Passive ventricular constraint amends the course of heart failure: a study in an ovine model of dilated cardiomyopathy

OBJECTIVE

Dilated cardiomyopathy (DCM) is associated with a progressive deterioration in cardiac function. We hypothesised that some of the deleterious effects of DCM could be reduced by mechanically limiting the degree of cardiac dilatation.

METHODS

A Transonic 20A cardiac output (CO) flow-probe was implanted in the pulmonary artery of 12 adult (52 +/- 4 kg) sheep. Early heart failure was created by rapid right ventricular (RV) pacing for 21 days at a rate which resulted in an initial 10% decrease in CO (to a maximum of 190 bpm). A custom polyester jacket (Acorn Cardiovascular, St Paul, MN) was then placed, via a partial lower sternotomy, on the ventricular epicardium of all sheep. Animals were randomised either to jacket retention (wrap) or removal (sham). Pacing was recommenced at a higher rate (that initiated a further 10% decrease in CO) for 28 days. Haemodynamic and echocardiographic parameters were determined at baseline, implant and at termination.

RESULTS

At termination, the left ventricular fractional shortening was significantly higher (p = 0.03), the degree of mitral valve regurgitation lower (scaled 0-3) (p = 0.03) and the left ventricular long axis area smaller (p = 0.02) in the wrap animals compared with sham.

CONCLUSIONS

In this model of heart failure, ventricular constraint with a polyester jacket diminished the deterioration in cardiac function associated with progressive dilated cardiomyopathy. These results suggest that maintainance of a more normal cardiac size and shape may be beneficial in patients with dilated cardiomyopathy.

Mid- and long-term similarity of ventricular response to paroxysmal atrial fibrillation: digoxin versus placebo

The effects of digoxin on ventricular response during atrial fibrillation (AF) and consequent effects on arrhythmic symptoms have still not been fully explained. This study investigated whether the treatment by digoxin contributes to mid- and long-term stabilization of ventricular cycles in patients with paroxysmal AF. A population of 45 patients with paroxysmal AF underwent 24-hour ECG recordings during each arm of a randomized crossover trial comparing digoxin and placebo. This yielded 30 Holter recordings from 22 patients that contained AF episodes lasting in excess of 2 minutes and with acceptably low Holter noise. Each AF episode was divided into nonoverlapping segments of 30 seconds and the distribution of RR intervals in each segment was compared with the distribution of all other AF segments in the same recording using the Kolmogorov-Smirnov test. The percentage of tests that revealed significant differences at levels of P < or = 0.01, and P < or = 0.001 were sorted according to the time between the segments compared. The comparisons of these results were performed between: (a) all recordings on placebo (n = 16) and all recordings on digoxin (n = 14), and (b) between recordings on placebo and on digoxin in 8 patients in whom paired analysis was possible. Adjacent AF segments (distance 0) differed significantly only in < 30% of both recordings on placebo and on digoxin. However, with increasing the distance between segments, the proportion of the significant differences between RR interval distributions increased more with placebo than with digoxin (P < 10(-300), Chi-square test). Paired data revealed larger differences between placebo and digoxin with increasing distance between segments. Thus in patients with paroxysmal AF, digoxin leads to more reproducible patterns of ventricular cycles that may be better tolerated clinically.

Effects of left atrial dilatation on the endocardial atrial defibrillation threshold: a study in an ovine model of pacing induced dilated cardiomyopathy

Left atrial (LA) dilation is a common finding in patients with chronic atrial fibrillation (AF). Progressive dilatation may alter the atrial defibrillation threshold (ADFT). In our study, epicardial electrodes were implanted on the LA free wall and right ventricular apex of eight adult sheep. Large surface area, coiled endocardial electrodes were positioned in the coronary sinus and right atrium (RA). LA dilatation was induced by rapid ventricular pacing (190 beats/min) for 6 weeks and echocardiographically assessed weekly along with the ADFT (under propofol anesthesia). LA effective refractory period (ERP) was measured every 2-3 days using a standard extra stimulus technique and 400 ms drive. The AF cycle length (AFCL) was assessed from LA electrograms. During the 6 weeks of pacing the mean LA area increased from 6.1 +/- 1.5 to 21.3 +/- 2.4 cm2. There were no significant changes in the mean ADFT (122 +/- 15 V), circuit impedance (46 +/- 5 omega), or LA AFCL (136 +/- 23 ms). There was a significant increase in the mean LA ERP (106 +/- 10 ms at day 0, and 120 +/- 13 ms at day 42 of pacing). In this study, using chronically implanted defibrillation leads, the minimal energy requirements for successful AF were not significantly altered by ongoing left atrial dilatation. This finding is a further endorsement of the efficiency of the coronary sinus/RA shock vector. Furthermore, the apparent stability of the AF present may be a further indication of a link between the type of AF and the ADFT.

Distribution of fast heart rate episodes during paroxysmal atrial fibrillation

OBJECTIVE

To investigate the defibrillator waiting time (time between the recognition of atrial fibrillation and the actual shock) by studying paroxysmal atrial fibrillation episodes with RR intervals shorter than a certain limit (that is, episodes during which defibrillation should not be attempted).

METHODS

Long term 24 hour Holter recordings from a digoxin v placebo crossover study in patients with paroxysmal atrial fibrillation were analysed. In all, 23 recordings with atrial fibrillation episodes of at least 1000 ventricular cycles and with < 20% Holter artefacts or noise were used (11 recorded on placebo and 12 on digoxin). For each recording, the mean ("mean waiting time") and maximum ("maximum waiting time") duration of continuous sections of atrial fibrillation episodes with all RR intervals shorter than a certain threshold were evaluated, ranging the threshold from 400 to 1000 ms in 10 ms steps. For each threshold, the mean and maximum waiting times were compared between recordings on placebo and on digoxin.

RESULTS

Both the mean and maximum waiting times increased exponentially with increasing threshold. Practically acceptable mean waiting times less than one minute were observed with thresholds below 600 ms. There were no significant differences in mean waiting times and maximum waiting times between recordings on placebo and digoxin, and only a trend towards shorter waiting times on digoxin.

CONCLUSIONS

Introduction of a minimum RR interval threshold required to deliver atrial defibrillation leads to practically acceptable delays between atrial fibrillation recognition and the actual shock. These delays are not prolonged by digoxin treatment.

Susceptibility to atrial fibrillation: a study in an ovine model of pacing-induced early heart failure

INTRODUCTION

The development of susceptibility to atrial fibrillation (AF) is a common consequence of many forms of cardiovascular disease, especially heart failure. In this study we used a sheep model of pacing-induced stable early heart failure to describe, quantify, and relate the level of susceptibility to AF to changes in structural and electrophysiologic parameters.

METHODS AND RESULTS

Epicardial electrodes were implanted on the atria and right ventricles of nine sheep. The AF threshold, atrial vulnerability period, atrial effective refractory period (ERP), and interatrial conduction time were examined during control and over a 6-week period of ventricular pacing at 190 beats/min. Left atrial (LA) area and left ventricular (LV) fractional shortening were monitored using echocardiography. There were significant increases in LA susceptibility to AF (P < 0.0003), LA area (P < 0.0002), and LA ERP400 (P < 0.0002). Rate of increase in LA area was related positively to AF susceptibility (P = 0.02) and inversely to LA ERP400 (P = 0.002). LV fractional shortening decreased to approximately 50% of control value (P < 0.00001). No changes were observed in right atrial electrophysiology.

CONCLUSION

In this study, susceptibility (the ability of an extrastimulus to induce AF) was rigorously measured within a predetermined format. Significant relationships were found to exist between susceptibility, certain of the observed changes in atrial electrophysiology and structure.

Is the automatic atrial defibrillator a promising approach?

Atrial fibrillation is a common arrhythmia, accounting for more consumption of medical resources than any other arrhythmia. The impact of the disease results from the combination of a loss of atrial contraction, and atrial control over cardiac rate. Studies in animals demonstrated the basic feasibility of atrial defibrillation using electrodes passed intravenously. Subsequent studies in patients confirmed that low-energy shocks were effective in converting atrial fibrillation and were safe if delivered synchronous to the R wave in the absence of a short preceding RR interval. Preliminary experience suggests that a small implanted device might provide beneficial therapy for patients with recurring episodes of persistent, drug-refractory, atrial fibrillation.

Ventricular proarrhythmic effects of ventricular cycle length and shock strength in a sheep model of transvenous atrial defibrillation

BACKGROUND

Synchronized cardioversion is generally accepted as safe for the treatment of ventricular tachycardia and atrial fibrillation when shocks are synchronized to the R wave and delivered transthoracically. However, others have shown that during attempted transvenous cardioversion of rapid ventricular tachycardia, ventricular fibrillation (VF) may be induced. It was our objective to evaluate conditions (short and irregular cycle lengths [CL]) under which VF might be induced during synchronized electrical conversion of atrial fibrillation with transvenous electrodes.

METHODS AND RESULTS

In 16 sheep (weight, 62 +/- 7.8 kg), atrial defibrillation thresholds (ADFT) were determined for a 3-ms/3-ms biphasic shock delivered between two catheters each having 6-cm coil electrodes, one in the great cardiac vein under the left atrial appendage and one in the right atrial appendage along the anterolateral atrioventricular groove. A hexapolar mapping catheter was positioned in the right ventricular apex for shock synchronization. In 8 sheep (group A), a shock intensity 20 V less than the ADFT was used for testing, and in the remaining 8 sheep (group B), a shock intensity of twice ADFT was used. With a modified extrastimulus technique, a basic train of eight stimuli alone (part 1) and with single (part 2) and double (part 3) extrastimuli were applied to right ventricular plunge electrodes. Atrial defibrillation shocks were delivered synchronized to the last depolarization. In part 4, shocks were delivered during atrial fibrillation. The preceding CL was evaluated over a range of 150 to 1000 milliseconds. Shocks were also delayed 2, 20, 50, and 100 milliseconds after the last depolarization from the stimulus (parts 1 through 3) or intrinsic depolarization (part 4). The mean ADFT for group A was 127 +/- 48 V, 0.71 +/- 0.60 J and for group B, 136 +/- 37 V, 0.79 +/- 0.42 J (NS, P > .15). Of 1870 shocks delivered, 11 episodes of VF were induced. Group A had no episodes of VF in part 1, two episodes of VF in part 2 (CL, 240 and 230 milliseconds with 2-millisecond delay), and one episode each in parts 3 (CL, 280 milliseconds with 2-millisecond delay) and 4 (CL, 240 milliseconds with 100-millisecond delay). Group B had two episodes in part 1 (CL, 250 and 300 milliseconds with 20-millisecond delay), three episodes in part 2 (CL, 230, 230, and 250 milliseconds with 2-millisecond delay), and one episode each in parts 3 (CL, 260 milliseconds with 2-millisecond delay) and 4 (198 milliseconds with 100-millisecond delay). No episodes of VF were induced for shocks delivered after a CL > 300 milliseconds.

CONCLUSIONS

Synchronized transvenous atrial defibrillation shocks delivered on beats with a short preceding ventricular cycle length (< 300 milliseconds) are associated with a significantly increased risk of initiation of VF. To decrease the risk of ventricular proarrhythmia, short CLs should be avoided.

Internal cardioversion of atrial fibrillation in sheep

BACKGROUND

The cardioversion efficacy of multiple defibrillation waveforms and electrode systems was compared in a sheep model of atrial fibrillation.

METHODS AND RESULTS

Sustained atrial fibrillation could be induced with rapid atrial pacing in 23 (55%) of the animals. This study was performed in four parts. Six sheep with sustained atrial fibrillation were used for data analysis for each part, except in part 4 where five sheep without sustained atrial fibrillation were used. In part 1, four lead systems and four single capacitor truncated exponential defibrillation waveforms (two monophasic and two biphasic) were tested. In part 2, two transvenous lead systems were compared; one was a right-to-left system with one electrode located in the right side of the heart and the other electrode located in the left side of the heart, and the other was a totally right-sided system with both electrodes located in the right side of the heart. Eight (four monophasic and four biphasic) waveforms were tested with each lead system. In part 3, eight transvenous lead systems were compared, and two waveforms (one monophasic and one biphasic) were tested with each lead system. For parts 1-3, probability of success curves were determined for each waveform/lead system configuration using an up-down technique with 15 shocks per configuration. In part 4, shocks were synchronized to the QRS and given through two lead configurations during sinus rhythm in 20-V steps starting with 40 and ending with 500 V, and two waveforms were tested with each lead system (one monophasic and one biphasic). Ventricular fibrillation thresholds were determined by giving shocks during the T wave of sinus rhythm. For part 1, the three lead systems that used only intravenous catheter electrodes had significantly lower defibrillation requirements than the catheter-to-chest wall patch system. A 3/3-msec biphasic waveform had significantly lower defibrillation requirements than any of the other three waveforms in part 1. In part 2, the 3/3-msec biphasic waveform with a right-to-left lead system configuration had significantly lower defibrillation requirements than any other waveform lead system combination tested, and for each waveform tested, the right-to-left configuration had significantly lower requirements than the totally right-sided configuration. In part 3, for each waveform the right-to-left configuration had significantly lower voltage and energy requirements than the corresponding totally right-sided configuration. Furthermore, in part 3, waveform/lead configurations that probably generated high potential gradients near the sinoatrial node and near the atrioventricular node resulted in more postshock conduction disturbances. In part 4, there were no episodes of ventricular arrhythmias with shocks synchronized to the QRS. However, with synchronization to the T wave, ventricular fibrillation was induced in all five animals with the minimum tested voltage, which was 40 V.

CONCLUSIONS

This acute model yielded sustained atrial fibrillation in approximately 55% of the animals. Cardioversion of atrial fibrillation in sheep is possible with very low energy requirements using transvenous electrode systems (50% successful energy of 1.3 +/- 0.4 J for the 3/3-msec biphasic waveform with a right-to-left lead system). The biphasic waveform had the lowest defibrillation requirements of any waveforms tested, and right-to-left lead systems resulted in lower defibrillation requirements than totally right-sided lead systems. Also, lead systems that probably generated high potential gradients near the sinoatrial and atrioventricular node areas resulted in more frequent episodes of postshock conduction disturbances. Furthermore, synchronization of the shock to the QRS was vital to avoid potentially lethal postshock ventricular arrhythmias...

Effect of pulse separation between two sequential biphasic shocks given over different lead configurations on ventricular defibrillation efficacy

BACKGROUND

Two sequential biphasic shocks delivered over separate lead configurations markedly improve defibrillation efficacy compared with a single shock alone. We investigated the effect of varying the intershock interval between sequential biphasic shocks on defibrillation.

METHODS AND RESULTS

Defibrillation thresholds (DFTs) were obtained in six dogs for shock separations ranging from 0.2 to 125 msec. The first shock was given from a catheter electrode in the right ventricular apex to a patch on the left lateral thorax; the second was from a small patch on the left ventricular apex to a catheter electrode in the right ventricular outflow tract. When the interval between shocks was less than or equal to 10 msec or greater than or equal to 75 and less than or equal to 125 msec, the mean DFTs were less than that previously found for the first shock by itself (4.2 versus 7.4 J, p = 0.002). At a separation of 50 msec, however, there was a marked rise in the DFT to 27 J. The mean DFT for the second shock at a delay of 50 msec was not different from the mean DFT previously found for the second shock by itself (7.2 versus 7.0 J). These results were confirmed in another six dogs using defibrillation probability-of-success curves. In 12 other dogs, probability-of-success curves were generated for delays between shocks as a percentage of the activation interval during ventricular fibrillation. Minimum defibrillation energy requirements were at two separations, 0.2 msec and 90% of the activation interval.

CONCLUSIONS

The optimal intershock interval between two sequential biphasic shocks is either less than or equal to 10 msec or greater than or equal to 75 and less than or equal to 125 msec. The marked rise in the DFT at a shock separation of 50 msec, requiring more energy than that for the first shock alone, suggests that the second shock at this time delay is likely to reinduce fibrillation after it is halted by the first shock until the second shock is strong enough to defibrillate independently of the first shock.

Defibrillation with low voltage using a left ventricular catheter and four cutaneous patch electrodes in dogs

The purpose of this study was to determine a lower limit of defibrillation thresholds (DFTs) that could be used to evaluate nonthoracotomy lead configurations for implantable defibrillators. A lead configuration that consisted of a left ventricular catheter and four circumferential cutaneous patches was tested because it was hypothesized to create a relatively uniform electric field for defibrillation. In eight anesthetized dogs, three 8F defibrillating catheters with 6 cm platinum clad titanium tips were inserted into the right ventricle (R), right ventricular outflow tract (O), and left ventricle (L). Four cutaneous patch electrodes (4P), each with a surface area of 42 cm2, were placed on the left lateral, right lateral, anterior and posterior thorax. DFTs for ten lead configurations, consisting of different combinations of these electrodes, were evaluated. DFTs were determined by using a modified Purdue technique and applying a single capacitor biphasic shock with both phases 6 ms in duration after 15 sec of electrically induced fibrillation. The L(-)----4P+ configuration produced a lower DFT than R(-)----4P+ (3.2 +/- 1.6 J vs 8.0 +/- 4.2 J, P less than 0.001) with reduced current (2.6 +/- 0.7 A vs 4.1 +/- 1.2 A, P less than 0.001). Lowering the impedance by a mean of 40%, configurations that used four patches produced lower DFTs than those that used a single left lateral patch. The use of an O catheter produced lower DFTs only when used in conjunction with an R catheter.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional blood flow during cardiopulmonary resuscitation in dogs using simultaneous and nonsimultaneous compression and ventilation

We studied regional blood flow (QR) using radiolabeled microspheres and measured hemodynamic variables in 20 anesthetized dogs in normal sinus rhythm and during ventricular fibrillation treated with cardiopulmonary resuscitation (CPR). Nonsimultaneous compression and ventilation CPR (NSCV-CPR) was performed in seven dogs with a pneumatic piston that gave 50 chest compressions/min with an open airway with 10 ventilations at an airway pressure of 33 mm Hg interposed between each fifth and sixth compression. Simultaneous compression and ventilation (SCV-CPR) was performed in seven dogs with the piston and in six other dogs with a circumferential pneumatic vest. Both devices gave 30 compressions/min simultaneously with 30 ventilations that elevated airway pressure to 80 mm Hg., The abdomen was bound during SCV-CPR. Regional blood flow (mean +/- SD) to the cerebral hemispheres, cardiac ventricles, and kidneys, expressed as ml/min/100 g tissue, was 3.1 +/- 4.0, 3.4 +/- 3.3 and 1.5 +/- 1.5, respectively, during NSCV-CPR; 11.5 +/- 5.9, 4.9 +/- 4.7 and 2.7 +/- 2.7 during SCV-CPR (vest); and 16.2 +/- 7.2, 11.0 +/- 4.0 and 20.1 +/- 20.2 during SCV-CPR (piston) (all p less than 0.05 compared with NSCV-CPR). These results indicate that QR to all organs studied is reduced below normal sinus rhythm levels during CPR for ventricular fibrillation, QR to the brain is proportionately greater than QR to the heart and kidneys, and QR to the brain is greater with both forms of SCV-CPR than with NSCV-CPR.

Failure of one method of simultaneous chest compression, ventilation, and abdominal binding during CPR

Some modified methods of CPR improve carotid blood flow, but there are no studies to show that these modified techniques improve survival, Accordingly, an experimental CPR technique using simultaneous chest compression, ventilation (SCV-CPR), and abdominal binding was compared to standard CPR in beagle dogs. The modified technique utilized a broad-based bellows device that was mechanically compressed, producing chest compression, delivering a volume of air to the endotracheal tube, and pressurizing an abdominal binder. The duration of ventricular fibrillation and CPR was 5 min. Five of the 6 dogs could be resuscitated with standard CPR. None of 6 dogs could be resuscitated using this modified method of SCV-CPR and abdominal binding. The aortic diastolic pressure and the diastolic gradient between the aorta and right atrium was significantly different between the 2 groups. Because these pressures relate to the coronary perfusion pressure, they may explain the discrepancy in the survival rate. This study suggests increasing carotid blood flow during CPR will not necessarily improve survival.