Mechanistic insights into very slow conduction in branching cardiac tissue: a model study

Sequence-Dependent Repolarization Is Modulated by Endogenous Action Potential Duration Gradients Rather Than Electrical Coupling in Ventricular Myocardium

BACKGROUND

Previous studies suggest the relationship between activation time (AT) and action potential duration (APD) in the heart is dependent on electrotonic coupling, but this has not been directly tested. This study assessed whether acute changes in electrical coupling, or other determinants of conduction or repolarization, modulate APD heterogeneity.

METHODS AND RESULTS

Langendorff-perfused guinea pig hearts were epicardially paced and optically mapped after treatment with the gap junction uncoupler carbenoxolone, ephaptic uncoupler mannitol, ephaptic enhancer dextran 2MDa, sodium channel inhibitor flecainide, or rapid component of the delayed rectifier potassium channel inhibitor E4031. SD of APD and the AT-APD slope and coefficient of determination were quantified as metrics of APD heterogeneity. SD of APD increased with carbenoxolone, mannitol, and altered activation sequence. The AT-APD slope was insensitive to carbenoxolone, mannitol, dextran, flecainide, or E4031 but changed in response to activation sequence. The coefficient of determination did not change with carbenoxolone; decreased with mannitol, E4031, and activation sequence; but increased with dextran and flecainide. APD heterogeneity changes were dependent on whether the estimation used SD of APD or the AT-APD relationship. The pacing stimulus increased APD at the site of stimulation, revealing a confounding stimulus effect on APD within the measurement area. Simulations predict that the stimulus artifact and endogenous APD gradients are stronger determinants of APD heterogeneity than AT.

CONCLUSIONS

APD dependence on conduction is relatively small. Furthermore, APD heterogeneity within a mapping field of view is dependent on endogenous gradients, the stimulus artifact, and the experimental approach, rather than electrical coupling.

Non-Invasive Electroanatomical Mapping: A State-Space Approach for Myocardial Current Density Estimation

Electroanatomical mapping is a method for creating a model of the electrophysiology of the human heart. Medical professionals routinely locate and ablate the site of origin of cardiac arrhythmias with invasive catheterization. Non-invasive localization takes the form of electrocardiographic (ECG) or magnetocardiographic (MCG) imaging, where the goal is to reconstruct the electrical activity of the human heart. Non-invasive alternatives to catheter electroanatomical mapping would reduce patients' risks and open new venues for treatment planning and prevention. This work introduces a new system state-based method for estimating the electrical activity of the human heart from MCG measurements. Our model enables arbitrary propagation paths and velocities. A Kalman filter optimally estimates the current densities under the given measurements and model parameters. In an outer optimization loop, these model parameters are then optimized via gradient descent. This paper aims to establish the foundation for future research by providing a detailed mathematical explanation of the algorithm. We demonstrate the feasibility of our method through a simplified one-layer simulation. Our results show that the algorithm can learn the propagation paths from the magnetic measurements. A threshold-based segmentation into healthy and pathological tissue yields a DICE score of 0.84, a recall of 0.77, and a precision of 0.93.

Enhanced optimization-based method for the generation of patient-specific models of Purkinje networks

Cardiac Purkinje networks are a fundamental part of the conduction system and are known to initiate a variety of cardiac arrhythmias. However, patient-specific modeling of Purkinje networks remains a challenge due to their high morphological complexity. This work presents a novel method based on optimization principles for the generation of Purkinje networks that combines geometric and activation accuracy in branch size, bifurcation angles, and Purkinje-ventricular-junction activation times. Three biventricular meshes with increasing levels of complexity are used to evaluate the performance of our approach. Purkinje-tissue coupled monodomain simulations are executed to evaluate the generated networks in a realistic scenario using the most recent Purkinje/ventricular human cellular models and physiological values for the Purkinje-ventricular-junction characteristic delay. The results demonstrate that the new method can generate patient-specific Purkinje networks with controlled morphological metrics and specified local activation times at the Purkinje-ventricular junctions.

The Primary Alteration of Ventricular Myocardium Conduction: The Significant Determinant of Left Bundle Branch Block Pattern

Intraventricular conduction disturbances (IVCD) are currently generally accepted as ECG diagnostic categories. They are characterized by defined QRS complex patterns that reflect the abnormalities in the intraventricular sequence of activation that can be caused by pathology in the His-Purkinje conduction system (HP) or ventricular myocardium. However, the current understanding of the IVCD's underlying mechanism is mostly attributed to HP structural or functional alterations. The involvement of the working ventricular myocardium is only marginally mentioned or not considered. This opinion paper is focused on the alterations of the ventricular working myocardium leading to the most frequent IVCD pattern-the left bundle branch block pattern (LBBB). Recognizing the underlying mechanisms of the LBBB patterns and the involvement of the ventricular working myocardium is of utmost clinical importance, considering a patient's prognosis and indication for cardiac resynchronization therapy.

Intracardiac Electrogram Targets for Ventricular Tachycardia Ablation

The pathogenesis of ventricular tachycardia (VT) in most patients with a prior myocardial scarring is reentry involving compartmentalized muscle fibers protected within the scar. Often the 12-lead ECG morphology of the VT itself is not available when treated with a defibrillator. Consequently, VT ablation takes on an interesting challenge of finding critical targets in sinus rhythm. High-density recordings are essential to evaluate a substrate based on whole electrogram voltage and activation delay, supplemented with substrate perturbation through alternate site pacing or introducing an extra stimulation. In this article, we discuss contemporary intracardiac electrogram targets for VT ablation, with explanation on each of their specific fundamental physiology.

Electrophysiological and anatomical factors determine arrhythmic risk in acute myocardial ischaemia and its modulation by sodium current availability

Acute myocardial ischaemia caused by coronary artery disease is one of the main causes of sudden cardiac death. Even though sodium current blockers are used as anti-arrhythmic drugs, decreased sodium current availability, also caused by mutations, has been shown to increase arrhythmic risk in ischaemic patients. The mechanisms are still unclear. Our goal is to exploit perfect control and data transparency of over 300 high-performance computing simulations to investigate arrhythmia mechanisms in acute myocardial ischaemia with variable sodium current availability. The human anatomically based torso-biventricular electrophysiological model used includes representation of realistic ventricular anatomy and fibre architecture, as well as ionic to electrocardiographic properties. Simulations show that reduced sodium current availability increased arrhythmic risk in acute regional ischaemia due to both electrophysiological (increased dispersion of refractoriness across the ischaemic border zone) and anatomical factors (conduction block from the thin right ventricle to thick left ventricle). The asymmetric ventricular anatomy caused high arrhythmic risk specifically for ectopic stimuli originating from the right ventricle and ventricular base. Increased sodium current availability was ineffective in reducing arrhythmic risk for septo-basal ectopic excitation. Human-based multiscale modelling and simulations reveal key electrophysiological and anatomical factors determining arrhythmic risk in acute ischaemia with variable sodium current availability.

Signature signal strategy: Electrogram-based ventricular tachycardia mapping

Multiple decades of work have recognized complexities of substrates responsible for ventricular tachycardia (VT). There is sufficient evidence that 3 critical components of a re-entrant VT circuit, namely, region of slow conduction, zone of unidirectional block, and exit site, are located in spatial vicinity to each other in the ventricular scar. Each of these components expresses characteristic electrograms in sinus rhythm, at initiation of VT, and during VT, respectively. Despite this, abnormal electrograms are widely targeted without appreciation of these signature electrograms during contemporary VT ablation. Our aim is to stimulate physiology-based VT mapping and a targeted ablation of VT. In this article, we focus on these 3 underappreciated aspects of the physiology of ischemic scar-related VT circuits that have practical applications during a VT ablation procedure. We explore the anatomic and functional elements underlying these distinctive bipolar electrograms, specifically the contribution of tissue branching, conduction restitution, and wave curvature to the substrate, as they pertain to initiation and maintenance of VT. We propose a VT ablation approach based on these 3 electrogram features that can be a potential practical means to recognize critical elements of a VT circuit and target ablation.

Missing Link between Molecular Aspects of Ventricular Arrhythmias and QRS Complex Morphology in Left Ventricular Hypertrophy

The aim of this opinion paper is to point out the knowledge gap between evidence on the molecular level and clinical diagnostic possibilities in left ventricular hypertrophy (LVH) regarding the prediction of ventricular arrhythmias and monitoring the effect of therapy. LVH is defined as an increase in left ventricular size and is associated with increased occurrence of ventricular arrhythmia. Hypertrophic rebuilding of myocardium comprises interrelated processes on molecular, subcellular, cellular, tissue, and organ levels affecting electrogenesis, creating a substrate for triggering and maintaining arrhythmias. The knowledge of these processes serves as a basis for developing targeted therapy to prevent and treat arrhythmias. In the clinical practice, the method for recording electrical phenomena of the heart is electrocardiography. The recognized clinical electrocardiogram (ECG) predictors of ventricular arrhythmias are related to alterations in electrical impulse propagation, such as QRS complex duration, QT interval, early repolarization, late potentials, and fragmented QRS, and they are not specific for LVH. However, the simulation studies have shown that the QRS complex patterns documented in patients with LVH are also conditioned remarkably by the alterations in impulse propagation. These QRS complex patterns in LVH could be potentially recognized for predicting ventricular arrhythmia and for monitoring the effect of therapy.

Information theory to tachycardia therapy: electrogram entropy predicts diastolic microstructure of reentrant ventricular tachycardia

There is no known strategy to differentiate which multicomponent electrograms in sinus rhythm maintain reentrant ventricular tachycardia (VT). Low entropy in the voltage breakdown of a multicomponent electrogram can localize conditions suitable for reentry but has not been validated against the classic VT activation mapping. We examined whether low entropy in a late and diversely activated ventricular scar region characterizes and differentiates the diastolic path of VT and represents protected tissue channels devoid of side branches. Intraoperative bipolar electrogram (BiEGM) activation and entropy maps were obtained during sinus rhythm in 17 patients with ischemic cardiomyopathy and compared with diastolic activation paths of VT (total of 39 VTs). Mathematical modeling of a zigzag main channel with side branches was also used to further validate structural representation of low entropy in the ventricular scar. A median of one region per patient (range: 1–2 regions) was identified in sinus rhythm, in which BiEGMwith the latest mean activation time and adjacent minimum entropy were assembled together in a high-activation dispersion region. These regions accurately recognized diastolic paths of 34 VTs, often to multiple inducible VTs within a single individual arrhythmogenic region. In mathematical modeling, side branching from the main channel had a strong influence on the BiEGMcomposition along the main channel. The BiEGMobtained from a long unbranched channel had the lowest entropy compared with those with multiple side branches. In conclusion, among a population of multicomponent sinus electrograms, those that demonstrate low entropy and are delayed colocalize to critical long-protected channels of VT. This information is pertinent for planning VT ablation in sinus rhythm.

NEW & NOTEWORTHY Entropy is a measure to quantify breakdown in information. Electrograms from a protected tissue channel can only possess a few states in their voltage and thus less information. In contrast, current-load interactions from side branches in unprotected channels introduce a number of dissimilar voltage deflections and thus high information. We compare here a mapping approach based on entropy against a rigorous reference standard of activation mapping during VT and entropy was assessed in sinus rhythm.

Myofibroblasts Electrotonically Coupled to Cardiomyocytes Alter Conduction: Insights at the Cellular Level from a Detailed In silico Tissue Structure Model

Fibrotic myocardial remodeling is typically accompanied by the appearance of myofibroblasts (MFBs). In vitro, MFBs were shown to slow conduction and precipitate ectopic activity following gap junctional coupling to cardiomyocytes (CMCs). To gain further mechanistic insights into this arrhythmogenic MFB-CMC crosstalk, we performed numerical simulations in cell-based high-resolution two-dimensional tissue models that replicated experimental conditions. Cell dimensions were determined using confocal microscopy of single and co-cultured neonatal rat ventricular CMCs and MFBs. Conduction was investigated as a function of MFB density in three distinct cellular tissue architectures: CMC strands with endogenous MFBs, CMC strands with coating MFBs of two different sizes, and CMC strands with MFB inserts. Simulations were performed to identify individual contributions of heterocellular gap junctional coupling and of the specific electrical phenotype of MFBs. With increasing MFB density, both endogenous and coating MFBs slowed conduction. At MFB densities of 5-30%, conduction slowing was most pronounced in strands with endogenous MFBs due to the MFB-dependent increase in axial resistance. At MFB densities >40%, very slow conduction and spontaneous activity was primarily due to MFB-induced CMC depolarization. Coating MFBs caused non-uniformities of resting membrane potential, which were more prominent with large than with small MFBs. In simulations of MFB inserts connecting two CMC strands, conduction delays increased with increasing insert lengths and block appeared for inserts >1.2 mm. Thus, electrophysiological properties of engineered CMC-MFB co-cultures depend on MFB density, MFB size and their specific positioning in respect to CMCs. These factors may influence conduction characteristics in the heterocellular myocardium.

Cytokine Effects on Mechano-Induced Electrical Activity in Atrial Myocardium

The role of cytokines as regulators of stretch-related mechanisms is of special importance since mechano-sensitivity plays an important role in a wide variety of biological processes. Here, we elucidate the influence of cytokine application on mechano-sensitivity and mechano-transduction. The atrial myocardial stretch induces production of interleukin (IL)-2, IL-6, IL-13, IL-17A, and IL-18 with exception of tumor necrosis factor α (TNF-α), IL-1β, and vascular endothelial growth factor B (VEGF-B). Positive ionotropic effect was specific for VEGF-B, negative ionotropic effects were specific for TNF-α, IL-1β, IL-2, IL-6, IL-13, IL-17A and IL-18, while IL-1α doesn't show direct ionotropic effect. The IL-2, IL-6, IL-17A, IL-18, and VEGF-B cause elongation of the APD, in comparison with the reduced APD caused by the IL-13. The TNF-α, IL-1β, and IL-18 influences L-type Ca²⁺ channels, IL-2 has an inhibitory effect on the fast Na⁺ channels while IL-17A and VEGF-B were specific for Kir channels. With exception of the IL-1α, IL-2, and VEGF-B, all analyzed cytokines include nitric oxide dependent signaling with resultant combined effects on mechano-gated and Ca²⁺ channels. The relationships between these pathways and the time-dependence of their activation are of important considerations in the evaluation of cytokine-induced electrical abnormality, specific for cardiac dysfunctions. In general, the discussion presented in this review covers research devoted to counterbalance between different cytokines in the regulation of stretch-induced effects in rat atrial myocardium.

ABBREVIATIONS

APs: action potentials; APD25: action potential durations to 25% of re-polarization; APD50: action potential durations to 50% of repolarization; APD90: action potential durations to 90% of repolarization; MGCs: mechanically gated channels.

Rapid automatic segmentation of abnormal tissue in late gadolinium enhancement cardiovascular magnetic resonance images for improved management of long-standing persistent atrial fibrillation

Background

Atrial fibrillation (AF) is the most common heart rhythm disorder. In order for late Gd enhancement cardiovascular magnetic resonance (LGE CMR) to ameliorate the AF management, the ready availability of the accurate enhancement segmentation is required. However, the computer-aided segmentation of enhancement in LGE CMR of AF is still an open question. Additionally, the number of centres that have reported successful application of LGE CMR to guide clinical AF strategies remains low, while the debate on LGE CMR’s diagnostic ability for AF still holds. The aim of this study is to propose a method that reliably distinguishes enhanced (abnormal) from non-enhanced (healthy) tissue within the left atrial wall of (pre-ablation and 3 months post-ablation) LGE CMR data-sets from long-standing persistent AF patients studied at our centre.

Methods

Enhancement segmentation was achieved by employing thresholds benchmarked against the statistics of the whole left atrial blood-pool (LABP). The test-set cross-validation mechanism was applied to determine the input feature representation and algorithm that best predict enhancement threshold levels.

Results

Global normalized intensity threshold levels T_PRE = 1 1/4 and T_POST = 1 5/8 were found to segment enhancement in data-sets acquired pre-ablation and at 3 months post-ablation, respectively. The segmentation results were corroborated by using visual inspection of LGE CMR brightness levels and one endocardial bipolar voltage map. The measured extent of pre-ablation fibrosis fell within the normal range for the specific arrhythmia phenotype. 3D volume renderings of segmented post-ablation enhancement emulated the expected ablation lesion patterns. By comparing our technique with other related approaches that proposed different threshold levels (although they also relied on reference regions from within the LABP) for segmenting enhancement in LGE CMR data-sets of AF patients, we illustrated that the cut-off levels employed by other centres may not be usable for clinical studies performed in our centre.

Conclusions

The proposed technique has great potential for successful employment in the AF management within our centre. It provides a highly desirable validation of the LGE CMR technique for AF studies. Inter-centre differences in the CMR acquisition protocol and image analysis strategy inevitably impede the selection of a universally optimal algorithm for segmentation of enhancement in AF studies.

Techniques for automated local activation time annotation and conduction velocity estimation in cardiac mapping

Measurements of cardiac conduction velocity provide valuable functional and structural insight into the initiation and perpetuation of cardiac arrhythmias, in both a clinical and laboratory context. The interpretation of activation wavefronts and their propagation can identify mechanistic properties of a broad range of electrophysiological pathologies. However, the sparsity, distribution and uncertainty of recorded data make accurate conduction velocity calculation difficult. A wide range of mathematical approaches have been proposed for addressing this challenge, often targeted towards specific data modalities, species or recording environments. Many of these algorithms require identification of activation times from electrogram recordings which themselves may have complex morphology or low signal-to-noise ratio. This paper surveys algorithms designed for identifying local activation times and computing conduction direction and speed. Their suitability for use in different recording contexts and applications is assessed.

Left ventricular hypertrophy: The relationship between the electrocardiogram and cardiovascular magnetic resonance imaging

Conventional assessment of left ventricular hypertrophy (LVH) using the electrocardiogram (ECG), for example, by the Sokolow-Lyon, Romhilt-Estes or Cornell criteria, have relied on assessing changes in the amplitude and/or duration of the QRS complex of the ECG to quantify LV mass. ECG measures of LV mass have typically been validated by imaging with echocardiography or cardiovascular magnetic resonance imaging (CMR). However, LVH can be the result of diverse etiologies, and LVH is also characterized by pathological changes in myocardial tissue characteristics on the genetic, molecular, cellular, and tissue level beyond a pure increase in the number of otherwise normal cardiomyocytes. For example, slowed conduction velocity through the myocardium, which can be due to diffuse myocardial fibrosis, has been shown to be an important determinant of conventional ECG LVH criteria regardless of LV mass. Myocardial tissue characterization by CMR has emerged to not only quantify LV mass, but also detect and quantify the extent and severity of focal or diffuse myocardial fibrosis, edema, inflammation, myocarditis, fatty replacement, myocardial disarray, and myocardial deposition of amyloid proteins (amyloidosis), glycolipids (Fabry disease), or iron (siderosis). This can be undertaken using CMR techniques including late gadolinium enhancement (LGE), T1 mapping, T2 mapping, T2* mapping, extracellular volume fraction (ECV) mapping, fat/water-weighted imaging, and diffusion tensor CMR. This review presents an overview of current and emerging concepts regarding the diagnostic possibilities of both ECG and CMR for LVH in an attempt to narrow gaps in our knowledge regarding the ECG diagnosis of LVH.

Non-uniform dispersion of the source-sink relationship alters wavefront curvature

The distribution of cellular source-sink relationships plays an important role in cardiac propagation. It can lead to conduction slowing and block as well as wave fractionation. It is of great interest to unravel the mechanisms underlying evolution in wavefront geometry. Our goal is to investigate the role of the source-sink relationship on wavefront geometry using computer simulations. We analyzed the role of variability in the microscopic source-sink relationship in driving changes in wavefront geometry. The electrophysiological activity of a homogeneous isotropic tissue was simulated using the ten Tusscher and Panfilov 2006 action potential model and the source-sink relationship was characterized using an improved version of the Romero et al. safety factor formulation (SF_m2). Our simulations reveal that non-uniform dispersion of the cellular source-sink relationship (dispersion along the wavefront) leads to alterations in curvature. To better understand the role of the source-sink relationship in the process of wave formation, the electrophysiological activity at the initiation of excitation waves in a 1D strand was examined and the source-sink relationship was characterized using the two recently updated safety factor formulations: the SF_m2 and the Boyle-Vigmond (SF_VB) definitions. The electrophysiological activity at the initiation of excitation waves was intimately related to the SF_m2 profiles, while the SF_VB led to several counterintuitive observations. Importantly, with the SF_m2 characterization, a critical source-sink relationship for initiation of excitation waves was identified, which was independent of the size of the electrode of excitation, membrane excitability, or tissue conductivity. In conclusion, our work suggests that non-uniform dispersion of the source-sink relationship alters wavefront curvature and a critical source-sink relationship profile separates wave expansion from collapse. Our study reinforces the idea that the safety factor represents a powerful tool to study the mechanisms of cardiac propagation in silico, providing a better understanding of cardiac arrhythmias and their therapy.

Ventricular tachycardia in coronary artery disease

Ventricular arrhythmias are important contributors to morbidity and mortality in patients with coronary artery disease. Ventricular fibrillation accounts for the majority of deaths occurring in the acute phase of ischemia, whereas sustained, monomorphic ventricular tachycardia due to reentry generated in the scar tissue develops most often in the setting of healed myocardial infarction, especially in patients with lower left ventricular ejection fraction. Despite determinant advances in population education and myocardial infarction management, the ventricular tachycardia risk in the overall population with coronary artery disease continues to be a major problem in clinical practice. The initial evaluation of a patient presenting with ventricular tachycardia requires a 12-lead electrocardiogram, which can be helpful to confirm the diagnosis, suggest the presence of potential underlying heart disease, and identify the location of the ventricular tachycardia circuit. An invasive electrophysiologic study is usually crucial to determine the mechanism of the arrhythmia once induced and to provide guidance for ablation. The approach for ventricular tachycardia ablation depends on several factors, including inducibility, sustainability, and clinical tolerance of ventricular tachycardia. The paper also reviews other therapeutic options for patients with ventricular tachycardia associated with coronary artery disease, including antiarrhythmic drug therapy, surgical ablation, and current implantable cardioverter-defibrillator indications.

Roles of subcellular Na+ channel distributions in the mechanism of cardiac conduction

The gap junction and voltage-gated Na(+) channel play an important role in the action potential propagation. The purpose of this study was to elucidate the roles of subcellular Na(+) channel distribution in action potential propagation. To achieve this, we constructed the myocardial strand model, which can calculate the current via intercellular cleft (electric-field mechanism) together with gap-junctional current (gap-junctional mechanism). We conducted simulations of action potential propagation in a myofiber model where cardiomyocytes were electrically coupled with gap junctions alone or with both the gap junctions and the electric field mechanism. Then we found that the action potential propagation was greatly affected by the subcellular distribution of Na(+) channels in the presence of the electric field mechanism. The presence of Na(+) channels in the lateral membrane was important to ensure the stability of propagation under conditions of reduced gap-junctional coupling. In the poorly coupled tissue with sufficient Na(+) channels in the lateral membrane, the slowing of action potential propagation resulted from the periodic and intermittent dysfunction of the electric field mechanism. The changes in the subcellular Na(+) channel distribution might be in part responsible for the homeostatic excitation propagation in the diseased heart.

Extracellular matrix of collagen modulates intracellular calcium handling and electrophysiological characteristics of HL-1 cardiomyocytes with activation of angiotensin II type 1 receptor

BACKGROUND

Myocardial fibrosis plays a critical role in heart failure, resulting in cardiac structural and electrical remodeling which can induce atrial arrhythmias. Collagen is the major element of fibrosis. However, it is not clear whether collagen can directly regulate the calcium homeostasis and the electrophysiologic characteristics of cardiomyocytes. The aim of this study was to determine the effects of collagen on calcium homeostasis and the electrical properties of atrial cardiomyocytes.

METHODS AND RESULTS

HL-1 cardiomyocytes were cultured with and without collagen type I (1 or 10 μg/mL) or losartan (10 μmol/L). Whole-cell clamp, indo-1 fluorescence, and Western blotting were used to evaluate the action potential (AP) and ionic currents, intracellular calcium homeostasis, and calcium regulatory proteins. Compared with the control samples, there was no significant difference in collagen (1 μg/mL)-treated HL-1 cardiomyocytes. However, collagen (10 μg/mL)-treated HL-1 cardiomyocytes exhibited larger intracellular calcium ([Ca(2+)](i)) transients by 113% and a larger sarcoplasmic reticulum calcium content by 86%. Collagen (10 μg/mL)-treated HL-1 cardiomyocytes had higher expression of sarcoplasmic reticulum ATPase (SERCA2a) and Thr17-phosphorylated phospholamban but similar protein expressions of the Na(+)/Ca(2+) exchanger and ryanodine receptor. Collagen (10 μg/mL)-treated HL-1 cardiomyocytes (n = 11) had larger AP amplitude (104 ± 5 vs 83 ± 7 mV; P < .05), and shorter 90% of AP duration (25 ± 2 vs 33 ± 2 ms, P < .05) than control cells (n = 11). Moreover, collagen (10 μg/mL)-treated HL-1 cells had larger I(to) and I(Ksus) values than control cells. The administration of losartan (10 μmol/L) attenuated collagen-induced changes in [Ca(2+)](i) transients, [Ca(2+)](i) stores, AP morphology, ionic currents, SERCA2a, and Thr17-phosphorylated phospholamban expressions.

CONCLUSIONS

This study demonstrates that collagen can directly modulate the calcium dynamics and electrical activities of atrial cardiomyocytes, which are associated with the renin-angiotensin system. These findings suggest a critical role of collagen in electrical remodeling during fibrosis.

Inflammatory cytokines and atrial fibrillation: current and prospective views

Atrial fibrillation (AF) is the most common sustained arrhythmia and a challenging clinical problem encountered in daily clinical practice. There is an increasing body of evidence linking inflammation to a broad spectrum of cardiovascular conditions including AF. Historical evidence supports an association between AF and inflammation and is consistent with the association of AF with inflammatory conditions of the heart, such as myocarditis and pericarditis. AF has been associated with myocardial oxidative stress, and antioxidant agents have demonstrated antiarrhythmic benefit in humans. Increased plasma interleukin (IL)-6, C-reactive protein (CRP), and plasma viscosity support the existence of an inflammatory state among "typical" populations with chronic AF. These indexes of inflammation are related to the prothrombotic state and may be linked to the clinical characteristics of the patients (underlying vascular disease and comorbidities), rather than simply to the presence of AF itself. It has been suggested that inflammation may have a role in the development of atrial arrhythmias after cardiac surgery, and that a genetic predisposition to develop postoperative complications exists. Cytokines can have a prognostic significance; IL-6 levels, CRP, and other cytokines may have prognostic value in AF. Cytokine lowering therapies, statins, angiotensin converting enzyme inhibitors and other anti-inflammatory agents may have a role in the treatment of AF. The present article provides an overview of the evidence linking inflammatory cytokines to AF and their therapeutic and prognostic implications.

Multipolar QRST isointegral maps and QT dispersion in old myocardial infarction

Chronic myocardial infarction (CMI) may create, due to structural heterogeneity, abnormal electrophysiological substrates which trigger re-entrant life-threatening ventricular arrhythmias.

METHODS

Electrical instability is assessed using body surface mapping (BSM) [multipolar isointegral QRST maps (mp I(QRST))] and 12-lead ECG (QT dispersion: QTd: the difference between maximal and minimal QT interval). The aim was to find the relation between mp I(QRST) and QTd in CMI patients.

RESULTS

The 32 CMI patients, underwent 12-lead ECG and 64-lead BSM. The 80% (25) of the patients had mp I(QRST) maps. QTd was larger in patients with mp than those with dipolar maps (dp): 170 +/- 20 ms in mp vs 94 +/- 19 ms in dp, respectively. The latter, mp I(QRST) was associated with a decrease of maximum and a stronger minimum.

CONCLUSIONS

Multipolar I(QRST) is associated with a loss of maximum values and increased absolute values of the minimum in CMI patients. I(QRST) and QTd provide similar information in predicting postinfarction arrhythmia risk.

A computer study of the effects of branching dimension on safety factor distribution and propagation in a cardiac conduction network

Branching conduction networks are responsible for coordinated distribution of activation throughout the heart, but the effects of branching geometry on the efficiency of distribution and the safety of propagation remain unclear. We have developed a simplified computer model to investigate this issue in a systemic fashion. A simplified 2D model that reproduces key features of the right atrial pectinate muscle network has been developed. This consists of a large main strand that gives rise to regularly spaced perpendicular branches. Safety factor (SF) and activation time (AT) within the network are estimated for a range of different branch dimensions. The SF is reduced as branch dimension is increased due to the larger current load and is least at the proximal edge of the junction between the main strand and branches. On the other hand, activation efficiency depends on appropriate balance between the load imposed by branching and source which they subsequently provide. With repeated stimulation at progressively decreasing coupling intervals, the SF and conduction fall within the network, but the locations of block varied with branching dimension, again reflecting spatial variation in the balance between current source and current load. We hypothesize that the observed geometry of the branching network optimizes distribution efficiency and propagation safety.

Optimal velocity and safety of discontinuous conduction through the heterogeneous Purkinje-ventricular junction

Slow and discontinuous wave conduction through nonuniform junctions in cardiac tissues is generally considered unsafe and proarrythmogenic. However, the relationships between tissue structure, wave conduction velocity, and safety at such junctions are unknown. We have developed a structurally and electrophysiologically detailed model of the canine Purkinje-ventricular junction (PVJ) and varied its heterogeneity parameters to determine such relationships. We show that neither very fast nor very slow conduction is safe, and there exists an optimal velocity that provides the maximum safety factor for conduction through the junction. The resultant conduction time delay across the PVJ is a natural consequence of the electrophysiological and morphological differences between the Purkinje fiber and ventricular tissue. The delay allows the PVJ to accumulate and pass sufficient charge to excite the adjacent ventricular tissue, but is not long enough for the source-to-load mismatch at the junction to be enhanced over time. The observed relationships between the conduction velocity and safety factor can provide new insights into optimal conditions for wave propagation through nonuniform junctions between various cardiac tissues.

Effects of fibroblast-myocyte coupling on cardiac conduction and vulnerability to reentry: A computational study

BACKGROUND

Recent experimental studies have documented that functional gap junctions form between fibroblasts and myocytes, raising the possibility that fibroblasts play roles in cardiac electrophysiology that extend beyond acting as passive electrical insulators.

OBJECTIVE

The purpose of this study was to use computational models to investigate how fibroblasts may affect cardiac conduction and vulnerability to reentry under different fibroblast-myocyte coupling conditions and tissue structures.

METHODS

Computational models of two-dimensional tissue with fibroblast-myocyte coupling were developed and numerically simulated. Myocytes were modeled by the phase I of the Luo-Rudy model, and fibroblasts were modeled by a passive model.

RESULTS

Besides slowing conduction by cardiomyocyte decoupling and electrotonic loading, fibroblast coupling to myocytes elevates myocyte resting membrane potential, causing conduction velocity to first increase and then decrease as fibroblast content increases, until conduction failure occurs. Fibroblast-myocyte coupling can also enhance conduction by connecting uncoupled myocytes. These competing effects of fibroblasts on conduction give rise to different conduction patterns under different fibroblast-myocyte coupling conditions and tissue structures. Elevation of myocyte resting potential due to fibroblast-myocyte coupling slows sodium channel recovery, which extends postrepolarization refractoriness. Owing to this prolongation of the myocyte refractory period, reentry was more readily induced by a premature stimulation in heterogeneous tissue models when fibroblasts were electrotonically coupled to myocytes compared with uncoupled fibroblasts acting as pure passive electrical insulators.

CONCLUSIONS

Fibroblasts affect cardiac conduction by acting as obstacles or by creating electrotonic loading and elevating myocyte resting potential. Functional fibroblast-myocyte coupling prolongs the myocyte refractory period, which may facilitate induction of reentry in cardiac tissue with fibrosis.

Pleiotropic effects of statins in atrial fibrillation patients: the evidence

Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice. The understanding of the pathophysiology of AF has changed during the last several decades, and a significant role of inflammation and of the renin-angiotensin-aldosterone system has been postulated both experimentally and clinically. There is emerging evidence of an association between inflammation and AF, and mounting evidence links increased C-reactive protein levels not only to already existing AF but also to the risk of developing future AF. The beneficial effects of statins on AF have been reported in several studies. Several randomized clinical and large observational studies have shown similar result that show the beneficial effect of statins in AF. In clinical studies, statins were considered effective in preventing AF after electrical cardioversion, post-ablation, and after permanent pacemaker and implantable cardioverter defibrillator insertion. The antiarrhythmic mechanisms of statins regarding AF prevention in patients with heart failure are still not clear. Perioperative statin use has been associated with favorable postoperative outcome in both cardiovascular and noncardiovascular conditions. Despite a growing body of evidence that drugs with anti-inflammatory properties such as statins may prevent AF, the observed positive effects of statins on the burden of AF appeared to be independent of their cholesterol-reducing properties. However, further data from large-scale randomized trials are clearly needed.

The relative role of refractoriness and source-sink relationship in reentry generation during simulated acute ischemia

During acute myocardial ischemia, reentrant episodes may lead to ventricular fibrillation (VF), giving rise to potentially mortal arrhythmias. VF has been traditionally related to dispersion of refractoriness and more recently to the source-sink relationship. Our goal is to theoretically investigate the relative role of dispersion of refractoriness and source-sink mismatch in vulnerability to reentry in the specific situation of regional myocardial acute ischemia. The electrical activity of a regionally ischemic tissue was simulated using a modified version of the Luo-Rudy dynamic model. Ischemic conditions were varied to simulate the time-course of acute ischemia. Our results showed that dispersion of refractoriness increased with the severity of ischemia. However, no correlation between dispersion of refractoriness and the width of the vulnerable window was found. Additionally, in approximately 50% of the reentries, unidirectional block (UDB) took place in cells completely recovered from refractoriness. We examined patterns of activation after premature stimulation and they were intimately related to the source-sink relationship, quantified by the safety factor (SF). Moreover, the isoline where the SF dropped below unity matched the area where propagation failed. It was concluded that the mismatch of the source-sink relationship, rather than solely refractoriness, was the ultimate cause of the UDB leading to reentry. The SF represents a very powerful tool to study the mechanisms responsible for reentry.

Three-dimensional impedance mapping as an aid to circumferential pulmonary vein isolation in paroxysmal atrial fibrillation

During circumferential pulmonary vein isolation, radiofrequency lesions are created in the transition zone between the left atrium and the pulmonary veins, outside the ostia, to avoid stenosis. Three-dimensional impedance maps were constructed for 25 patients with paroxysmal atrial fibrillation. In the first 15 patients, impedance was measured inside the pulmonary veins (165.4 +/- 7.5 Omega), the ostium (141.6 +/- 7.3 Omega) and the left atrium (131.09 +/- 8.3 Omega). An impedance of 136 Omega identified the outer limit of the atrium (area under the receiver operating characteristic curve, 0.85). In the subsequent 10 patients, a single operator who was blinded to the anatomic position of the catheter tip was able to determine, by impedance measurement alone, whether the point targeted for radiofrequency ablation was in the left atrium or the ostium of the pulmonary vein. The positive predictive value for identifying the left atrium was 91% and the negative predictive value was 73%. In patients with paroxysmal atrial fibrillation, three-dimensional impedance mapping was helpful in guiding circumferential pulmonary vein isolation.

The impact of statin use on atrial fibrillation

The aim of the present systematic review is to present an overview of the evidence linking atrial fibrillation (AF), inflammation and oxidative stress, with emphasis on the potential of statins to decrease the incidence of different types of AF, including new-onset AF, after electrical cardioversion (EC) and after cardiac surgery. Observational and clinical trials have studied the impact of statin therapy on new-onset, post-EC or postoperative AF. Data from different observational trials have shown that treatment with statins significantly reduces the incidence of new-onset AF in the primary and secondary prevention. The data are insufficient to recommend the use of statins before EC. Finally, perioperative statin therapy may represent an important non-antiarrhythmic adjunctive therapeutic strategy for the prevention of postoperative AF.

Models for mechanistic investigations of pacing arrthymogenesis and cardiac tissue structure

Two-dimensional in silico models have been constructed for investigating electrical dynamics arising due to pacing rates and tissue discontinuities. Discontinuities (structures) are introduced explicitly through flux discontinuities in the intracellular space. These models use isotropic electrophysiological properties with heterogeneity arising solely from tissue structure. Both simplified and tissue-specific structures can be used together with membrane models with varying restitution properties. Stimuli are delivered at increasing pacing rates, and solution restarts enable the investigation of repeat stimulation at any of the rates. Investigations using these models are providing new insights into mechanisms leading to conduction block and arrhythmogenesis in cardiac tissue.

Electrical and structural remodeling in left ventricular hypertrophy-a substrate for a decrease in QRS voltage?

Electrical remodeling in advanced stages of cardiovascular diseases creates a substrate for triggering and maintenance of arrhythmias. The electrical remodeling is a continuous process initiated already in the early stages of cardiological pathology. The aim of this opinion article was to discuss the changes in electrical properties of myocardium in left ventricular hypertrophy (LVH), with special focus on its early stage, as well as their possible reflection in the QRS amplitude of the electrocardiogram. It critically appraises the classical hypothesis related to the QRS voltage changes in LVH. The hypothesis of the relative voltage deficit is discussed in the context of supporting evidence from clinical studies, animal experiments, and simulation studies. The underlying determinants of electrical impulse propagation which may explain discrepancies between "normal" ECG findings and increased left ventricular size/mass in LVH are reviewed.

Fibrillatory conduction in branching atrial tissue--Insight from volumetric and monolayer computer models

Increased local load in branching atrial tissue (muscle fibers and bundle insertions) influences wave propagation during atrial fibrillation (AF). This computer model study reveals two principal phenomena: if the branching is distant from the driving rotor (>19 mm), the load causes local slowing of conduction or wavebreaks. If the driving rotor is close to the branching, the increased load causes first a slow drift of the rotor towards the branching. Finally, the rotor anchors, and a stable, repeatable pattern of activation can be observed. Variation of the bundle geometry from a cylindrical, volumetric structure to a flat strip of a comparable load in a monolayer model changed the local activation sequence in the proximity of the bundle. However, the global behavior and the basic effects are similar in all models. Wavebreaks in branching tissue contribute to the chaotic nature of AF (fibrillatory conduction). The stabilization (anchoring) of driving rotors by branching tissue might contribute to maintain sustained AF.

Excitation of the intrinsic conduction system through his and interventricular septal pacing

BACKGROUND

Direct His bundle pacing results in rapid synchronous ventricular activation. However, clinical experiences with such pacing have been associated with long procedure times and compromised pacing and sensing performance.

METHODS

We evaluated myocardial activation sequences (AS) for pacing of the His bundle and peri-His region and assessed acute pacing performance using custom-designed plunge electrodes. Unipolar pacing was performed in isolated swine hearts (n = 10) using four quadripolar stimulation/sensing electrodes implanted into the interventricular septum and equally spaced between the membranous septum and the coronary sinus ostium (zones 1-4, respectively; electrode depth (ED) 1 = most distal, ED 4 = most proximal). Optimal pacing sites were defined as: pacing thresholds < or = 1.5 V, a P-R ratio of < or = 0.5, and > or = 50% occurrence of an intrinsic midseptal left ventricular (LV) endocardial electrical breakout (BO) and activation pattern.

RESULTS

Pacing thresholds improved with greater depth of electrode location within the septum (ED 1: 1.51 +/- 0.8 V vs ED 4: 5.2 +/- 3.8 V, P < 0.001), as did the P-R ratio (0.34 +/- 0.6 vs 0.78 +/- 1.0, P < 0.05). His potentials were only observed in zone 1 and 2 electrodes (0.12 and 0.02 mV, respectively). Only electrodes in zones 1 and 2 produced LV endocardial electrical BOs in the midseptal region that demonstrated an intrinsic-like endocardial AS. Depth 1 and 2 electrodes (11.75 and 8.75 mm, respectively) in zone 1 satisfied all three optimal pacing site requirements.

CONCLUSIONS

This study has shown that LV activation patterns similar to sinus rhythm may be achieved without direct activation of the His bundle, while maintaining acceptable pacing and sensing performance. These data indicate that pacing systems designed to stimulate the tissues below the point at which the His bundle penetrates the central fibrous body may provide improved system efficiency and LV performance in comparison to both direct His bundle pacing and traditional pacing sites.

Connexin30.2 containing gap junction channels decelerate impulse propagation through the atrioventricular node

In the mammalian heart, gap junction channels between electrically coupled cardiomyocytes are necessary for impulse propagation and coordinated contraction of atria and ventricles. Recently, mouse connexin30.2 (Cx30.2) was shown to be expressed in the cardiac conduction system, predominantly in sinoatrial and atrioventricular (AV) nodes. The corresponding gap junctional channels expressed in HeLa cells exhibit the lowest unitary conductance (9 pS) of all connexin channels. Here we report that Cx30.2 slows down the propagation of excitation through the AV node. Mice expressing a LacZ reporter gene instead of the Cx30.2 coding region (Cx30.2(LacZ/LacZ)) exhibit a PQ interval that is approximately 25% shorter than in WT littermates. By recording atrial, His, and ventricular signals with intracardiac electrodes, we show that this decrease is attributed to significantly accelerated conduction above the His bundle (atrial-His interval: 27.9 +/- 5.1 ms in Cx30.2(LacZ/LacZ) versus 37.1 +/- 4.1 ms in Cx30.2(+/+) mice), whereas HV conduction is unaltered. Atrial stimulation revealed an elevated AV-nodal conduction capacity and faster ventricular response rates during induced episodes of atrial fibrillation in Cx30.2(LacZ/LacZ) mice. Our results show that Cx30.2 contributes to the slowdown of impulse propagation in the AV node and additionally limits the maximum number of beats conducted from atria to ventricles. Thus, it is likely to be involved in coordination of atrial and ventricular contraction and to fulfill a protective role toward pathophysiological states such as atrial tachyarrhythmias (e.g., atrial fibrillation) by preventing rapid conduction to the ventricles potentially associated with hemodynamic deterioration.

Endocardial impedance mapping during circumferential pulmonary vein ablation of atrial fibrillation differentiates between atrial and venous tissue

BACKGROUND

Circumferential pulmonary vein ablation (CPVA) is an effective treatment for atrial fibrillation (AF). Accurate left atrial (LA) mapping is essential for creating lesions at the LA-pulmonary vein (PV) junction, avoiding PV stenosis.

OBJECTIVES

The purpose of this study was to establish whether endocardial impedance varies within the LA and PVs and whether it is a useful tool for mapping and ablation.

METHODS

Pilot Phase: Three-dimensional LA maps were created using CARTO. Impedance (Z) was measured using a radiofrequency generator at multiple points in the LA, PV ostia (PVO), and deep PVs in 79 patients undergoing their first AF ablation (group 1) and 29 patients undergoing repeat CPVA (group 2). Prospective Phase: In an additional 20 patients, using pilot phase data, one operator defined catheter tip location as either LA or PVO based on CARTO and fluoroscopy. A second operator blinded to CARTO simultaneously did the same based on impedance at 15 +/- 4 points per patient.

RESULTS

Group 1: Z(LA) was 99.4 +/- 9.0 omega. Z(PVO) was higher (109.2 +/- 8.5 omega), rising further as the catheter advanced into deep PV (137 omega +/- 18). Z(PVO) differed from Z(LA) by 9 +/- 4 omega. Group 2 had a lower Z(LA) and Z(PVO) compared with group 1 (P <.05). Impedance monitoring differentiated between LA and PVO, with 91% specificity and sensitivity, 96% positive predictive value, and 81% negative predictive value. At 3-month follow-up, no patients had evidence of PV stenosis on magnetic resonance imaging.

CONCLUSION

Impedance mapping reliably identifies the LA-PV transitional zone, facilitating AF ablation, and its use is associated with a low incidence of PV stenosis.

Measuring surface potential components necessary for transmembrane current computation using microfabricated arrays

This study was designed to test the feasibility of using microfabricated electrodes to record surface potentials with sufficiently fine spatial resolution to measure the potential gradients necessary for improved computation of transmembrane current density. To assess that feasibility, we recorded unipolar electrograms from perfused rabbit right ventricular free wall epicardium ( n = 6) using electrode arrays that included 25-μm sensors fabricated onto a flexible substrate with 75-μm interelectrode spacing. Electrode spacing was therefore on the size scale of an individual myocyte. Signal conditioning adjacent to the sensors to control lead noise was achieved by routing traces from the electrodes to the back side of the substrate where buffer amplifiers were located. For comparison, recordings were also made using arrays built from chloridized silver wire electrodes of either 50-μm (fine wire) or 250-μm (coarse wire) diameters. Electrode separations were necessarily wider than with microfabricated arrays. Comparable signal-to-noise ratios (SNRs) of 21.2 ± 2.2, 32.5 ± 4.1, and 22.9 ± 0.7 for electrograms recorded using microfabricated sensors ( n = 78), fine wires ( n = 78), and coarse wires ( n = 78), respectively, were found. High SNRs were maintained in bipolar electrograms assembled using spatial combinations of the unipolar electrograms necessary for the potential gradient measurements and in second-difference electrograms assembled using spatial combinations of the bipolar electrograms necessary for surface Laplacian (SL) measurements. Simulations incorporating a bidomain representation of tissue structure and a two-dimensional network of guinea pig myocytes prescribed following the Luo and Rudy dynamic membrane equations were completed using 12.5-μm spatial resolution to assess contributions of electrode spacing to the potential gradient and SL measurements. In those simulations, increases in electrode separation from 12.5 to 75.0, 237.5, and 875.0 μm, which were separations comparable to the finest available with our microfabricated, fine wire, and coarse wire arrays, led to 10%, 42%, and 81% reductions in maximum potential gradients and 33%, 76%, and 96% reductions in peak-to-peak SLs. Maintenance of comparable SNRs for source electrograms was therefore important because microfabrication provides a highly attractive methods to achieve spatial resolutions necessary for improved computation of transmembrane current density.

Is atrial fibrillation an inflammatory disorder?

There is mounting evidence to support the influence of inflammation in the pathogenesis of atrial fibrillation (AF). Indeed, AF is associated with increased levels of known inflammatory markers, even after adjustment for confounding factors. The renin-angiotensin-aldosterone system (RAAS) appears to play a key role in this process. Atrial biopsies from patients with AF have also confirmed the presence of inflammation. Furthermore, there is preliminary evidence to support a number of drug therapies that have the potential to reduce the clinical burden of AF. In this review, we present an overview of the evidence supporting a link between inflammation and AF, and some of the drug therapies, such as the angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, steroids, fish oils, and vitamin C, that might be efficacious in the prevention of AF by modulating inflammatory pathways.

Ventricular Tachycardia Duration and Form Are Associated with Electrical Discontinuities Bounding the Core of the Reentrant Circuit

BACKGROUND

Successful prediction of reentrant ventricular tachycardia duration and form from sinus-rhythm electrogram signals in canine hearts is relevant to clinical studies, to potentially improve catheter ablation treatment during EP study.

METHODS/RESULTS

Following LAD ligation of canine hearts, activation maps were constructed from 312 border zone sites 4-5 days postinfarction. When reentrant ventricular tachycardia was inducible via programmed stimulation, the core of the circuit was defined on the maps as the enclosed area formed by the adjoining lines of slowest conduction and block bounding the protected region of the reentrant circuit. The number, location, and width of points of entrance or exit of the activation wavefront about the core were determined. Core perimeter location was then marked on the sinus-rhythm activation map, and the difference in activation time at opposite recording sites along the core perimeter was measured. Mean sinus-rhythm activation was highly discontinuous along the core perimeter in 10 transient reentry experiments (30.1 +/- 4.4 ms), moderately discontinuous in 13 sustained experiments (16.7 +/- 1.8 ms), and only slightly discontinuous in 5 noninducible experiments (9.7 +/- 1.7 ms). For transient versus sustained experiments, the entrance/exit points were narrower (mean: 6.5 +/- 1.0 mm vs 9.5 +/- 1.8 mm) with larger sinus-rhythm discontinuity across them (mean: 23.8 +/- 6.0 ms vs 11.8 +/- 2.1 ms). As core size increased, so did the number of entrance/exits present during reentry (P < 0.001). With increasing core size, four-loop (quatrefoil) reentry was frequently observed.

CONCLUSIONS

Whether reentrant ventricular tachycardia will be inducible in the canine infarct border zone, and its duration and form, is associated with the characteristics of electrical discontinuities present about the core perimeter.

A theoretical model of the high-frequency arrhythmogenic depolarization signal following myocardial infarction

Theoretical body-surface potentials were computed from single, branching and tortuous strands of Luo-Rudy dynamic model cells, representing different areas of an infarct scar. When action potential (AP) propagation either in longitudinal or transverse direction was slow (3-12 cm/s), the depolarization signals contained high-frequency (100-300 Hz) oscillations. The frequencies were related to macroscopic propagation velocity and strand architecture by simple formulas. Next, we extended a mathematical model of the QRS-complex presented in our earlier work to simulate unstable activation wavefront. It combines signals from different strands with small timing fluctuations relative to a large repetitive QRS-like waveform and can account for dynamic changes of real arrhythmogenic micropotentials. Variance spectrum of wavelet coefficients calculated from the composite QRS-complex contained the high frequencies of the individual abnormal signals. We conclude that slow AP propagation through fibrotic regions after myocardial infarction is a source of high-frequency arrhythmogenic components that increase beat-to-beat variability of the QRS, and wavelet variance parameters can be used for ventricular tachycardia risk assessment.

Basic mechanisms of cardiac impulse propagation and associated arrhythmias

Propagation of excitation in the heart involves action potential (AP) generation by cardiac cells and its propagation in the multicellular tissue. AP conduction is the outcome of complex interactions between cellular electrical activity, electrical cell-to-cell communication, and the cardiac tissue structure. As shown in this review, strong interactions occur among these determinants of electrical impulse propagation. A special form of conduction that underlies many cardiac arrhythmias involves circulating excitation. In this situation, the curvature of the propagating excitation wavefront and the interaction of the wavefront with the repolarization tail of the preceding wave are additional important determinants of impulse propagation. This review attempts to synthesize results from computer simulations and experimental preparations to define mechanisms and biophysical principles that govern normal and abnormal conduction in the heart.

Fibrosis in left atrial tissue of patients with atrial fibrillation with and without underlying mitral valve disease

OBJECTIVE

To examine the hypothesis that major extracellular matrix (ECM) proteins are expressed differently in the left atrial tissue of patients in sinus rhythm (SR), lone atrial fibrillation (AF), and AF with underlying mitral valve disease (MVD).

DESIGN

Case-control study.

PATIENTS

118 patients with lone AF, MVD+AF, and SR.

MAIN OUTCOME MEASURES

Collagen I, collagen III, and fibronectin protein expression measured by quantitative western blotting techniques and immunohistochemical methods.

RESULTS

Protein concentrations increased in patients with AF (all forms) compared with those in SR (all forms): collagen I (1.15 (0.11) v 0.45 (0.28), respectively; p = 0.002), collagen III (0.74 (0.05) v 0.46 (0.11); p = 0.002, and fibronectin (0.88 (0.06) v 0.62 (0.13); p = 0.08). Especially, collagen I was similarly enhanced in both lone AF (1.49 (0.15) and MVD+AF (1.53 (0.16) compared with SR (0.56 (0.28); both p = 0.01). Collagen III was not significantly increased in lone AF but was significantly increased in AF combined with MVD (0.84 (0.07) both compared with SR (0.46 (0.11); p = 0.01). The concentration of fibronectin was not significantly increased in lone AF and MVD+AF (both compared with SR). Furthermore, there was a similar degree of enhanced collagen expression in paroxysmal AF and chronic AF.

CONCLUSIONS

AF is associated with fibrosis. Forms of AF differ from each other in collagen III expression. However, there was no systematic difference in ECM expression between paroxysmal AF and chronic AF. Enhanced concentrations of ECM proteins may have a role in structural remodelling and the pathogenesis of AF as a result of separation of the cells by fibrotic depositions.