A clinical-in silico study on the effectiveness of multipoint bicathodic and cathodic-anodal pacing in cardiac resynchronization therapy

Up to one-third of patients undergoing cardiac resynchronization therapy (CRT) are nonresponders. Multipoint bicathodic and cathodic-anodal left ventricle (LV) stimulations could overcome this clinical challenge, but their effectiveness remains controversial. Here we evaluate the performance of such stimulations through both in vivo and in silico experiments, the latter based on computer electromechanical modeling. Seven patients, all candidates for CRT, received a quadripolar LV lead. Four stimulations were tested: right ventricular (RVS); conventional single point biventricular (S-BS); multipoint biventricular bicathodic (CC-BS) and multipoint biventricular cathodic-anodal (CA-BS). The following parameters were processed: QRS duration; maximal time derivative of arterial pressure (dPdt_max); systolic arterial pressure (P_sys); and stroke volume (SV). Echocardiographic data of each patient were then obtained to create an LV geometric model. Numerical simulations were based on a strongly coupled Bidomain electromechanical coupling model. Considering the in vivo parameters, when comparing S-BS to RVS, there was no significant decrease in SV (from 45 ± 11 to 44 ± 20 ml) and 6% and 4% increases of dPdt_max and P_sys, respectively. Focusing on in silico parameters, with respect to RVS, S-BS exhibited a significant increase of SV, dPdt_max and P_sys. Neither the in vivo nor in silico results showed any significant hemodynamic and electrical difference among S-BS, CC-BS and CA-BS configurations. These results show that CC-BS and CA-BS yield a comparable CRT performance, but they do not always yield improvement in terms of hemodynamic parameters with respect to S-BS. The computational results confirmed the in vivo observations, thus providing theoretical support to the clinical experiments.

Effects of mechanical feedback on the stability of cardiac scroll waves: A bidomain electro-mechanical simulation study

In this work, we investigate the influence of cardiac tissue deformation on re-entrant wave dynamics. We have developed a 3D strongly coupled electro-mechanical Bidomain model posed on an ideal monoventricular geometry, including fiber direction anisotropy and stretch-activated currents (SACs). The cardiac mechanical deformation influences the bioelectrical activity with two main mechanical feedback: (a) the geometric feedback (GEF) due to the presence of the deformation gradient in the diffusion coefficients and in a convective term depending on the deformation rate and (b) the mechano-electric feedback (MEF) due to SACs. Here, we investigate the relative contribution of these two factors with respect to scroll wave stability. We extend the previous works [Keldermann et al., Am. J. Physiol. Heart Circ. Physiol. 299, H134-H143 (2010) and Hu et al., PLoS One 8(4), e60287 (2013)] that were based on the Monodomain model and a simple non-selective linear SAC, while here we consider the full Bidomain model and both selective and non-selective components of SACs. Our simulation results show that the stability of cardiac scroll waves is influenced by MEF, which in case of low reversal potential of non-selective SACs might be responsible for the onset of ventricular fibrillation; GEF increases the scroll wave meandering but does not determine the scroll wave stability.

Joint influence of transmural heterogeneities and wall deformation on cardiac bioelectrical activity: A simulation study

The aim of this work is to investigate, by means of numerical simulations, the influence of myocardial deformation due to muscle contraction and relaxation on the cardiac repolarization process in presence of transmural intrinsic action potential duration (APD) heterogeneities. The three-dimensional electromechanical model considered consists of the following four coupled components: the quasi-static transversely isotropic finite elasticity equations for the deformation of the cardiac tissue; the active tension model for the intracellular calcium dynamics and cross-bridge binding; the anisotropic Bidomain model for the electrical current flow through the deforming cardiac tissue; the membrane model of ventricular myocytes, including stretch-activated channels. The numerical simulations are based on our finite element parallel solver, which employs Multilevel Additive Schwarz preconditioners for the solution of the discretized Bidomain equations and Newton-Krylov methods for the solution of the discretized non-linear finite elasticity equations. Our findings show that: (i) the presence of intrinsic transmural cellular APD heterogeneities is not fully masked by electrotonic current flow or by the presence of the mechanical deformation; (ii) despite the presence of transmural APD heterogeneities, the recovery process follows the activation sequence and there is no significant transmural repolarization gradient; (iii) with or without transmural APD heterogeneities, epicardial electrograms always display the same wave shape and discordance between the polarity of QRS complex and T-wave; (iv) the main effects of the mechanical deformation are an increase of the dispersion of repolarization time and APD, when computed over the total cardiac domain and over the endo- and epicardial surfaces, while there is a slight decrease along the transmural direction.

Assessment of genetic diversity in lentils (Lens culinaris Medik.) based on SNPs

This study is the first attempt to establish an SNP database for the purpose of estimating the genetic diversity and relatedness of Palestinian lentil genotypes. A total of 14 lentil accessions (11 local, two supplied by ICARDA, and one introduced from Italy) were investigated. By sequencing two genes, lectin and lipid transfer protein 5 (LTP5), four SNPs were detected (three in the first and one in latter gene) with average frequencies of one SNP every 228 and 578 bp, respectively. In addition, in LTP5 two single-nucleotide indels were observed in the non-coding part of the gene. Four haplotypes were identified in the lectin gene, three in LTP5. One lectin haplotype coincided with that present in GenBank belonging to two cultivated varieties, two were rather similar to this, whereas the last one turned out closer to the sequence of one wild lentil accession, indicating the existence of diversity in the Palestinian germplasm. These results, enhancing the available knowledge of lentil genetic resources in Palestine, may contribute to their conservation and utilization in breeding projects.

A reliability analysis of cardiac repolarization time markers

Only a limited number of studies have addressed the reliability of extracellular markers of cardiac repolarization time, such as the classical marker RT(eg) defined as the time of maximum upslope of the electrogram T wave. This work presents an extensive three-dimensional simulation study of cardiac repolarization time, extending the previous one-dimensional simulation study of a myocardial strand by Steinhaus [B.M. Steinhaus, Estimating cardiac transmembrane activation and recovery times from unipolar and bipolar extracellular electrograms: a simulation study, Circ. Res. 64 (3) (1989) 449]. The simulations are based on the bidomain - Luo-Rudy phase I system with rotational fiber anisotropy and homogeneous or heterogeneous transmural intrinsic membrane properties. The classical extracellular marker RT(eg) is compared with the gold standard of fastest repolarization time RT(tap), defined as the time of minimum derivative during the downstroke of the transmembrane action potential (TAP). Additionally, a new extracellular marker RT90(eg) is compared with the gold standard of late repolarization time RT90(tap), defined as the time when the TAP reaches 90% of its resting value. The results show a good global match between the extracellular and transmembrane repolarization markers, with small relative mean discrepancy (<or=1.6%) and high correlation coefficients (>or=0.92), ensuring a reasonably good global match between the associated repolarization sequences. However, large local discrepancies of the extracellular versus transmembrane markers may ensue in regions where the curvature of the repolarization front changes abruptly (e.g. near front collisions) or is negligible (e.g. where repolarization proceeds almost uniformly across fiber). As a consequence, the spatial distribution of activation-recovery intervals (ARI) may provide an inaccurate estimate of (and weakly correlated with) the spatial distribution of action potential durations (APD).

Modeling ventricular repolarization: effects of transmural and apex-to-base heterogeneities in action potential durations

Heterogeneities in the densities of membrane ionic currents of myocytes cause regional variations in action potential duration (APD) at various intramural depths and along the apico-basal and circumferential directions in the left ventricle. This work extends our previous study of cartesian slabs to ventricular walls shaped as an ellipsoidal volume and including both transmural and apex-to-base APD heterogeneities. Our 3D simulation study investigates the combined effect on repolarization sequences and APD distributions of: (a) the intrinsic APD heterogeneity across the wall and along the apex-to-base direction, and (b) the electrotonic currents that modulate the APDs when myocytes are embedded in a ventricular wall with fiber rotation and orthotropic anisotropy. Our findings show that: (i) the transmural and apex-to-base heterogeneities have only a weak influence on the repolarization patterns on myocardial layers parallel to the epicardium; (ii) the patterns of APD distribution on the epicardial surface are mostly affected by the apex-to-base heterogeneities and do not reveal the APD transmural heterogeneity; (iii) the transmural heterogeneity is clearly discernible in both repolarization and APD patterns only on transmural sections; (iv) the apex-to-base heterogeneity is clearly discernible only in APD patterns on layers parallel to the epicardium. Thus, in our orthotropic ellipsoidal wall, the complex 3D electrotonic modulation of APDs does not fully mix the effects of the transmural and apex-to-base heterogeneity. The intrinsic spatial heterogeneity of the APDs is unmasked in the modulated APD patterns only in the appropriate transmural or intramural sections. These findings are independent of the stimulus location (epicardial, endocardial) and of Purkinje involvement.

Monophasic action potentials generated by bidomain modeling as a tool for detecting cardiac repolarization times

Unipolar electrograms (EGs) and hybrid (or unorthodox or unipolar) monophasic action potentials (HMAPs) are currently the only proposed extracellular electrical recording techniques for obtaining cardiac recovery maps with high spatial resolution in exposed and isolated hearts. Estimates of the repolarization times from the HMAP downstroke phase have been the subject of recent controversies. The goal of this paper is to computationally address the controversies concerning the HMAP information content, in particular the reliability of estimating the repolarization time from the HMAP downstroke phase. Three-dimensional numerical simulations were performed by using the anisotropic bidomain model with a region of short action potential durations. EGs, transmembrane action potentials (TAPs), and HMAPs elicited by an epicardial stimulation close or away from a permanently depolarized site were computed. The repolarization time was computed as the moment of EG fastest upstroke (RTeg) during the T wave, of HMAP fastest downstroke (RTHMAP), and of TAP fastest downstroke (RTtap). The latter was taken as the gold standard for repolarization time. We also compared the times (RT90HMAP, RT90tap) when the HMAP and TAP first reach 90% of their resting value during the downstroke. For all explored sites, the HMAP downstroke closely followed the TAP downstroke, which is the expression of local repolarization activity. Results show that HMAP and TAP markers are highly correlated, and both markers RTHMAP and RTeg (RT90HMAP) are reliable estimates of the TAP reference marker RTtap (RT90tap). Therefore, the downstroke phase of the HMAP contains valuable information for assessing repolarization times.