Rotor termination is critically dependent on kinetic properties of I kur inhibitors in an in silico model of chronic atrial fibrillation

How synergy between mechanistic and statistical models is impacting research in atrial fibrillation

Atrial fibrillation (AF) with multiple complications, high morbidity and mortality, and low cure rates, has become a global public health problem. Although significant progress has been made in the treatment methods represented by anti-AF drugs and radiofrequency ablation, the therapeutic effect is not as good as expected. The reason is mainly because of our lack of understanding of AF mechanisms. This field has benefited from mechanistic and (or) statistical methodologies. Recent renewed interest in digital twin techniques by synergizing between mechanistic and statistical models has opened new frontiers in AF analysis. In the review, we briefly present findings that gave rise to the AF pathophysiology and current therapeutic modalities. We then summarize the achievements of digital twin technologies in three aspects: understanding AF mechanisms, screening anti-AF drugs and optimizing ablation strategies. Finally, we discuss the challenges that hinder the clinical application of the digital twin heart. With the rapid progress in data reuse and sharing, we expect their application to realize the transition from AF description to response prediction.

Using cardiac ionic cell models to interpret clinical data

For over 100 years cardiac electrophysiology has been measured in the clinic. The electrical signals that can be measured span from noninvasive ECG and body surface potentials measurements through to detailed invasive measurements of local tissue electrophysiology. These electrophysiological measurements form a crucial component of patient diagnosis and monitoring; however, it remains challenging to quantitatively link changes in clinical electrophysiology measurements to biophysical cellular function. Multi-scale biophysical computational models represent one solution to this problem. These models provide a formal framework for linking cellular function through to emergent whole organ function and routine clinical diagnostic signals. In this review, we describe recent work on the use of computational models to interpret clinical electrophysiology signals. We review the simulation of human cardiac myocyte electrophysiology in the atria and the ventricles and how these models are being used to link organ scale function to patient disease mechanisms and therapy response in patients receiving implanted defibrillators, \cardiac resynchronisation therapy or suffering from atrial fibrillation and ventricular tachycardia. There is a growing use of multi-scale biophysical models to interpret clinical data. This allows cardiologists to link clinical observations with cellular mechanisms to better understand cardiopathophysiology and identify novel treatment strategies. This article is categorized under: Cardiovascular Diseases > Computational Models Cardiovascular Diseases > Biomedical Engineering Cardiovascular Diseases > Molecular and Cellular Physiology.

Understanding AF Mechanisms Through Computational Modelling and Simulations

AF is a progressive disease of the atria, involving complex mechanisms related to its initiation, maintenance and progression. Computational modelling provides a framework for integration of experimental and clinical findings, and has emerged as an essential part of mechanistic research in AF. The authors summarise recent advancements in development of multi-scale AF models and focus on the mechanistic links between alternations in atrial structure and electrophysiology with AF. Key AF mechanisms that have been explored using atrial modelling are pulmonary vein ectopy; atrial fibrosis and fibrosis distribution; atrial wall thickness heterogeneity; atrial adipose tissue infiltration; development of repolarisation alternans; cardiac ion channel mutations; and atrial stretch with mechano-electrical feedback. They review modelling approaches that capture variability at the cohort level and provide cohort-specific mechanistic insights. The authors conclude with a summary of future perspectives, as envisioned for the contributions of atrial modelling in the mechanistic understanding of AF.

Understanding the Beat-to-Beat Variations of P-Waves Morphologies in AF Patients During Sinus Rhythm: A Scoping Review of the Atrial Simulation Studies

The remarkable advances in high-performance computing and the resulting increase of the computational power have the potential to leverage computational cardiology toward improving our understanding of the pathophysiological mechanisms of arrhythmias, such as Atrial Fibrillation (AF). In AF, a complex interaction between various triggers and the atrial substrate is considered to be the leading cause of AF initiation and perpetuation. In electrocardiography (ECG), P-wave is supposed to reflect atrial depolarization. It has been found that even during sinus rhythm (SR), multiple P-wave morphologies are present in AF patients with a history of AF, suggesting a higher dispersion of the conduction route in this population. In this scoping review, we focused on the mechanisms which modify the electrical substrate of the atria in AF patients, while investigating the existence of computational models that simulate the propagation of the electrical signal through different routes. The adopted review methodology is based on a structured analytical framework which includes the extraction of the keywords based on an initial limited bibliographic search, the extensive literature search and finally the identification of relevant articles based on the reference list of the studies. The leading mechanisms identified were classified according to their scale, spanning from mechanisms in the cell, tissue or organ level, and the produced outputs. The computational modeling approaches for each of the factors that influence the initiation and the perpetuation of AF are presented here to provide a clear overview of the existing literature. Several levels of categorization were adopted while the studies which aim to translate their findings to ECG phenotyping are highlighted. The results denote the availability of multiple models, which are appropriate under specific conditions. However, the consideration of complex scenarios taking into account multiple spatiotemporal scales, personalization of electrophysiological and anatomical models and the reproducibility in terms of ECG phenotyping has only partially been tackled so far.

The role of personalized atrial modeling in understanding atrial fibrillation mechanisms and improving treatment

Atrial fibrillation is the most common arrhythmia in humans and is associated with high morbidity, mortality and health-related expenses. Computational approaches have been increasingly utilized in atrial electrophysiology. In this review we summarize the recent advancements in atrial fibrillation modeling at the organ scale. Multi-scale atrial models now incorporate high level detail of atrial anatomy, tissue ultrastructure and fibrosis distribution. We provide the state-of-the art methodologies in developing personalized atrial fibrillation models with realistic geometry and tissue properties. We then focus on the use of multi-scale atrial models to gain mechanistic insights in AF. Simulations using atrial models have provided important insight in the mechanisms underlying AF, showing the importance of the atrial fibrotic substrate and altered atrial electrophysiology in initiation and maintenance of AF. Last, we summarize the translational evidence that supports incorporation of computational modeling in clinical practice for development of personalized treatment strategies for patients with AF. In early-stages clinical studies, AF models successfully identify patients where pulmonary vein isolation alone is not adequate for treatment of AF and suggest novel targets for ablation. We conclude with a summary of the future developments envisioned for the field of atrial computational electrophysiology.

Computational Modeling of Electrophysiology and Pharmacotherapy of Atrial Fibrillation: Recent Advances and Future Challenges

The pathophysiology of atrial fibrillation (AF) is broad, with components related to the unique and diverse cellular electrophysiology of atrial myocytes, structural complexity, and heterogeneity of atrial tissue, and pronounced disease-associated remodeling of both cells and tissue. A major challenge for rational design of AF therapy, particularly pharmacotherapy, is integrating these multiscale characteristics to identify approaches that are both efficacious and independent of ventricular contraindications. Computational modeling has long been touted as a basis for achieving such integration in a rapid, economical, and scalable manner. However, computational pipelines for AF-specific drug screening are in their infancy, and while the field is progressing quite rapidly, major challenges remain before computational approaches can fill the role of workhorse in rational design of AF pharmacotherapies. In this review, we briefly detail the unique aspects of AF pathophysiology that determine requirements for compounds targeting AF rhythm control, with emphasis on delimiting mechanisms that promote AF triggers from those providing substrate or supporting reentry. We then describe modeling approaches that have been used to assess the outcomes of drugs acting on established AF targets, as well as on novel promising targets including the ultra-rapidly activating delayed rectifier potassium current, the acetylcholine-activated potassium current and the small conductance calcium-activated potassium channel. Finally, we describe how heterogeneity and variability are being incorporated into AF-specific models, and how these approaches are yielding novel insights into the basic physiology of disease, as well as aiding identification of the important molecular players in the complex AF etiology.

Synergistic Anti-arrhythmic Effects in Human Atria with Combined Use of Sodium Blockers and Acacetin

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Developing effective and safe anti-AF drugs remains an unmet challenge. Simultaneous block of both atrial-specific ultra-rapid delayed rectifier potassium (K⁺) current (I_Kur) and the Na⁺ current (I_Na) has been hypothesized to be anti-AF, without inducing significant QT prolongation and ventricular side effects. However, the antiarrhythmic advantage of simultaneously blocking these two channels vs. individual block in the setting of AF-induced electrical remodeling remains to be documented. Furthermore, many I_Kur blockers such as acacetin and AVE0118, partially inhibit other K⁺ currents in the atria. Whether this multi-K⁺-block produces greater anti-AF effects compared with selective I_Kur-block has not been fully understood. The aim of this study was to use computer models to (i) assess the impact of multi-K⁺-block as exhibited by many I_Kur blokers, and (ii) evaluate the antiarrhythmic effect of blocking I_Kur and I_Na, either alone or in combination, on atrial and ventricular electrical excitation and recovery in the setting of AF-induced electrical-remodeling. Contemporary mathematical models of human atrial and ventricular cells were modified to incorporate dose-dependent actions of acacetin (a multichannel blocker primarily inhibiting I_Kur while less potently blocking I_to, I_Kr, and I_Ks). Rate- and atrial-selective inhibition of I_Na was also incorporated into the models. These single myocyte models were then incorporated into multicellular two-dimensional (2D) and three-dimensional (3D) anatomical models of the human atria. As expected, application of I_Kur blocker produced pronounced action potential duration (APD) prolongation in atrial myocytes. Furthermore, combined multiple K⁺-channel block that mimicked the effects of acacetin exhibited synergistic APD prolongations. Synergistically anti-AF effects following inhibition of I_Na and combined I_Kur/K⁺-channels were also observed. The attainable maximal AF-selectivity of I_Na inhibition was greatly augmented by blocking I_Kur or multiple K⁺-currents in the atrial myocytes. This enhanced anti-arrhythmic effects of combined block of Na⁺- and K⁺-channels were also seen in 2D and 3D simulations; specially, there was an enhanced efficacy in terminating re-entrant excitation waves, exerting improved antiarrhythmic effects in the human atria as compared to a single-channel block. However, in the human ventricular myocytes and tissue, cellular repolarization and computed QT intervals were modestly affected in the presence of actions of acacetin and I_Na blockers (either alone or in combination). In conclusion, this study demonstrates synergistic antiarrhythmic benefits of combined block of I_Kur and I_Na, as well as those of I_Na and combined multi K⁺-current block of acacetin, without significant alterations of ventricular repolarization and QT intervals. This approach may be a valuable strategy for the treatment of AF.

Rate-Dependent Role of IKur in Human Atrial Repolarization and Atrial Fibrillation Maintenance

The atrial-specific ultrarapid delayed rectifier K⁺ current (I_Kur) inactivates slowly but completely at depolarized voltages. The consequences for I_Kur rate-dependence have not been analyzed in detail and currently available mathematical action-potential (AP) models do not take into account experimentally observed I_Kur inactivation dynamics. Here, we developed an updated formulation of I_Kur inactivation that accurately reproduces time-, voltage-, and frequency-dependent inactivation. We then modified the human atrial cardiomyocyte Courtemanche AP model to incorporate realistic I_Kur inactivation properties. Despite markedly different inactivation dynamics, there was no difference in AP parameters across a wide range of stimulation frequencies between the original and updated models. Using the updated model, we showed that, under physiological stimulation conditions, I_Kur does not inactivate significantly even at high atrial rates because the transmembrane potential spends little time at voltages associated with inactivation. Thus, channel dynamics are determined principally by activation kinetics. I_Kur magnitude decreases at higher rates because of AP changes that reduce I_Kur activation. Nevertheless, the relative contribution of I_Kur to AP repolarization increases at higher frequencies because of reduced activation of the rapid delayed-rectifier current I_Kr. Consequently, I_Kur block produces dose-dependent termination of simulated atrial fibrillation (AF) in the absence of AF-induced electrical remodeling. The inclusion of AF-related ionic remodeling stabilizes simulated AF and greatly reduces the predicted antiarrhythmic efficacy of I_Kur block. Our results explain a range of experimental observations, including recently reported positive rate-dependent I_Kur-blocking effects on human atrial APs, and provide insights relevant to the potential value of I_Kur as an antiarrhythmic target for the treatment of AF.

In silico assessment of genetic variation in KCNA5 reveals multiple mechanisms of human atrial arrhythmogenesis

A recent experimental study investigating patients with lone atrial fibrillation identified six novel mutations in the KCNA5 gene. The mutants exhibited both gain- and loss-of-function of the atrial specific ultra-rapid delayed rectifier K⁺ current, I_Kur. The aim of this study is to elucidate and quantify the functional impact of these KCNA5 mutations on atrial electrical activity. A multi-scale model of the human atria was updated to incorporate detailed experimental data on I_Kur from both wild-type and mutants. The effects of the mutations on human atrial action potential and rate dependence were investigated at the cellular level. In tissue, we assessed the effects of the mutations on the vulnerability to unidirectional conduction patterns and dynamics of re-entrant excitation waves. Gain-of-function mutations shortened the action potential duration in single cells, and stabilised and accelerated re-entrant excitation in tissue. Loss-of-function mutations had heterogeneous effects on action potential duration and promoted early-after-depolarisations following beta-adrenergic stimulation. In the tissue model, loss-of-function mutations facilitated breakdown of excitation waves at more physiological excitation rates than the wild-type, and the generation of early-after-depolarisations promoted unidirectional patterns of excitation. Gain- and loss-of-function I_Kur mutations produced multiple mechanisms of atrial arrhythmogenesis, with significant differences between the two groups of mutations. This study provides new insights into understanding the mechanisms by which mutant I_Kur contributes to atrial arrhythmias. In addition, as I_Kur is an atrial-specific channel and a number of I_Kur-selective blockers have been developed as anti-AF agents, this study also helps to understand some contradictory results on both pro- and anti-arrhythmic effects of blocking I_Kur.

In a recent study, six mutations resulting in either gain-of-function or loss-of-function in the ultra-rapid delayed rectifier potassium current I_Kur, were identified to be associated with atrial fibrillation (AF). However, the causative link between the mutant I_Kur (either gain- or loss-of-function) and AF genesis, especially the difference and similarity between the two mutant groups, has not been elucidated. In our study, we used multiscale computational models to investigate the mechanism of arrhythmogenesis mediated by the two groups of mutations. The results suggest that the gain-of-function mutations shortened atrial action potential duration, stabilised and accelerated re-entrant excitation waves in tissue; the loss-of-function mutation promoted early-after-depolarisations following beta-adrenergic stimulation and thus wave breaks in tissue. We show these two groups of mutants carrying I_Kur produced multiple mechanisms of atrial arrhythmogenesis, with significant differences between the two groups. Our study provides new insights into understanding the mechanisms by which mutant I_Kur contributes to atrial arrhythmias. In addition, as I_Kur is an atrial-specific channel and a number of I_Kur-selective blockers have been developed as anti-AF agents, this study also helps to understand some contradictory results on both pro- and anti-arrhythmic effects of blocking I_Kur.

Atrial Heterogeneity Generates Re-entrant Substrate during Atrial Fibrillation and Anti-arrhythmic Drug Action: Mechanistic Insights from Canine Atrial Models

Anti-arrhythmic drug therapy is a frontline treatment for atrial fibrillation (AF), but its success rates are highly variable. This is due to incomplete understanding of the mechanisms of action of specific drugs on the atrial substrate at different stages of AF progression. We aimed to elucidate the role of cellular, tissue and organ level atrial heterogeneities in the generation of a re-entrant substrate during AF progression, and their modulation by the acute action of selected anti-arrhythmic drugs. To explore the complex cell-to-organ mechanisms, a detailed biophysical models of the entire 3D canine atria was developed. The model incorporated atrial geometry and fibre orientation from high-resolution micro-computed tomography, region-specific atrial cell electrophysiology and the effects of progressive AF-induced remodelling. The actions of multi-channel class III anti-arrhythmic agents vernakalant and amiodarone were introduced in the model by inhibiting appropriate ionic channel currents according to experimentally reported concentration-response relationships. AF was initiated by applied ectopic pacing in the pulmonary veins, which led to the generation of localized sustained re-entrant waves (rotors), followed by progressive wave breakdown and rotor multiplication in both atria. The simulated AF scenarios were in agreement with observations in canine models and patients. The 3D atrial simulations revealed that a re-entrant substrate was typically provided by tissue regions of high heterogeneity of action potential duration (APD). Amiodarone increased atrial APD and reduced APD heterogeneity and was more effective in terminating AF than vernakalant, which increased both APD and APD dispersion. In summary, the initiation and sustenance of rotors in AF is linked to atrial APD heterogeneity and APD reduction due to progressive remodelling. Our results suggest that anti-arrhythmic strategies that increase atrial APD without increasing its dispersion are effective in terminating AF.

The mechanisms behind the most common arrhythmia, atrial fibrillation (AF), remain unclear and anti-arrhythmic drug therapy is often ineffective. In this paper, we develop and apply a novel comprehensive 3D model of canine atria to investigate the role of atrial heterogeneity in the mechanisms of AF and anti-arrhythmic drug action. We find that regions of high heterogeneity of action potential duration (APD) throughout the atria typically provide substrate for arrhythmogenic re-entrant waves during both AF initiation and progression. These mechanistic insights are directly linked with the efficacy of two clinically used class III anti-arrhythmic drugs: amiodarone is more effective at terminating AF than vernakalant, because it leads to an increase in atrial APD without increasing its dispersion. Our computational results are consistent with clinical observations and can help explain the superior efficacy of amiodarone in the clinical treatment of AF at late stages. This framework can easily be extended to investigate the action of other anti-arrhythmic drugs and translated to the human atria. By incorporating patient-specific anatomical and electrophysiological information, and after undergoing careful validation, the proposed in silico approach can become a useful tool to evaluate and potentially guide anti-arrhythmic therapy in the clinic.

Comparison of Detailed and Simplified Models of Human Atrial Myocytes to Recapitulate Patient Specific Properties

Computer studies are often used to study mechanisms of cardiac arrhythmias, including atrial fibrillation (AF). A crucial component in these studies is the electrophysiological model that describes the membrane potential of myocytes. The models vary from detailed, describing numerous ion channels, to simplified, grouping ionic channels into a minimal set of variables. The parameters of these models, however, are determined across different experiments in varied species. Furthermore, a single set of parameters may not describe variations across patients, and models have rarely been shown to recapitulate critical features of AF in a given patient. In this study we develop physiologically accurate computational human atrial models by fitting parameters of a detailed and of a simplified model to clinical data for five patients undergoing ablation therapy. Parameters were simultaneously fitted to action potential (AP) morphology, action potential duration (APD) restitution and conduction velocity (CV) restitution curves in these patients. For both models, our fitting procedure generated parameter sets that accurately reproduced clinical data, but differed markedly from published sets and between patients, emphasizing the need for patient-specific adjustment. Both models produced two-dimensional spiral wave dynamics for that were similar for each patient. These results show that simplified, computationally efficient models are an attractive choice for simulations of human atrial electrophysiology in spatially extended domains. This study motivates the development and validation of patient-specific model-based mechanistic studies to target therapy.

Human atrial cell models to analyse haemodialysis-related effects on cardiac electrophysiology: work in progress

During haemodialysis (HD) sessions, patients undergo alterations in the extracellular environment, mostly concerning plasma electrolyte concentrations, pH, and volume, together with a modification of sympathovagal balance. All these changes affect cardiac electrophysiology, possibly leading to an increased arrhythmic risk. Computational modeling may help to investigate the impact of HD-related changes on atrial electrophysiology. However, many different human atrial action potential (AP) models are currently available, all validated only with the standard electrolyte concentrations used in experiments. Therefore, they may respond in different ways to the same environmental changes. After an overview on how the computational approach has been used in the past to investigate the effect of HD therapy on cardiac electrophysiology, the aim of this work has been to assess the current state of the art in human atrial AP models, with respect to the HD context. All the published human atrial AP models have been considered and tested for electrolytes, volume changes, and different acetylcholine concentrations. Most of them proved to be reliable for single modifications, but all of them showed some drawbacks. Therefore, there is room for a new human atrial AP model, hopefully able to physiologically reproduce all the HD-related effects. At the moment, work is still in progress in this specific field.

Mathematical approaches to understanding and imaging atrial fibrillation: significance for mechanisms and management

Atrial fibrillation (AF) is the most common sustained arrhythmia in humans. The mechanisms that govern AF initiation and persistence are highly complex, of dynamic nature, and involve interactions across multiple temporal and spatial scales in the atria. This article aims to review the mathematical modeling and computer simulation approaches to understanding AF mechanisms and aiding in its management. Various atrial modeling approaches are presented, with descriptions of the methodological basis and advancements in both lower-dimensional and realistic geometry models. A review of the most significant mechanistic insights made by atrial simulations is provided. The article showcases the contributions that atrial modeling and simulation have made not only to our understanding of the pathophysiology of atrial arrhythmias, but also to the development of AF management approaches. A summary of the future developments envisioned for the field of atrial simulation and modeling is also presented. The review contends that computational models of the atria assembled with data from clinical imaging modalities that incorporate electrophysiological and structural remodeling could become a first line of screening for new AF therapies and approaches, new diagnostic developments, and new methods for arrhythmia prevention.

Pharmacology of voltage-gated potassium channel Kv1.5--impact on cardiac excitability

Voltage activated potassium (Kv) channels are intensely investigated targets within the pharmacological strategies to treat cardiac arrhythmia. For atrial fibrillation (AF) substances inhibiting the ultra rapid outward rectifying Kv current (IKur) and its underlying Kv1.5 channel have been developed. Here we describe potential limitations of this approach with respect to critical parameters of Kv channel pharmacology. In healthy tissue IKur/Kv1.5 inhibition can unexpectedly lead to action potential shortening with corresponding arrhythmogenic effects. In tissue with chronic AF, electrical remodeling occurs which is accompanied with changes in ion channel expression and composition. As a consequence atrial tissue exhibits a different pharmacological fingerprint. New strategies to obtain more mechanistic insight into drug target interaction are needed for better understanding the pharmacological potential of IKur/Kv1.5 inhibition for AF treatment.

Isoenzyme-specific regulation of cardiac Kv1.5/Kvβ1.2 ion channel complex by protein kinase C: central role of PKCβII

The ultrarapidly activating delayed rectifier current, I(Kur), is a main determinant of atrial repolarization in humans. I(Kur) and the underlying ion channel complex Kv1.5/Kvβ1.2 are negatively regulated by protein kinase C. However, the exact mode of action is only incompletely understood. We therefore analyzed isoenzyme-specific regulation of the Kv1.5/Kvβ1.2 ion channel complex by PKC. Cloned ion channel subunits were heterologously expressed in Xenopus oocytes, and measurements were performed using the double-electrode voltage-clamp technique. Activation of PKC with phorbol 12-myristate 13-acetate (PMA) resulted in a strong reduction of Kv1.5/Kvβ1.2 current. This effect could be prevented using the PKC inhibitor staurosporine. Using the bisindolylmaleimide Ro-31-8220 as an inhibitor and ingenol as an activator of the conventional PKC isoforms, we were able to show that the Kv1.5/Kvβ1.2 ion channel complex is mainly regulated by conventional isoforms. Whereas pharmacological inhibition of PKCα with HBDDE did not attenuate the PMA-induced effect, current reduction could be prevented using inhibitors of PKCβ. Here, we show the isoform βII plays a central role in the PKC-dependent regulation of Kv1.5/Kvβ1.2 channels. These results add to the current understanding of isoenzyme-selective regulation of cardiac ion channels by protein kinases.