacing stimuli invariably captured the ventricles and overdrove the shock-induced ventricular tachycardia. However, the burst pacing never appeared to break a tachycardia, since the termination of pacing was followed immediately by the resumption of the shock-induced ventricular tachycardia. The presence of ouabain did not alter the response of the ventricles to postshock burst pacing. Administration of verapamil (0.5 mg/kg) had no effect on the duration of shock-induced ventricular arrhythmia. Elevation of the serum potassium level to 8.5 +/- 0.6 mEq/L drastically reduced the duration of postshock ventricular tachycardia in both the presence and absence of ouabain. The results suggest that postshock ventricular ectopy results from an abnormality of impulse initiation rather than reentry.

Biphasic contractions induced by milrinone at low temperature in ferret ventricular muscle: role of the sarcoplasmic reticulum and transmembrane calcium influx

The effects of milrinone were studied in ferret papillary muscle stimulated at various rates and temperatures from 23 degrees to 36 degrees C. In voltage-clamp experiments, 50 micrograms/ml (0.237 mM) milrinone induced a 2.1-fold increase in calcium current at 28 degrees or 36 degrees C. At 50 micrograms/ml, milrinone transiently increased contractility in all muscles at 28 degrees C, but its steady-state effect was either increased (+50%) or decreased (-24.7%) steady-state twitch amplitude. A negative inotropic effect always occurred below 27 degrees C. Milrinone decreased the total twitch duration and split the twitch into two components (P1 and P2) in the absence of any evidence of aberrant conduction. Increasing milrinone concentration from 50 to 300 micrograms/ml decreased P1 and increased P2. Ryanodine (100 mM) or caffeine (10 mM) suppressed P1. Contractions elicited after 30 seconds of rest were also biphasic in the presence of milrinone, but not in its absence. P2 of post-rest contraction was increased by caffeine or calcium (10 mM) and decreased by cobalt (2 mM) when drugs were applied at the beginning of the rest. Ryanodine and caffeine also suppressed P1 of post-rest contraction. The evidence suggests that P1 may be caused by Ca release from the sarcoplasmic reticulum and P2 by increased Ca influx during the action potential via the calcium channel. It is also suggested that P2 may be present under control conditions, but to a lesser extent, and masked by a large P1.

Potassium exchange in the human heart during atrial pacing and myocardial ischaemia

Potassium homoeostasis in the heart was studied during atrial pacing in 20 patients undergoing diagnostic coronary angiography. The potassium concentrations in the coronary sinus and a systemic artery were recorded continuously by means of catheter tip potassium electrodes. Ten patients with coronary artery disease and a positive exercise test developed chest pain and ST segment depression on the electrocardiogram during atrial pacing. Potassium concentrations in the coronary sinus rose initially and increased further when myocardial ischaemia developed. Ten patients including five with normal coronary arteries remained symptom free during atrial pacing with no electrocardiographic changes. In these patients coronary sinus potassium concentration increased at the onset of pacing, but returned to near control values despite continued pacing. In both groups arterial potassium concentration remained constant. Immediately after the end of pacing there was an abrupt transient fall in potassium concentrations in the coronary sinus to below control values. These results indicate that in man, as in other species, an increase in heart rate causes the transient movement of potassium out of the cell into the extracellular space. The onset of myocardial ischaemia is associated with a further loss of potassium from the cell. The end of pacing or ischaemia is accompanied by a re-uptake of potassium by heart muscle.

Effects of potassium conductance inhibitors on spontaneous diastolic depolarization and abnormal automaticity in human atrial fibers

The capability of generating spontaneous diastolic depolarization and automaticity was investigated in vitro by means of standard microelectrode techniques in 50 human atrial preparations. Samples were classified within two groups: group 1 was composed of 12 well-polarized preparations exhibiting action potentials that were fast responses (mean maximum diastolic potential: -75.5 mV and Vmax greater than 100 V/s); group 2 was composed of 38 partially-depolarized samples (mean maximum diastolic potential: -50.3 mV and Vmax less than 10 V/s) and was further divided into two subgroups. Subgroup 2A consisted of 20 spontaneously beating preparations and subgroup 2B consisted of 18 non-automatic partially-depolarized specimens. Highly-polarized fibers from group 1, although exhibiting a slight diastolic depolarization which was almost entirely suppressed by 2 mM caesium, never presented spontaneous activity under our experimental conditions. 90% of automatic fibers from subgroup 2A were sampled from dilated atria. In automatic preparations, diastolic depolarization was usually separated into two phases: an initial phase, also present in non-automatic fibers, and a late phase. Changes in the initial phase were not accompanied by concomitant changes in the spontaneous rate. Abnormal automaticity was clearly related to the late diastolic phase (absent in non-automatic fibers), the generation of which appeared to be a specific property of automatic fibers. The use of K conductance inhibitors (caesium, 4-aminopyridine, barium, low K solutions) provided indirect evidence that neither delayed outward ix current nor if type inward current are principally responsible for abnormal automaticity.

Effects of verapamil on ischemia-induced changes in extracellular K+, pH, and local activation in the pig

In experimental animals, the calcium channel-blocking agents lessen the arrhythmogenic, ionic, metabolic, and electrical changes that occur during acute myocardial ischemia. To date, these effects have been studied separately, and the effects of these agents on local activation have not been correlated with ionic or metabolic effects. In open-chest, anesthetized swine, we used bipolar and ion-selective plunge electrodes to simultaneously measure ischemia-induced changes in left ventricular local activation, extracellular K+ ([K+]e), and extracellular pH (pHe). The effects of verapamil (0.2 mg/kg) on these variables were studied during a series of 10 min occlusions of the left anterior descending coronary artery. Compared with control occlusions, verapamil (1) slowed the rise in [K+]e at the center of the ischemic zone and at its lateral margin and decreased the peak [K+]e by 0.9 mM at the center (p less than .05) and by 0.1 mM at the margin (p = .10); (2) slowed the development of acidosis and decreased the peak level of acidosis beyond that expected solely as a result of serial occlusions by 0.19 pH units at the center (p less than .05) and by 0.07 pH units at the margin (p = .10); and (3) slowed the development of local activation delay and often prevented the local activation block that was observed during control occlusions. Effects on local activation became less marked at [K+]e levels greater than 9.0 mM, and the effects of verapamil on local activation were not explained solely by its effects on the local rise in [K+]e or fall in pHe. A possible mechanism for this additional effect on local activation is suggested by preliminary results showing a diminution by verapamil of ionic inhomogeneity.

The efficacy of lidocaine and verapamil alone and in combination on spontaneously occurring automatic ventricular tachycardia in conscious dogs one day after right coronary artery occlusion

Occlusion of the right coronary artery (RCA) in the dog is associated with spontaneous sustained ventricular tachycardia (VT) during the 18 to 26 hours post occlusion period. Electrophysiologic studies suggest that these tachycardias are caused mainly by an automatic mechanism. In the present study we evaluated in 16 conscious dogs with VT 1 day after RCA occlusion the efficacy of (1) lidocaine (L), which depresses primarily the mechanism of enhanced normal automaticity; (2) verapamil (V), which depresses the mechanism of abnormal and triggered automaticity; and (3) combination of both L and V on these VTs. The RCA was occluded in 16 anesthetized closed-chest dogs by intracoronary balloon inflation. All 16 dogs had spontaneous VT while in the conscious state during the 18 to 26 hours post occlusion study period. L (5 mg/kg intravenously) bolus restored within 1 minute normal sinus rhythm (NSR), with a mean rate of 118 +/- 14 bpm, in dogs (n = 7) which had their VTs overdrive suppressed and had a mean rate of 145 +/- 14 bpm (range 110 to 150 bpm). L was ineffective in dogs (n = 9) which did not have their VTs overdrive suppressed and had a mean VT rate of 192 +/- 24 bpm (range 175 to 250 bpm). In contrast, however, V (0.15 mg/kg intravenously) was ineffective in all seven dogs with the slower VT rates, but was effective in restoring NSR with a mean rate of 140 +/- 14 bpm in six out of nine dogs with the faster VT rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Current concepts on the electrophysiology of the myocardium

Each heart beat is triggered by a characteristic change in the electrical potential that exists across the membranes of the cells of the heart. This 'cardiac action potential' is shown in figure 1 A and it is the result of currents of ions (figure 1 B) which flow across the cell membrane via so-called ion channels. During diastole the cell is at 'rest' and the cell interior is negative; this resting potential is the result of positive K ions flowing out of the cell via one type of K channel. This particular K current is known as iK, 1. During the upstroke (phase 0) of the action potential the cell is depolarized and the cell interior becomes positive because of a large influx of positive Na ions into the cell. This Na current (iNa) is short lived but despite this the cell remains depolarized for several hundred milliseconds during the characteristic plateau (phase 2) of the action potential because positive Ca ions now flow into the cell. Although this Ca current (iCa) is an important factor underlying the plateau phase, it is helped because the efflux of K ions via iK, 1 is curtailed as a result of a special property known as anomalous rectification. Finally the action potential is brought to an end as the Ca current gradually declines (inactivates) whereas the movement of K out of the cell (via a second set of K channels) gradually increases. This K current is known as iK.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of automaticity and triggered activity in the canine heart one to four days after myocardial infarction

Both abnormal automaticity and triggered activity induced by delayed afterdepolarizations have been proposed as the primary mechanism for ventricular tachycardia (VT) occurring in dogs 24 hr after ligation of the left anterior descending coronary artery. Because of this controversy, we studied the effects of ventricular pacing and therapeutic concentrations of lidocaine and ethmozin on sustained rhythmic activity of isolated subendocardial preparations excised from the infarct, and on VT in conscious dogs. There were differences in the sustained rhythmic activity cycle length of isolated preparations and the VT cycle length that were attributable to the absence of sympathetic input in the former and its presence in the latter. In isolated tissues, pacing for 1 or 10 beats reset the sustained rhythmic activity and pacing for 1 min induced overdrive suppression. Lidocaine (5 micrograms/ml) had no effect on sustained rhythmic activity but ethmozin (2 micrograms/ml) suppressed it. Delayed afterdepolarizations occurred but appeared to be induced by pacing or by the hyperpolarization associated with recovery. Although delayed afterdepolarizations were infrequent at 24 hr, their frequency increased with the hyperpolarization of the membrane that occurred at 48 to 96 hr after infarction. Delayed afterdepolarizations also occurred more readily when superfusate temperature was lowered. In conscious dogs, pacing the VT for 1 or 10 beats or 1 min had no effect. Lidocaine (2 to 10 micrograms/ml) did not affect the VT but ethmozin (2 to 5 micrograms/ml) increased VT cycle length significantly. Pacing for 1 min in the presence of ethmozin, but not lidocaine, converted VT to sinus rhythm. Our results suggest that although delayed afterdepolarizations occur at 24 hr after infarction in the standard Harris preparation, they are most readily seen as an accompaniment of hyperpolarization, pacing, or lowering of bath temperature. The predominant rhythm at 24 hr appears to be automatic.

Ventricular fibrillation

Ventricular fibrillation is the most common mechanism of sudden unexpected cardiac death in persons with asymptomatic or symptomatic coronary artery disease. The electrophysiologic mechanisms reviewed in this article include: automaticity of pacemaker fibers, transformation of nonpacemaker into pacemaker fibers, "injury" currents and reentry. Some of the conditions facilitating ventricular fibrillation include bradycardia, long QT syndrome, electrocution, electrolyte imbalance, drugs, sympathetic stimulation and myocardial ischemia. Electrophysiologic studies during acute myocardial ischemia suggest that the earliest activity at the onset of arrhythmia may originate at the sites of the surviving Purkinje fibers or at the epicardial rim. Reentrant arrhythmias arising in ischemic myocardium are attributed to nonhomogeneous distribution of local hyperkalemia and acidosis.

Spontaneous ventricular tachycardia associated with isolated right ventricular infarction, one day after right coronary artery occlusion in the dog: studies on the site of origin and mechanism

The electrophysiologic and arrhythmic properties of isolated infarcted right ventricle (RV) were studied in 17 dogs during the first 24 hours after complete occlusion of the right coronary artery (RCA). During the 16-to-20-hour post occlusion period, spontaneously occurring sustained monomorphic ventricular tachycardia (VT) was present in all 17 dogs. Overdrive ventricular pacing (cycle lengths 200 to 250 msec) caused significant suppression of the VT when the rate of the VT was slower than 150 bpm (range 120 to 145 bpm) (n = 9), but had negligible effect when VT rate was higher than 150 bpm (range 160 to 245 bpm (n = 8). Overdrive pacing could not terminate either the slow or the fast type of VT. Bipolar intramural electrograms have showed electrical activity in the infarcted RV zone to precede Q wave of the VT by 15.4 +/- 5.8 msec regardless of VT rate. Microelectrode studies on isolated RV endocardial infarcted tissues 24 hours after RCA occlusions have shown the presence of spontaneous repetitive activity at a rate of 87 +/- 47 bpm, which was overdrive suppressed in dogs with slow VT, and spontaneous activity at a rate of 115.2 +/- 36 bpm (p less than 0.05) which was not overdrive suppressed in dogs with fast VT. Maximum diastolic potential, action potential amplitude, and Vmax of surviving subendocardial Purkinje fibers (SEPF) in the infarct zone were slightly but significantly depressed (p less than 0.05), and they manifested enhanced phase 4 depolarization, giving rise to automatic impulse initiation. Although action potential duration of these fibers was somewhat prolonged (p less than 0.05), no conduction delay occurred. Histopathologic examinations have shown necrosis of the basal two thirds of the RV, with no left ventricular involvement. Electron microscopy revealed lipid accumulation in the surviving SEPF as the sole abnormality. We conclude (1) that occlusion of the RCA in the dog is associated with high survival rate despite extensive necrosis involving exclusively the RV and (2) that VT seen during the 20 to 24 hours after occlusion arise in the infarcted zone of the RV, by an enhanced automatic mechanism in the surviving SEPF, possibly caused by cytoplasmic lipid accumulation. This model, by virtue of its high survival rate and frequency of late VTs, should be useful in providing clues to determine factors involved in the genesis of early VT/VF and for the evaluation of new pharmacologic agents during the 20- to 24-hour VT period.