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Elliott MK, Strocchi M, Sieniewicz BJ, Mehta V, Wijesuriya N, deVere F, Howell S, Thorpe A, Martic D, Bishop MJ, Niederer S, Rinaldi CA. Left bundle branch area pacing reduces epicardial dispersion of repolarization compared with biventricular cardiac resynchronization therapy. Heart Rhythm 2023; 20:1629-1636. [PMID: 37516414 DOI: 10.1016/j.hrthm.2023.07.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Biventricular endocardial pacing (BiV-endo) and left bundle branch area pacing (LBBAP) are novel methods of delivering cardiac resynchronization therapy. These techniques are associated with improved activation times and acute hemodynamic response compared with conventional biventricular epicardial pacing (BiV-epi); however, the effects on repolarization and arrhythmic risk are unknown. OBJECTIVE The purpose of this study was to compare the effects of temporary BiV-epi, BiV-endo, and LBBAP on epicardial left ventricular (LV) repolarization using electrocardiographic imaging (ECGi). METHODS Eleven patients indicated for cardiac resynchronization therapy underwent a temporary pacing protocol with ECGi. BiV-endo was delivered via endocardial stimulation of the LV lateral wall. LBBAP was delivered by pacing the LV septum. Epicardial LV repolarization time (LVRT-95; time taken for 95% of the LV to repolarize), LV RT dispersion, mean LV activation recovery interval (ARI), LV ARI dispersion, and RT gradients were calculated. RESULTS The protocol was completed in 10 patients. During LBBAP, there were significant reductions in LVRT-95 (94.9 ± 17.4 ms vs 125.0 ± 29.4 ms; P = .03) and LV RT dispersion (29.4 ± 6.3 ms vs 40.8 ± 11.4 ms; P = .015) compared with BiV-epi. In contrast, there were no significant differences between baseline, BiV-epi, or BiV-endo. There was a nonsignificant reduction in mean RT gradients between LBBAP and baseline rhythm (0.74 ± 0.22 ms/mm vs 1.01 ± 0.31 ms/mm; P = .07). There were no significant differences in mean LV ARI or LV ARI dispersion between groups. CONCLUSION Temporary LBBAP reduces epicardial dispersion of repolarization compared with conventional BiV-epi. Further study is required to determine whether these repolarization changes on ECGi translate into a reduced risk of ventricular arrhythmia in clinical practice.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Benjamin J Sieniewicz
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Felicity deVere
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sandra Howell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew Thorpe
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Elliott MK, Strocchi M, Mehta VS, Wijesuriya N, Mannakkara NN, Jackson T, Pereira H, Behar JM, Bishop MJ, Niederer S, Rinaldi CA. Dispersion of repolarization increases with cardiac resynchronization therapy and is associated with left ventricular reverse remodeling. J Electrocardiol 2022; 72:120-127. [PMID: 35468456 PMCID: PMC10171825 DOI: 10.1016/j.jelectrocard.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE Cardiac resynchronization therapy (CRT) reduces ventricular activation times and electrical dyssynchrony, however the effect on repolarization is unclear. In this study, we sought to investigate the effect of CRT and left ventricular (LV) remodeling on dispersion of repolarization using electrocardiographic imaging (ECGi). METHODS 11 patients with heart failure and electrical dyssynchrony underwent ECGi 1-day and 6-months post CRT. Reconstructed epicardial electrograms were used to create maps of activation time, repolarization time (RT) and activation recovery intervals (ARI) and calculate measures of RT, ARI and their dispersion. ARI was corrected for heart rate (cARI). RESULTS Compared to baseline rhythm, LV cARI dispersion was significantly higher at 6 months (28.2 ± 7.7 vs 36.4 ± 7.2 ms; P = 0.03) but not after 1 day (28.2 ± 7.7 vs 34.4 ± 6.8 ms; P = 0.12). There were no significant differences from baseline to CRT for mean LV cARI or RT metrics. Significant LV remodeling (>15% reduction in end-systolic volume) was an independent predictor of increase in LV cARI dispersion (P = 0.04) and there was a moderate correlation between the degree of LV remodeling and the relative increase in LV cARI dispersion (R = -0.49) though this was not statistically significant (P = 0.12). CONCLUSION CRT increases LV cARI dispersion, but this change was not fully apparent until 6 months post implant. The effects of CRT on LV cARI dispersion appeared to be dependent on LV reverse remodeling, which is in keeping with evidence that the risk of ventricular arrhythmia after CRT is higher in non-responders compared to responders.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nilanka N Mannakkara
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tom Jackson
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Helder Pereira
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Elliott MK, Costa CM, Whitaker J, Gemmell P, Mehta VS, Sidhu BS, Gould J, Williams SE, O'Neill M, Razavi R, Niederer S, Bishop MJ, Rinaldi CA. Effect of scar and pacing location on repolarization in a porcine myocardial infarction model. Heart Rhythm O2 2022; 3:186-195. [PMID: 35496454 PMCID: PMC9043407 DOI: 10.1016/j.hroo.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background The effect of chronic ischemic scar on repolarization is unclear, with conflicting results from human and animal studies. An improved understanding of electrical remodeling within scar and border zone tissue may enhance substrate-guided ablation techniques for treatment of ventricular tachycardia. Computational modeling studies have suggested increased dispersion of repolarization during epicardial, but not endocardial, left ventricular pacing, in close proximity to scar. However, the effect of endocardial pacing near scar in vivo is unknown. Objective The purpose of this study was to investigate the effect of scar and pacing location on local repolarization in a porcine myocardial infarction model. Methods Six model pigs underwent late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging followed by electroanatomic mapping of the left ventricular endocardium. LGE-CMR images were registered to the anatomic shell and scar defined by LGE. Activation recovery intervals (ARIs), a surrogate for action potential duration, and local ARI gradients were calculated from unipolar electrograms within areas of late gadolinium enhancement (aLGE) and healthy myocardium. Results There was no significant difference between aLGE and healthy myocardium in mean ARI (304.20 ± 19.44 ms vs 300.59 ± 19.22 ms; P = .43), ARI heterogeneity (23.32 ± 11.43 ms vs 24.85 ± 12.99 ms; P = .54), or ARI gradients (6.18 ± 2.09 vs 5.66 ± 2.32 ms/mm; P = .39). Endocardial pacing distance from scar did not affect ARI gradients. Conclusion Our findings suggest that changes in ARI are not an intrinsic property of surviving myocytes within scar, and endocardial pacing close to scar does not affect local repolarization.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Caroline Mendonca Costa
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Philip Gemmell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Chen S, Meng G, Doytchinova A, Wong J, Straka S, Lacy J, Li X, Chen PS, Everett Iv TH. Skin Sympathetic Nerve Activity and the Short-Term QT Interval Variability in Patients With Electrical Storm. Front Physiol 2022; 12:742844. [PMID: 35002752 PMCID: PMC8728059 DOI: 10.3389/fphys.2021.742844] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Skin sympathetic nerve activity (SKNA) and QT interval variability are known to be associated with ventricular arrhythmias. However, the relationship between the two remains unclear. Objective: The aim was to test the hypothesis that SKNA bursts are associated with greater short-term variability of the QT interval (STVQT) in patients with electrical storm (ES) or coronary heart disease without arrhythmias (CHD) than in healthy volunteers (HV). Methods: We simultaneously recorded the ECG and SKNA during sinus rhythm in patients with ES (N = 10) and CHD (N = 8) and during cold-water pressor test in HV (N = 12). The QT and QTc intervals were manually marked and calculated within the ECG. The STVQT was calculated and compared to episodes of SKNA burst and non-bursting activity. Results: The SKNA burst threshold for ES and HV was 1.06 ± 1.07 and 1.88 ± 1.09 μV, respectively (p = 0.011). During SKNA baseline and burst, the QT/QTc intervals and STVQT for ES and CHD were significantly higher than those of the HV. In all subjects, SKNA bursts were associated with an increased STVQT (from 6.43 ± 2.99 to 9.40 ± 5.12 ms, p = 0.002 for ES; from 9.48 ± 4.40 to 12.8 ± 5.26 ms, p = 0.016 for CHD; and from 3.81 ± 0.73 to 4.49 ± 1.24 ms, p = 0.016 for HV). The magnitude of increased STVQT in ES (3.33 ± 3.06 ms) and CHD (3.34 ± 2.34 ms) was both higher than that of the HV (0.68 ± 0.84 ms, p = 0.047 and p = 0.020). Conclusion: Compared to non-bursting activity, SKNA bursts were associated with a larger increase in the QTc interval and STVQT in patients with heart disease than in HV.
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Affiliation(s)
- Songwen Chen
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guannan Meng
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Anisiia Doytchinova
- The Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, United States
| | - Johnson Wong
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Susan Straka
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Julie Lacy
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, IN, United States
| | - Peng-Sheng Chen
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Thomas H Everett Iv
- The Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States
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Taggart P, Pueyo E, Duijvenboden SV, Porter B, Bishop M, Sampedro-Puente DA, Orini M, Hanson B, Rinaldi CA, Gill JS, Lambiase P. Emerging evidence for a mechanistic link between low-frequency oscillation of ventricular repolarization measured from the electrocardiogram T-wave vector and arrhythmia. Europace 2021; 23:1350-1358. [PMID: 33880542 PMCID: PMC8427352 DOI: 10.1093/europace/euab009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 11/17/2022] Open
Abstract
Strong recent clinical evidence links the presence of prominent oscillations of ventricular repolarization in the low-frequency range (0.04–0.15 Hz) to the incidence of ventricular arrhythmia and sudden death in post-MI patients and patients with ischaemic and non-ischaemic cardiomyopathy. It has been proposed that these oscillations reflect oscillations of ventricular action potential duration at the sympathetic nerve frequency. Here we review emerging evidence to support that contention and provide insight into possible underlying mechanisms for this association.
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Affiliation(s)
- Peter Taggart
- Department of Cardiovascular Sciences, University College London, London, UK
| | - Esther Pueyo
- BSICOS Group, 13A, 11S, Aragon, University of Zaragoza, Spain.,CIBER-BBN, Zaragoza, Spain
| | | | - Bradley Porter
- Department of Imaging Sciences and Biomedical Engineering, KCL, London, UK
| | - Martin Bishop
- Department of Imaging Sciences and Biomedical Engineering, KCL, London, UK
| | | | - M Orini
- Department of Cardiovascular Sciences, University College London, London, UK
| | - B Hanson
- UCL Mechanical Engineering, University College London, London, UK
| | | | | | - Pier Lambiase
- Department of Cardiovascular Sciences, University College London, London, UK
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Borovac JA, D'Amario D, Bozic J, Glavas D. Sympathetic nervous system activation and heart failure: Current state of evidence and the pathophysiology in the light of novel biomarkers. World J Cardiol 2020; 12:373-408. [PMID: 32879702 PMCID: PMC7439452 DOI: 10.4330/wjc.v12.i8.373] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/19/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a complex clinical syndrome characterized by the activation of at least several neurohumoral pathways that have a common role in maintaining cardiac output and adequate perfusion pressure of target organs and tissues. The sympathetic nervous system (SNS) is upregulated in HF as evident in dysfunctional baroreceptor and chemoreceptor reflexes, circulating and neuronal catecholamine spillover, attenuated parasympathetic response, and augmented sympathetic outflow to the heart, kidneys and skeletal muscles. When these sympathoexcitatory effects on the cardiovascular system are sustained chronically they initiate the vicious circle of HF progression and become associated with cardiomyocyte apoptosis, maladaptive ventricular and vascular remodeling, arrhythmogenesis, and poor prognosis in patients with HF. These detrimental effects of SNS activity on outcomes in HF warrant adequate diagnostic and treatment modalities. Therefore, this review summarizes basic physiological concepts about the interaction of SNS with the cardiovascular system and highlights key pathophysiological mechanisms of SNS derangement in HF. Finally, special emphasis in this review is placed on the integrative and up-to-date overview of diagnostic modalities such as SNS imaging methods and novel laboratory biomarkers that could aid in the assessment of the degree of SNS activation and provide reliable prognostic information among patients with HF.
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Affiliation(s)
- Josip Anđelo Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
- Working Group on Heart Failure of Croatian Cardiac Society, Zagreb 10000, Croatia
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, IRCCS Fondazione Policlinico A. Gemelli, Universita Cattolica Sacro Cuore, Rome 00168, Italy
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
| | - Duska Glavas
- Working Group on Heart Failure of Croatian Cardiac Society, Zagreb 10000, Croatia
- Clinic for Cardiovascular Diseases, University Hospital of Split, Split 21000, Croatia
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7
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Duijvenboden SV, Porter B, Pueyo E, Sampedro-Puente DA, Fernandez-Bes J, Sidhu B, Gould J, Orini M, Bishop MJ, Hanson B, Lambiase P, Razavi R, Rinaldi CA, Gill JS, Taggart P. Complex Interaction Between Low-Frequency APD Oscillations and Beat-to-Beat APD Variability in Humans Is Governed by the Sympathetic Nervous System. Front Physiol 2020; 10:1582. [PMID: 32038279 PMCID: PMC6987475 DOI: 10.3389/fphys.2019.01582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Recent clinical, experimental and modeling studies link oscillations of ventricular repolarization in the low frequency (LF) (approx. 0.1 Hz) to arrhythmogenesis. Sympathetic provocation has been shown to enhance both LF oscillations of action potential duration (APD) and beat-to-beat variability (BVR) in humans. We hypothesized that beta-adrenergic blockade would reduce LF oscillations of APD and BVR of APD in humans and that the two processes might be linked. METHODS AND RESULTS Twelve patients with normal ventricles were studied during routine electrophysiological procedures. Activation-recovery intervals (ARI) as a conventional surrogate for APD were recorded from 10 left and 10 right ventricular endocardial sites before and after acute beta-adrenergic adrenergic blockade. Cycle length was maintained constant with right ventricular pacing. Oscillatory behavior of ARI was quantified by spectral analysis and BVR as the short-term variability. Beta-adrenergic blockade reduced LF ARI oscillations (8.6 ± 4.5 ms2 vs. 5.5 ± 3.5 ms2, p = 0.027). A significant correlation was present between the initial control values and reduction seen following beta-adrenergic blockade in LF ARI (r s = 0.62, p = 0.037) such that when initial values are high the effect is greater. A similar relationship was also seen in the beat-to beat variability of ARI (r s = 0.74, p = 0.008). There was a significant correlation between the beta-adrenergic blockade induced reduction in LF power of ARI and the witnessed reduction of beat-to-beat variability of ARI (r s = 0.74, p = 0.01). These clinical results accord with recent computational modeling studies which provide mechanistic insight into the interactions of LF oscillations and beat-to-beat variability of APD at the cellular level. CONCLUSION Beta-adrenergic blockade reduces LF oscillatory behavior of APD (ARI) in humans in vivo. Our results support the importance of LF oscillations in modulating the response of BVR to beta-adrenergic blockers, suggesting that LF oscillations may play role in modulating beta-adrenergic mechanisms underlying BVR.
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Affiliation(s)
| | - Bradley Porter
- School of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Esther Pueyo
- BSICOS Group, I3A, IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER-BBN, Madrid, Spain
| | | | | | - Baldeep Sidhu
- School of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Justin Gould
- School of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Michele Orini
- Department of Clinical Pharmacology, Queen Mary University of London, London, United Kingdom
| | - Martin J. Bishop
- School of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Ben Hanson
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Pier Lambiase
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Reza Razavi
- School of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | | | | | - Peter Taggart
- Institute of Cardiovascular Science, University College London, London, United Kingdom
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8
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Bauer A, Klemm M, Rizas KD, Hamm W, von Stülpnagel L, Dommasch M, Steger A, Lubinski A, Flevari P, Harden M, Friede T, Kääb S, Merkely B, Sticherling C, Willems R, Huikuri H, Malik M, Schmidt G, Zabel M. Prediction of mortality benefit based on periodic repolarisation dynamics in patients undergoing prophylactic implantation of a defibrillator: a prospective, controlled, multicentre cohort study. Lancet 2019; 394:1344-1351. [PMID: 31488371 DOI: 10.1016/s0140-6736(19)31996-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND A small proportion of patients undergoing primary prophylactic implantation of implantable cardioverter defibrillators (ICDs) experiences malignant arrhythmias. We postulated that periodic repolarisation dynamics, a novel marker of sympathetic-activity-associated repolarisation instability, could be used to identify electrically vulnerable patients who would benefit from prophylactic implantation of ICDs by way of a reduction in mortality. METHODS We did a prespecified substudy of EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD), a prospective, investigator-initiated, non-randomised, controlled cohort study done at 44 centres in 15 EU countries. Patients aged 18 years or older with ischaemic or non-ischaemic cardiomyopathy and reduced left ventricular ejection fraction (≤35%) were eligible for inclusion if they met guideline-based criteria for primary prophylactic implantation of ICDs. Periodic repolarisation dynamics from 24-h Holter recordings were assessed blindly in patients the day before ICD implantation or on the day of study enrolment in patients who were conservatively managed. The primary endpoint was all-cause mortality. Propensity scoring and multivariable models were used to assess the interaction between periodic repolarisation dynamics and the treatment effect of ICDs on mortality. FINDINGS Between May 12, 2014, and Sept 7, 2018, 1371 patients were enrolled in our study. 968 of these patients underwent ICD implantation, and 403 were treated conservatively. During follow-up (median 2·7 years [IQR 2·0-3·3] in the ICD group and 1·2 years [0·8-2·7] in the control group), 138 (14%) patients died in the ICD group and 64 (16%) patients died in the control group. We noted a 43% reduction in mortality in the ICD group compared with the control group (adjusted hazard ratio [HR] 0·57 [95% CI 0·41-0·79]; p=0·0008). Periodic repolarisation dynamics significantly predicted the treatment effect of ICDs on mortality (adjusted p=0·0307). The mortality benefits associated with ICD implantation were greater in patients with periodic repolarisation dynamics of 7·5 deg or higher (n=199; adjusted HR 0·25 [95% CI 0·13-0·47] for the ICD group vs the control group; p<0·0001) than in those with periodic repolarisation dynamics less than 7·5 deg (n=1166; adjusted HR 0·69 [95% CI 0·47-1·00]; p=0·0492; pinteraction=0·0056). The number needed to treat was 18·3 (95% CI 10·6-4895·3) in patients with periodic repolarisation dynamics less than 7·5 deg and 3·1 (2·6-4·8) in those with periodic repolarisation dynamics of 7·5 deg or higher. INTERPRETATION Periodic repolarisation dynamics predict mortality reductions associated with prophylactic implantation of ICDs in contemporarily treated patients with ischaemic or non-ischaemic cardiomyopathy. Periodic repolarisation dynamics could help to guide treatment decisions about prophylactic ICD implantation. FUNDING The European Community's 7th Framework Programme.
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Affiliation(s)
- Axel Bauer
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany.
| | - Mathias Klemm
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany
| | - Wolfgang Hamm
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany
| | - Lukas von Stülpnagel
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany; Department of Electrical and Computer Engineering, Technical University of Munich, Munich, Germany
| | - Michael Dommasch
- German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany; Klinikum rechts der Isar, Medizinische Klinik und Poliklinik I, Technical University of Munich, Munich, Germany
| | - Alexander Steger
- German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany; Klinikum rechts der Isar, Medizinische Klinik und Poliklinik I, Technical University of Munich, Munich, Germany
| | - Andrezej Lubinski
- Department of Cardiology, Medical University of Lodz Hospital, Lodz, Poland
| | - Panagiota Flevari
- Second Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Markus Harden
- Department of Medical Statistics, Heart Center University Medical Center Göttingen, Göttingen, Germany; German Center for Cardiovascular Research partner site Göttingen, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, Heart Center University Medical Center Göttingen, Göttingen, Germany; German Center for Cardiovascular Research partner site Göttingen, Göttingen, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany
| | - Bela Merkely
- Department of Cardiology, Semmelweis University Heart Center, Budapest, Hungary
| | | | - Rik Willems
- University Hospitals of Leuven, Leuven, Belgium
| | - Heikki Huikuri
- Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Marek Malik
- Heart and Lung Institute, Imperial College London, London, UK
| | - Georg Schmidt
- German Center for Cardiovascular Research partner site, Munich Heart Alliance, Munich, Germany; Klinikum rechts der Isar, Medizinische Klinik und Poliklinik I, Technical University of Munich, Munich, Germany
| | - Markus Zabel
- Department of Cardiology and Pneumology, Heart Center University Medical Center Göttingen, Göttingen, Germany; German Center for Cardiovascular Research partner site Göttingen, Göttingen, Germany
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9
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van der Lingen ALCJ, Timmer SAJ, Allaart LJH, Rijnierse MT, van de Ven PM, van Rossum AC, Kemme MJB, van Halm VP, Allaart CP. The Benefit of Prophylactic Implantable Cardioverter Defibrillator Implantation in Asymptomatic Heart Failure Patients With a Reduced Ejection Fraction. Am J Cardiol 2019; 124:560-566. [PMID: 31270031 DOI: 10.1016/j.amjcard.2019.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/06/2019] [Accepted: 05/16/2019] [Indexed: 01/24/2023]
Abstract
Recommendations for prophylactic implantable cardioverter defibrillator (ICD) implantation in asymptomatic heart failure patients with a reduced left ventricular ejection fraction (LVEF) differ between guidelines. Evidence on the risk of appropriate device therapy (ADT) and death in New York Heart Association (NYHA) class I patients is scarce. Aim of this study is to evaluate ADT and mortality in NYHA-I primary prevention ICD patients with a LVEF ≤35%. A retrospective cohort was studied, including 572 patients with LVEF ≤35% who received a prophylactic ICD with or without resynchronization therapy (CRT-D). To evaluate the incidence of ADT and mortality, NYHA-I was compared with NYHA-II-III using Cox regression analysis. During a follow-up of 4.1 ± 2.4 years, 33% of the NYHA-I patients received ADT compared with 20% of the NYHA-II-III patients (hazard ratio 1.5, 95% confidence interval 1.04 to 2.31, p = 0.03). No differences in mortality were observed (hazard ratio 0.70, 95% confidence interval 0.49 to 1.07, p = 0.10). Additional analyses showed no difference in time to ADT excluding CRT patients (ICD-NYHA-I patients vs ICD-NYHA-II-III patients, p = 0.17) and comparing ischemic and nonischemic cardiomyopathy NYHA-I patients (p = 0.13). Multivariable Cox regression analyses showed that NYHA class was the strongest independent predictor of ADT. In conclusion, primary prevention NYHA-I ICD patients showed a higher incidence of ADT compared with NYHA-II-III ICD patients. These results strongly suggest that primary prevention NYHA-I patients with a LVEF ≤35% are likely to benefit from ICD therapy and should not be excluded from a potentially life-saving therapy.
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Affiliation(s)
| | - Stefan A J Timmer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Laurens J H Allaart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Mischa T Rijnierse
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Michiel J B Kemme
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Vokko P van Halm
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam, the Netherlands.
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10
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Sampedro-Puente DA, Fernandez-Bes J, Porter B, van Duijvenboden S, Taggart P, Pueyo E. Mechanisms Underlying Interactions Between Low-Frequency Oscillations and Beat-to-Beat Variability of Celullar Ventricular Repolarization in Response to Sympathetic Stimulation: Implications for Arrhythmogenesis. Front Physiol 2019; 10:916. [PMID: 31427979 PMCID: PMC6687852 DOI: 10.3389/fphys.2019.00916] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 07/04/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Enhanced beat-to-beat variability of ventricular repolarization (BVR) has been linked to arrhythmias and sudden cardiac death. Recent experimental studies on human left ventricular epicardial electrograms have shown that BVR closely interacts with low-frequency (LF) oscillations of activation recovery interval during sympathetic provocation. In this work human ventricular computational cell models are developed to reproduce the experimentally observed interactions between BVR and its LF oscillations, to assess underlying mechanisms and to establish a relationship with arrhythmic risk. Materials and Methods: A set of human ventricular action potential (AP) models covering a range of experimental electrophysiological characteristics was constructed. These models incorporated stochasticity in major ionic currents as well as descriptions of β-adrenergic stimulation and mechanical effects to investigate the AP response to enhanced sympathetic activity. Statistical methods based on Automatic Relevance Determination and Canonical Correlation Analysis were developed to unravel individual and common factors contributing to BVR and LF patterning of APD in response to sympathetic provocation. Results: Simulated results reproduced experimental evidences on the interactions between BVR and LF oscillations of AP duration (APD), with replication of the high inter-individual variability observed in both phenomena. ICaL, IKr and IK1 currents were identified as common ionic modulators of the inter-individual differences in BVR and LF oscillatory behavior and were shown to be crucial in determining susceptibility to arrhythmogenic events. Conclusions: The calibrated family of human ventricular cell models proposed in this study allows reproducing experimentally reported interactions between BVR and LF oscillations of APD. Ionic factors involving ICaL, IKr and IK1 currents are found to underlie correlated increments in both phenomena in response to sympathetic provocation. A link to arrhythmogenesis is established for concomitantly elevated levels of BVR and its LF oscillations.
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Affiliation(s)
| | | | - Bradley Porter
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | | | - Peter Taggart
- Department of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Esther Pueyo
- BSICOS Group, I3A, IIS Aragón, University of Zaragoza, Zaragoza, Spain.,CIBER-BBN, Madrid, Spain
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11
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Johnson DM, Antoons G. Arrhythmogenic Mechanisms in Heart Failure: Linking β-Adrenergic Stimulation, Stretch, and Calcium. Front Physiol 2018; 9:1453. [PMID: 30374311 PMCID: PMC6196916 DOI: 10.3389/fphys.2018.01453] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/25/2018] [Indexed: 12/22/2022] Open
Abstract
Heart failure (HF) is associated with elevated sympathetic tone and mechanical load. Both systems activate signaling transduction pathways that increase cardiac output, but eventually become part of the disease process itself leading to further worsening of cardiac function. These alterations can adversely contribute to electrical instability, at least in part due to the modulation of Ca2+ handling at the level of the single cardiac myocyte. The major aim of this review is to provide a definitive overview of the links and cross talk between β-adrenergic stimulation, mechanical load, and arrhythmogenesis in the setting of HF. We will initially review the role of Ca2+ in the induction of both early and delayed afterdepolarizations, the role that β-adrenergic stimulation plays in the initiation of these and how the propensity for these may be altered in HF. We will then go onto reviewing the current data with regards to the link between mechanical load and afterdepolarizations, the associated mechano-sensitivity of the ryanodine receptor and other stretch activated channels that may be associated with HF-associated arrhythmias. Furthermore, we will discuss how alterations in local Ca2+ microdomains during the remodeling process associated the HF may contribute to the increased disposition for β-adrenergic or stretch induced arrhythmogenic triggers. Finally, the potential mechanisms linking β-adrenergic stimulation and mechanical stretch will be clarified, with the aim of finding common modalities of arrhythmogenesis that could be targeted by novel therapeutic agents in the setting of HF.
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Affiliation(s)
- Daniel M Johnson
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Gudrun Antoons
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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12
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Meng L, Shivkumar K, Ajijola O. Autonomic Regulation and Ventricular Arrhythmias. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:38. [DOI: 10.1007/s11936-018-0633-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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Porter B, van Duijvenboden S, Bishop MJ, Orini M, Claridge S, Gould J, Sieniewicz BJ, Sidhu B, Razavi R, Rinaldi CA, Gill JS, Taggart P. Beat-to-Beat Variability of Ventricular Action Potential Duration Oscillates at Low Frequency During Sympathetic Provocation in Humans. Front Physiol 2018; 9:147. [PMID: 29670531 PMCID: PMC5893843 DOI: 10.3389/fphys.2018.00147] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/13/2018] [Indexed: 01/22/2023] Open
Abstract
Background: The temporal pattern of ventricular repolarization is of critical importance in arrhythmogenesis. Enhanced beat-to-beat variability (BBV) of ventricular action potential duration (APD) is pro-arrhythmic and is increased during sympathetic provocation. Since sympathetic nerve activity characteristically exhibits burst patterning in the low frequency range, we hypothesized that physiologically enhanced sympathetic activity may not only increase BBV of left ventricular APD but also impose a low frequency oscillation which further increases repolarization instability in humans. Methods and Results: Heart failure patients with cardiac resynchronization therapy defibrillator devices (n = 11) had activation recovery intervals (ARI, surrogate for APD) recorded from left ventricular epicardial electrodes alongside simultaneous non-invasive blood pressure and respiratory recordings. Fixed cycle length was achieved by right ventricular pacing. Recordings took place during resting conditions and following an autonomic stimulus (Valsalva). The variability of ARI and the normalized variability of ARI showed significant increases post Valsalva when compared to control (p = 0.019 and p = 0.032, respectively). The oscillatory behavior was quantified by spectral analysis. Significant increases in low frequency (LF) power (p = 0.002) and normalized LF power (p = 0.019) of ARI were seen following Valsalva. The Valsalva did not induce changes in conduction variability nor the LF oscillatory behavior of conduction. However, increases in the LF power of ARI were accompanied by increases in the LF power of systolic blood pressure (SBP) and the rate of systolic pressure increase (dP/dtmax). Positive correlations were found between LF-SBP and LF-dP/dtmax (rs = 0.933, p < 0.001), LF-ARI and LF-SBP (rs = 0.681, p = 0.001) and between LF-ARI and LF-dP/dtmax (rs = 0.623, p = 0.004). There was a strong positive correlation between the variability of ARI and LF power of ARI (rs = 0.679, p < 0.001). Conclusions: In heart failure patients, physiological sympathetic provocation induced low frequency oscillation (~0.1 Hz) of left ventricular APD with a strong positive correlation between the LF power of APD and the BBV of APD. These findings may be of importance in mechanisms underlying stability/instability of repolarization and arrhythmogenesis in humans.
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Affiliation(s)
- Bradley Porter
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | | | - Martin J. Bishop
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Michele Orini
- Guy's and St Thomas' Hospital, London, United Kingdom
| | - Simon Claridge
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Justin Gould
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Benjamin J. Sieniewicz
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Baldeep Sidhu
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Reza Razavi
- Department of Imaging Sciences and Biomedical Engineering, Kings College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Department of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Jaswinder S. Gill
- Department of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Peter Taggart
- Guy's and St Thomas' Hospital, London, United Kingdom
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14
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Van Weperen VYH, Vos MA, Van der Heyden MAG. Commentary: Autonomic Modulation in Patients with Heart Failure Increases Beat-to-Beat Variability of Ventricular Action Potential Duration. Front Physiol 2017; 8:459. [PMID: 28713288 PMCID: PMC5491645 DOI: 10.3389/fphys.2017.00459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/15/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Valerie Y H Van Weperen
- Department of Medical Physiology, Division of Heart and Lungs, University Medical Center UtrechtUtrecht, Netherlands
| | - Marc A Vos
- Department of Medical Physiology, Division of Heart and Lungs, University Medical Center UtrechtUtrecht, Netherlands
| | - Marcel A G Van der Heyden
- Department of Medical Physiology, Division of Heart and Lungs, University Medical Center UtrechtUtrecht, Netherlands
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